Endobronchial Stent Placement Research Articles

Malignant Airway Obstruction and Endobronchial Stent Placement: A Systematic Review on the Efficacy and Safety.

The systematic review aims to evaluate the efficacy and safety of endobronchial stent placement for malignant airway obstruction. A comprehensive search was conducted across multiple databases to identify relevant studies. Cohort studies, randomized controlled trials, and case-control studies examining the outcomes of endobronchial stent placement in patients with malignant airway obstruction were included. Data on pre-treatment evaluation, such as pulmonary function testing, dyspnea severity scoring systems, arterial blood gas parameters, imaging, and degree of obstruction, were also collected. Primary outcomes of interest included post-procedure stenosis, pulmonary function testing evaluation, blood gas parameters, and survival outcomes. Secondary outcomes encompassed improvements in clinical status, dyspnea grade, and procedure-related complications. A total of 27 studies met the inclusion criteria and were included in the systematic review. The included studies demonstrated promising outcomes of endobronchial stent placement in managing malignant airway obstruction. Post-procedure airway diameters, pulmonary function testing, and blood gas parameters improved significantly. Survival outcomes varied among studies. Furthermore, endobronchial stent placement was associated with improvements in clinical status and dyspnea grade. Procedure-related complications ranged from pain, hemoptysis and mucus plugging to stent obstruction, migration and pneumothorax. This systematic review suggests that endobronchial stent placement is an effective and safe intervention for managing malignant airway obstruction. It offers significant improvements in post-procedure stenosis, pulmonary function testing, blood gas parameters, and clinical outcomes. However, further studies with larger sample sizes and standardized reporting are warranted to better evaluate the long-term efficacy and safety of endobronchial stent placement for malignant airway obstruction.

Safety of Anti-Fibrotic Therapy for Interstitial Lung Disease Prior to Lung Transplantation

Purpose The use of anti-fibrotic drugs before lung transplantation (LTx) may interfere with wound-healing and increase peri-operative bleeding. The aim of this study was to assess the safety of pre-transplant administration of anti-fibrotic agents as a bridge to LTx for interstitial lung disease (ILD). Methods This is a single-center retrospective cohort study. A total of 91 patients with ILD underwent LTx between June 2008 and December 2019. Among them, 36 patients received anti-fibrotic therapy (pirfenidone: n=27; nintedanib: n=5; both: n=4) before LTx (treatment group), and 55 patients did not receive it (control group). Early post-transplant outcome was compared between the two groups. The anti-fibrotic treatment was discontinued the day before surgery in brain-dead donor lung transplantation, whereas it was discontinued in advance in living-donor lobar lung transplantation (17±12 days before LTx). Results Blood loss during surgery did not significantly differ between the two groups (median: 740 ml in the treatment group vs. 1185 ml in the control group, P=0.38). Re-thoracotomy for hemothorax was required in 3 patients (8.3%) in the treatment group and 2 patients (3.6%) in the control group (P=0.38). Chest wound healed normally in all patients. Anastomotic airway complication occurred in 4 patients (11.1%) in the treatment group and 5 patients (9.1%) in the control group (P=0.74). Among the 4 patients who developed airway complication in the treatment group, two patients with bronchial stenosis required bronchoscopic intervention, including balloon dilation, endobronchial stent placement, and laser ablative therapy. Other two patients with anastomotic dehiscence could be conservatively managed. No patient died within the first 30 days after LTx, and in-hospital mortality was similar in both groups (2.8% in the treatment vs. 1.8% in the control group, P=1.00). Conclusion Pre-transplant anti-fibrotic therapy did not negatively affect the early post-transplant outcomes without any significant increase in the risk of post-operative would-healing and bleeding problems and anastomotic airway complications.

