Scott Oh

Covered Balloon-Expanding Stents in Airway Stenosis

BACKGROUND The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. METHODS This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patients self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. RESULTS Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). CONCLUSIONS Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.Background: The balloon-expanding stents are widely available but rarely described for use within the tracheobronchial tree. This report describes our experience with these stents in airway stenosis particularly as a lobar salvage therapy. Methods: This was a retrospective review of all records in which the balloon-expanding stents were used at a tertiary medical center. Ages, sex, location of stenosis, etiology of stenosis, stent size, duration of stent placement and associated interventions for airway stenosis were recorded. Patient’s self-reported respiratory symptoms, dyspnea scale, and radiographic imaging at baseline and after stent placement were also reported. Results: Twenty-one Atrium iCAST stents were inserted in 18 patients with malignant and benign airway disease. The median age was 69.5 years (interquartile range, 53.5 to 74). Most stents (n=20, 95%) were deployed in the lobar airways. There was a significant improvement in the modified Medical Research Council dyspnea scale from median of 3 to 2 (P<0.05). Self-reported respiratory symptoms improved in 14 patients (78%, P<0.05). Radiographic improvement post Atrium iCAST stent placement was achieved in 15 patients (83%). No deaths were related to airway stenting complications. Adverse events related to stents included migration (n=2, 9.5%), granulation tissue formation (n=2, 9.5%) and mucus plugging (n=1, 4.8%). Conclusions: Lobar stenting with balloon-expanding metallic stents appears feasible, safe and improves symptoms as well as radiographic atelectasis in patients with lobar airway stenosis in this small case series. Larger studies are needed to confirm this observation and to address long-term safety.

Iatrogenic Endobronchial Bleeding: Speed Things Up or Cool It Down?

D iagnostic and therapeutic bronchoscopy is the most common procedure performed by chest physicians. However, the occurrence of bleeding, especially after a transbronchial biopsy (TBBx), is a real and a frightening possibility. In 1964, Tsuboi et al1 published a report promoting TBBx in the diagnosis of lung cancer. Since then, the safety of performing TBBx under moderate sedation in an outpatient setting has been well established.2,3 Although TBBx is safe, significant and even life-threatening hemoptysis occurs in 1% to 2% of cases.4,5 Rates as high as 45% have been reported depending on its definition, biopsy technique, and risk factors.6 Several risk factors for TBBx-associated bleeding have been reported including thrombocytopenia, thrombocytosis, anticoagulation, uremia, liver disease, an immunocompromised state, and pulmonary hypertension.7–12 Clopidogrel is associated with a significantly increased bleeding risk, but aspirin alone is not.13,14 Deaths associated with bleeding from TBBx are exceedingly rare but may be underreported. In one of the largest series to date, no deaths were reported from a Japanese study that included >57,000 patients.15 Correctable risk factors should always be identified and optimized before performing TBBx. The infrastructure and staff necessary for emergent resuscitation should be readily available should an unexpected life-threatening complication such as massive bleeding occur. As with all procedures, the risks and benefits must be carefully considered, including the need to withhold antiplatelet and/or anticoagulation therapies before the biopsies. Procedural maneuvers to minimize bleeding risk include preferentially sampling dependent segments when clinically appropriate to limit contamination.16 The technique of wedging the bronchoscope into the target airway during and after the biopsy until hemostasis is achieved, with or without using the suction was described by Zavala17 in 1975. Disturbing stable clots after the biopsy by suctioning should also be avoided.16 Instillation of topical epinephrine, ice-cold saline, and tranexamic acid has been recommended to promote hemostasis in the setting of TBBx-associated bleeding. However, there are limited reports describing clinical outcomes that can convincingly advocate for or against these interventions. The British Thoracic Society Guidelines for diagnostic flexible bronchoscopy state that the risk for bronchoscopic-associated bleeding is low and will typically resolve spontaneously or with endoscopic instillation of cocaine or adrenaline. Prophylactic local vasoconstrictor therapy is recommended if bleeding is considered likely. For significant bleeding the British Thoracic