The Impact of Airway Complications on Survival Among Lung Transplant Recipients

IntroductionLong-term outcomes of airway complications (AC) after lung transplantation are unknown. The incidence of AC varies from 1.6% to 32% with the related mortality rate of 2% to 4%. The management of most AC is based on endobronchial methods, including balloon bronchoplasty, endobronchial stent placement, and ablative techniques. The aim of the study was to assess the connection between airway complications treated by bronchial intervention (BI) and the survival of lung transplant recipients. Materials and MethodsThe single-center retrospective study reviewed the cases of 165 patients (63 women [38.18%], 103 men [61, 82%]; median age at referral for lung transplantations (LTx), 41 years [range, 15-68 years]). The cohort was stratified into 2 groups comprising those whose procedures were complicated by ACs and those without. The primary outcome measured was mortality, with survival endpoints calculated at 6 months. ResultsThe comparison of the survival of recipients regarding underlying disease (cystic fibrosis [CF], chronic obstructive pulmonary disease [COPD], idiopathic pulmonary artery hypertension [IPAH], and others) with the use of the Kaplan-Meier estimator indicated that the only statistically significant (P = .0194) differences between patients who underwent BI and patients without BI performed were observed in CF patients (Fig 1). In any other diagnosis, the results were not statistically significant (P > .05). ConclusionsBronchoscopic intervention because of airway complications after lung transplantation are often-used procedures, but they have no impact on the survival of patients with cystic fibrosis.

Stenting in Non-Small Cell Lung Cancer: How Does It Affect the Outcomes?

Objective:Approximately 30% of lung cancer patients develop central airway obstruction (CAO) that remarkably shortens survival. There is little data about the benefits of stenting within this heterogeneous patient group. Our objective was to review their overall survival (OS) and their risk of hospitalization versus patients who did not have lesions requiring stent placement. Methods:We retrospectively reviewed charts of 171 non-small cell lung cancer (NSCLC) patients who underwent bronchoscopy in the University of Cincinnati Cancer Center from the year 2011 to 2013. Twenty-five patients with advanced lung cancer were evaluated by interventional pulmonology service for endobronchial stent placement for CAO. Eight patients did not require placement of a stent and 17 had obstructive lesions that required stenting by interventional pulmonology. Results:Demographical parameters such as age and gender did not have a significant impact on the risk of hospitalization or OS of both groups of patients, however, those whose lesions did not mandate stent placement had significantly lower odds of hospitalization compared to patients with CAO requiring a stent (OR: 15.913, 95% CI: 1.211-209.068, P = 0.0352). Patients with advanced NSCLC and CAO that required stent placement had an OS of 13.9 m [3.9-19.9 m] compared to an OS of 23.9 m for patients with CAO not requiring a stent. We found out that patients with less severe CAO have lower odds of hospitalization and better OS compared to patients with CAO mandating stent placement. Conclusion:CAO patients with interventional pulmonology (IP) evaluation and management in addition, may have improved OS suggesting that IP consultation might offer both improvement in quality of life and overall survival to patients with advanced NSCLC and CAO.

SQUAMOUS CELL CARCINOMA PRESENTING WITH OBSTRUCTION OF THE SUPERIOR VENA CAVA AND CENTRAL AIRWAYS

SESSION TITLE: Tuesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/22/2019 01:00 PM - 02:00 PM INTRODUCTION: One mechanism by which cancer causes morbidity/mortality is by mass effect with distortion, compression, or occlusion of nearby anatomical structures. Within the chest, tumors can exert these effects on the airways and vascular structures. This case illustrates the need for urgent intervention in a patient presenting with severe compression of multiple intrathoracic structures. CASE PRESENTATION: A 54 year-old man with chronic tobacco use and limited exposure to healthcare presented to the hospital with gradually progressive shortness of breath over several months, followed by facial swelling, severe wheezing, and recurrent syncope over the past few days. Exam was remarkable for facial flushing and diffuse inspiratory/expiratory wheezing. Laryngoscopy was performed, which did not suggest critical airway edema. Computed tomography (CT) of the chest demonstrated a large right-sided suprahilar mass, with severe compression of the superior vena cava (SVC) and right mainstem bronchus (RMB) and bronchus intermedius, narrowing of the right pulmonary artery and vein, and complete collapse of the right upper lobe. The patient underwent urgent placement of an 11x59mm balloon-expandable covered stent within the SVC, after which the patient reported improvement in facial swelling but minimal improvement in dyspnea. Next, he underwent bronchoscopy, which demonstrated significant extrinsic compression within the right mainstem bronchus; transbronchial needle aspirates of lymph nodes from Stations 4R and 7 were obtained, from which pathology results were consistent with squamous cell carcinoma (SCC). Because of the degree of bronchial compression, and the need for chemotherapy and radiation therapy which could temporarily cause tumoral inflammation and worsen compression/collapse of the right lung, bronchoscopy was repeated, and this time a 12x40mm self-expandable partially-covered stent was placed within the right mainstem bronchus. After this, the patient reported significant improvement in dyspnea, and was discharged to home in stable condition. DISCUSSION: This case describes pulmonary SCC presenting with symptoms of acute SVC syndrome and central airway compression. Lung cancer associated with either of these conditions has dramatically increased morbidity/mortality. In malignant SVC syndrome, stent placement has been shown to reduce SVC pressure and improve symptoms; there is moderate risk of stent re-obstruction. Though not free of risks, endobronchial stent placement can prevent the impending occlusion of a central airway, when surgical or endobronchial resection/debulking is not possible. In recent years, there have been numerous advances in the technology and variety of endobronchial stents for multiple indications. CONCLUSIONS: Malignant extrinsic compression of the SVC and central airways is associated with high morbidity/mortality and can be managed urgently and safely with stent placement. Reference #1: Avasarala SK, Freitag L, & Mehta AC. Metallic endobronchial stents: A contemporary resurrection [published online ahead of print December 11, 2018]. CHEST. doi:10.101/j.chest.2018.12.001. Reference #2: Niu S, Xu YS, Cheng L, & Cao C. Stent insertion for malignant superior vena cava syndrome: Effectiveness and long-term survival. Vascular and Interventional Radiology 2017, 122: 633-638. Reference #3: Mudambi L, Miller R, & Eapen GA. Malignant central airway obstruction. Journal of Thoracic Disease 2017, 9(10): 1087-1110. DISCLOSURES: No relevant relationships by Gabriel Ryan, source=Web Response

Management of Postintubational Tracheal Injury by Endoscopic Stent Placement: Case Report and Review of the Literature.

Endobronchial stent placement is a novel therapy for treatment of iatrogenic tracheal tears. A review of the available literature shows surgery and long-term intubation being the established treatment strategy.We describe the case of a 64-year-old woman with a tracheal rupture following endotracheal intubation for routine surgery. Pneumo-mediastinum and chest pain were the predominant symptoms. She was treated with a covered self-expandable metal stent that closed the tear and led to immediate symptom relief. After six weeks and complete healing of the trachea, the stent could be explanted. No stent complications occurred. A new algorithm for the treatment of these ruptures has been proposed.

Combined Small Cell Carcinoma of the Lung or a Coexistent Small Cell and Adenocarcinoma of the Lung?

SESSION TITLE: Lung Cancer Cases - Student/Resident SESSION TYPE: Student/Resident Case Report Slide PRESENTED ON: Sunday, October 25, 2015 at 03:15 PM - 04:15 PM INTRODUCTION: Combined small cell carcinomas (c-SCLC) are multiphasic lung cancers originating in lung tissue containing a component of small cell lung carcinoma (SCLC) admixed with one (or more) components of non-small cell lung carcinoma (NSCLC). CASE PRESENTATION: 66 y/o female presented to the hospital with cough of 3 weeks duration. She had been diagnosed with lung cancer 6 months prior to this presentation. At that time her biopsy revealed poorly differentiated lung adenocarcinoma (strong nuclear positivity for TTF-1 and focal positivity for Napsin-A) with EGFR mutation in exon 19 and she was started on chemotherapy with Erlotinib. During this admission CT scan of the chest revealed obstruction of right bronchus due to lymphadenopathy. She underwent bronchoscopy with ultrasound-guided biopsy of the lymph node and endobronchial stent placement. The biopsy revealed tumor cells positive for TTF-1, CD56, synaptophysin and NSE, but negative for chromogranin. An immunostain for Ki-67 shows 70% positivity in the tumor cells. Thus a diagnosis of small cell carcinoma was made. She was started on chemotherapy with carboplatin and etoposide. Unfortunately after the second cycle, she developed neutropenic fever and septic shock without response to antibiotics. At this point patient opted comfort as the primary goal. DISCUSSION: Lung cancer is the leading cause of cancer death for both men and women. SCLC comprises more than 90% of all small cell lung cancer cases. The remaining 10% are mixed small cell/non-small cell carcinomas called as c-SCLC. In our patient it is difficult to determine if the patient had a co-existing adenocarcinoma and a SCLC or a c-SCLC, which was diagnosed as adenocarcinoma during the first biopsy. It is also interesting to note that our patient had an EGFR mutation. EGFR mutation is rare in small cell lung cancer, and cases harboring EGFR mutations were more likely to be combined with adenocarcinoma. Inferior survival has been reported for patients with mixed carcinomas compared with patients having small cell carcinoma without a non-small cell component. However more recent reports have shown that these patients tend to have more localized, sometimes surgically resectable disease and a more favorable prognosis. Current thinking is that patients who have mixed histologies, should be treated as those the entire tumor is a small cell lung cancer. However, all patients should be managed individually based upon their stage of disease, age, and general medical condition. CONCLUSIONS: Due to the multiphasic nature of c-SCLC it can be difficult to distinguish it from a co-existing small cell and non-small cell cancer of the lung. When diagnosed, it should be treated as small cell lung cancer and the treatment should be based on the individual needs of the patient. Reference #1: [1] Mangum MD et al. Combined small-cell and non-small-cell lung cancer. J Clin Oncol. 1989 May;7(5):607-12. DISCLOSURE: The following authors have nothing to disclose: Abhishek Agarwal, Abhinav Agrawal, Karim Nathan, Vinay Palli, Deborah Park, Erin Jepsen No Product/Research Disclosure Information

Therapeutic Bronchoscopy for Malignant Central Airway Obstruction

There is significant variation between physicians in terms of how they perform therapeutic bronchoscopy, but there are few data on whether these differences impact effectiveness. This was a multicenter registry study of patients undergoing therapeutic bronchoscopy for malignant central airway obstruction. The primary outcome was technical success, defined as reopening the airway lumen to > 50% of normal. Secondary outcomes were dyspnea as measured by the Borg score and health-related quality of life (HRQOL) as measured by the SF-6D. Fifteen centers performed 1,115 procedures on 947 patients. Technical success was achieved in 93% of procedures. Center success rates ranged from 90% to 98% (P = .02). Endobronchial obstruction and stent placement were associated with success, whereas American Society of Anesthesiology (ASA) score > 3, renal failure, primary lung cancer, left mainstem disease, and tracheoesophageal fistula were associated with failure. Clinically significant improvements in dyspnea occurred in 90 of 187 patients measured (48%). Greater baseline dyspnea was associated with greater improvements in dyspnea, whereas smoking, having multiple cancers, and lobar obstruction were associated with smaller improvements. Clinically significant improvements in HRQOL occurred in 76 of 183 patients measured (42%). Greater baseline dyspnea was associated with greater improvements in HRQOL, and lobar obstruction was associated with smaller improvements. Technical success rates were high overall, with the highest success rates associated with stent placement and endobronchial obstruction. Therapeutic bronchoscopy should not be withheld from patients based solely on an assessment of risk, since patients with the most dyspnea and lowest functional status benefitted the most.

Endobronchial Stent Placement in Management of Massive Hemoptysis

Endobronchial Stent Placement in Management of Massive Hemoptysis

Endobronchial-Covered Stent Insertion as a Therapeutic Option in Massive Hemoptysis Caused by Lung Cancer

SESSION TITLE: Bronchology Student/Resident Case Report Posters SESSION TYPE: Medical Student/Resident Case Report PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM 02:30 PM INTRODUCTION: Among the myriad clinical presentations of lung cancer, life threatening hemoptysis may be the most difficult to treat. Identification of the site of bleeding within the airways plays a key role in the approach to management, as the location dictates the most efficacious treatment option. The most common treatments include pharmacological, bronchoscopic intervention, vascular embolization and surgical resection. We herein report a novel approach to massive hemoptysis in a patient found to have an actively bleeding carinal mass invading and obstructing the right main bronchus. CASE PRESENTATION: 66-year-old Caucasian female with past medical history of hypertension and smoking presented with massive hemoptysis which was immediately and successfully controlled and airway patency reestablished with the insertion of an endobronchial-covered stent. The mass was identified at bronchoscopy as squamous cell carcinoma and the patient was later referred for radiation therapy. Four weeks later, after receiving a total of 5 sessions of radiotherapy, the patient presented with throat discomfort and odynophagia. Computed tomography scan showed tumor reduction with increased lumen size of the right main bronchus and migration of the stent into the hypopharynx. The stent was successfully removed without incident. No episodes of additional hemoptysis occurred. DISCUSSION: When alternative treatment modalities fail or are precluded by the central location of the bleeding site, covered endobronchial stent placement should be considered an indispensible option in this select group of patients, as it can achieve immediate airway patency as well as tamponade of the bleeding focus. CONCLUSIONS: Complications of endobronchial stent placement including migration and perforation should be identified and treated early. Reference #1: Saad CP, Murthy S, Krizmanich G, Mehta AC. Self-expandable metallic airway stents and flexible bronchoscopy: long-term outcomes analysis. Chest. 2003; 124:1993-9. Reference #2: Brandes JC, Schmidt E, Yung R. Occlusive endobronchial stent placement as a novel management approach to massive hemoptysis from lung cancer. J Thorac Oncol. 2008; 3:1071-2 FREE TO VIEW

Traitement d’une fistule bronchopéricardique par prothèse endobronchique métallique

Bronchopericardial fistula is a rare condition leading to pneumopericardium. This medical condition is often related to neoplastic disease, or a complication of surgical interventions. The treatment approach depends on both the etiology and the clinical presentation. In stable patients, pericardial drain insertion and/or surgical resection of the fistula are considered options for persistent cases. We present the case of a bronchopericardial fistula treated by placement of an endobronchial stent. A 64-year-old man operated on for lung cancer had a recurrence treated with radiation and chemotherapy. A pneumopericadium was discovered when he presented with a new onset of atrial fibrillation. Bronchoscopy revealed a fistula tract. Pericardial drainage was persistent and did not improve the clinical situation. The poor health status of the patient contraindicated surgery and an alternative therapeutic approach with endobronchial stent placement was undertaken. The fistula sealed immediately, the pericardial drain could be removed removed and the patient was able to be discharged from hospital. Endobronchial stenting should be considered as a potential treatment option in patients with pneumopericardium secondary to bronchopericadial fistula, particularly where a non-surgical is required.

Treatment of Airway Complications Following Lung Transplantation

Objective To describe our experience in airway complications following lung transplantation and to suggest a management strategy using different interventional bronchoscopic techniques. Method Retrospective analysis of all airway complications following lung transplantation from January 1999 to July 2007. Results During this period, 223 patients underwent lung transplantation, with a total of 345 airway anastomoses. In 70 (20.23%), there were complications requiring endoscopic intervention. A total of 631 procedures were carried out in 52 patients. Thirty-three patients presented a combination of bronchial stenosis and bronchomalacia, 18 patients had bronchial stenosis alone and 1 patient presented dehiscence of the anastomosis. In most cases, pneumatic balloon dilatation was effective, although temporarily, and ultimately 47 patients required endobronchial stent placement. The most common complication associated with the use of stents was granulation tissue formation, seen in 57.3% of patients. After stent placement, forced expiratory volume in one second (FEV 1) improved significantly. Conclusion Airway complications after lung transplantation are frequent. Balloon dilatation was effective in only a few patients with bronchial stenosis, requiring stent placement in most. Airway permeabilization after endobronchial stent placement improved FEV 1 in these patients. Based on our experience, we propose a management strategy for airway complications after lung transplantation.

Postpneumonectomy Syndrome: Results of mediastinal repositioning vs. stent placement

Background: Postpneumonectomy syndrome (PPS) is a late complication of pneumonectomy characterized by mediastinal shift and bronchial compression. It is most common following right pneumonectomy but is also seen left pneumonectomy. It can be treated with mediastinal repositioning and tissue expander placement in the postpneumonectomy space, but there is some interest in less invasive modalities. Endobronchial stent placement may be an option. We looked at our experience treating PPS with these two modalities. Methods: All patients with PPS treated with mediastinal repositioning/tissue expander placement or bronchial stenting at our institution from 1991 to 2005 were reviewed. Results: Mean age at the time of pneumonectomy was 45 years. Mean follow-up was 33 months. Six patients underwent tissue expander placement. They had relief of symptoms with the following complications: wound infection, atrial fibrillation, expander leak and esophageal dysmotility. Two patients underwent silastic stent placement with immediate resolution of symptoms, however they suffered from frequent mucous plugging, stent migration, and granulation tissue formation requiring repeat bronchoscopic treatment and stent replacement. Conclusions: Mediastinal repositioning with tissue expander placement provides durable relief of symptoms. Endobronchial stenting is a less invasive treatment option for PPS, however patients require close follow-up due to a high complication rate. Need for frequent bronchoscopy often emergently present serious limitations in this small group.

Tracheobronchopathia Osteochondroplastica: Presentation of Ten Cases and Review of the Literature

Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease of the endobronchial system with nonspecific symptoms and different treatment approaches. We report on a group of patients with TO and discuss their presentation and their treatment modalities. Between 2000 and 2006, the medical records of patients with TO were studied at the Interventional Pulmonary Unit of the Tracheal Disease Research Center at Masih Daneshvary Hospital, a referral center for respiratory diseases in Tehran, Iran. We analyzed and studied patients' demographics, symptom presentation, radiographic appearance, bronchoscopic findings, and their subsequent treatment. Of the 8,760 patients who underwent flexible bronchoscopy (FOB) at our center over 6 years, 10 were diagnosed with TO; their median age was 51 years (range = 16-68 years) and 6 were men. Computerized tomography (CT) revealed mucosal irregularity and calcified nodules. Histopathologic examination of tissue biopsy through bronchoscopy was used for definitive diagnosis of TO. Bronchoscopy findings showed the endobronchial lesions to be firm and glossy. Cartilaginous nodules were present in central airways. Treatment included endobronchial Nd:YAG laser photoevaporation (LPE) (n = 10), coring of the lesions with the tip of the rigid bronchoscope (n = 4), and endobronchial stent placement (n = 1). Symptoms were considerably relieved in six cases but there was no significant improvement noted in three patients. One patient died after 6 years of treatment and follow-up. TO is a rare disease and the diagnosis should be suspected based on CT findings or bronchoscopic examination of the airways. Histopathologic examination is required for confirmation of diagnosis. Treatment is palliative and it includes LPE, coring through a rigid bronchoscope, and endobronchial stent placement.

Endobronchial Stent Placement for the Management of Airway Complications after Lung Transplantation

To retrospectively evaluate the efficacy and complications of endobronchial stent placement for the management of airway complications following lung transplant. From 1992 to 2003, tracheobronchial stenting was performed on 25 lung transplant recipients (16 male and 9 female; mean age 51.6 years; range 21-65 years). A total of 27 lesions were treated and 27 stents were deployed (nine bronchomalacia, 12 bronchial stenosis, three bronchial stenosis and bronchomalacia both and three anastomotic dehiscence). The clinical and bronchoscopic follow-up ranged from 1 month to 69 months. The technical success was 100%. Eighty-four percent of patients had immediate relief in dyspnea. The overall complication rate following stent placement was 0.049 per patient per month (23 complications/471 patient months). Stent migration and granulation tissue formation were the most frequent complications. The mean percentage change in FEV-1 was significantly greater than zero at 1 month and 6 months (P<.05) post-stent placement. The mean percentage change in FEV-1 was marginally greater than zero at 12 months (P=.07).The mean percentage change in FVC was marginally greater than zero at 1 month and 6 months (P=.08) post-stent. It was not significantly greater than zero at 12 months (P=1.00). Tracheobronchial stent placement provides effective palliation of postoperative airway complications in lung transplant with morbidity that can be managed effectively by available treatment options. Airway stenting may be used as a primary management option for airway complications after lung transplantation as a large number of patients are not suitable candidates for repeat surgery.

Placement of Multiple Airway Stents: Indications and Criteria for Stent Selection

Placement of Multiple Airway Stents: Indications and Criteria for Stent Selection

Interventional Techniques in the Management of Airway Complications Following Lung Transplantation

The last four decades have seen tremendous advances in the field of pulmonary transplantation. Vast improvements in the areas of surgical transplantation techniques, immunosuppressive agents, and postoperative care have all contributed to improved survival of patients. Advances in noninvasive imaging and bronchoscopy have allowed the pulmonary transplant team to intervene early in patients presenting with airway complications, often using minimally invasive procedures such as endobronchial balloon dilation or stent placement, or both. Stent technology itself has also improved and stents may sometimes be customized for treatment of short airway lesions or to optimize continued airflow through the sides of stents by creating openings using balloons or bronchoscopically directed laser. Preliminary work with brachytherapy may be decreasing the need for secondary reinterventions. The authors present an overview of some of these conventional and novel approaches to the treatment of airway complications after lung transplantation.

Endobronchial metallic stent placement for airway complications after lung transplantation: Longitudinal results

Background In lung transplant recipients, bronchial stenosis (SB) and bronchomalacia (MB) result in obstructive airway disease and allograft dysfunction due to pulmonary infection. We hypothesized that endobronchial metallic stent placement for SB and MB would result in long-term improvement in respiratory function and rates of pulmonary infection. Methods We studied symptomatic lung transplant recipients with bronchoscopic evidence of proximal airway complications (SB or MB) and a synchronous decline in forced expiratory volume in 1 second (FEV 1) of at least 10% in the 6-month period before intervention. Stent placement was the primary intervention for SB and all focal MB lesions and for recurrent or refractory SB lesions failing a single initial attempt at balloon dilation. FEV 1 and rates of pulmonary infection were assessed in the 12-month interval before and after stent placement. Spirometric evaluation was performed at 3-month intervals and compared with spirometry at the time of stent placement. The rates of pulmonary infection, determined by the number of antibiotics prescribed, was determined before and after endobronchial correction. Results Thirty recipients underwent a total of 75 procedures (50 stent insertions and 25 balloon dilations). FEV 1 improved significantly after stent placement compared with base line (1.29 ± 0.43 L) as follows: 3 months, 1.45 ± 0.50 L, p = 0.014; 6 months, 1.59 ± 0.57 L, p = 0.002; 12 months 1.59 ± 0.53 L, p = 0.006. The infection rate decreased from the 12-month period preceding stent insertion to the corresponding period after stent insertion (6.97/100 days ± 6.33 versus 5.74/100 days ± 7.76, p = 0.018). Recurrent SB occurred in 17.3%. No life-threatening complications occurred after stent placement and no deaths were attributed to stent malfunction or malposition. Conclusions In lung transplant recipients with SB and MB, maintenance of airway patency by stent placement is safe and resulted in improvements in lung function and reduced pulmonary infection rates for up to 1 year after their insertion.

Endobronchial Stent Placement for Treatment of Left Postpneumonectomy Syndrome

Postpneumonectomy syndrome is a rare complication, seen more commonly after right-side pneumonectomy than left-side pneumonectomy. It is characterized by a shift and rotation of the heart and mediastinum into the empty hemithorax, leading to marked hyperinflation of the remaining lung. The distal end of the trachea or mainstem bronchus becomes stretched and compressed extrinsically between the pulmonary artery anteriorly and the aorta or thoracic vertebrae posteriorly. The syndrome is manifested by dyspnea, cough, stridor, and recurrent pneumonia. We present a 42-year-old woman who presented with complaints of exercise intolerance 7.5 years after a left pneumonectomy. Chest radiography and computed tomography of the thorax were consistent with postpneumonectomy syndrome. Pulmonary function tests demonstrated severe obstructive and restrictive ventilatory defects, which was markedly worse than several months after the surgery. On visualization by flexible bronchoscopy, the right bronchus intermedius appeared notably narrowed and fish-mouthed, secondary to extrinsic compression. The patient was treated with an endobronchial stent to relieve the external compression of the bronchus intermedius. The patient demonstrated marked objective and subjective improvement.

An Endobronchial Cyst with Squamous Metaplasia at the Location of an Airway Stent

We report a case of an endobronchial cyst discovered on routine surveillance bronchoscopy 1 year after an endobronchial stent was placed in a 52-year-old woman who underwent a single left-lung transplant. The endobronchial stent was noted to be in proper position in the left mainstem bronchus with green, purulent secretions. At the distal edge of the stent was a pink fleshy mass obstructing 70% of the bronchus. An endobronchial biopsy was preformed and after the first “bite” of the mucosa, the entire mass disappeared and clear fluid was released. The endobronchial biopsy indicated squamous metaplasia. Cultures grew Streptococcus pneumoniae and transbronchial biopsy revealed mild rejection without airway involvement. The patient was treated with intravenous antibiotics and steroids. Repeat bronchoscopy 6 months later showed no recurrence of the mass. We conclude that the endobronchial cyst in this patient may have originated from a pre-existing “extracellular cyst” associated with the development of metaplasia. The metaplastic changes are likely associated with a foreign body reaction from endobronchial stent placement exacerbated by chronic inflammation. A review of the literature on endobronchial lesions is presented.