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J Thorac Cardiovasc Surg. Author manuscript; available in PMC 2010 July 1.
Published in final edited form as:
PMCID: PMC2894417
NIHMSID: NIHMS108291

REPLY TO LETTER TO THE EDITOR: RE: JTCVS-08-569 AIRWAY STENOSES AFTER LUNG TRANSPLANTATION: INCIDENCE, MANAGEMENT, AND OUTCOME

Patricia A. Thistlethwaite, M.D., Ph.D.a and James Harrell, M.D.b

We appreciate the interest that Drs. Anile and Ventura have in the management of lung transplant patients with distal focal bronchial stenosis (Type 3 disease) and diffuse distal stenosis (Type 4 disease). This is a complex group of patients to manage, and their airway issues can be challenging [1].

As a high volume center for bronchial stent placement (for causes other than transplantation), we have been uniformly disappointed with the use of expandable metallic stents. Metallic stents in the airway are associated with fracture, overgrowth of granulation tissue, erosion through the tracheobronchial wall, and are quite expensive. Although the cost of a single metallic stent is low in comparison to the total expense of lung transplantation, cost precludes having a large inventory of these stents available. We currently have an inventory of over 100 silastic stents (Silastic stents from Hood Laboratories, Pembroke, MA and Bryon Corporation, Woburn, MA). This inventory allows us to find the right stent for almost any airway, and allows us to taylor each stent to the individual’s patient’s needs and replace/upsize them as needed.

We have several practical tips for stenting of Type 3 and Type 4 bronchial stenosis:

  1. We have found that stenting of the subsegmental airways does not benefit the patient. Thus, we limit our stenting to the bronchial and segmental airways.
  2. We calibrate the size of stent to be placed based on the size of the rigid bronchoscope we are able to insert in the portion of bronchus affected. For example, if we are able to cannulate the affected bronchus with a 10 mm rigid bronchoscope, we would size the proximal portion of the stent to 10–12 mm.
  3. For difficult long stenoses, we often dilate the bronchus/segment and stent them, and come back in 2–3 months to remove the stent and replace it with a larger diameter one. This can be done sequentially, in order to maximally dilate the affected area.
  4. For distal left-sided problems, we routinely place the stent over the bifurcation of the upper and lower lobe, and cutting a small circular segment of out of the stent, using a 6mm dermal punch (Acuderm, Fort Lauderdale, FL). This stent contouring maintains the integrity of the stent, while allowing for ventilation of the upper lobe, which would otherwise be obstructed.
  5. For distal right-sided problems, we use step-down stents of various configurations (Hood Silastic 2-Step Stents with Posts and Mesh: Hood Laboratories). A step-down stent is one in which the proximal diameter is larger than the distal diameter, with tapering of the stent diameter in between. Step-down stents allow coverage down to the level of the superior segment of the lower lobe and right middle lobe, while maintaining patency and coverage of the anastomosis and proximal mainstem bronchus. We usually cut a 6 mm dermal punch hole in the stent for the right upper lobe to allow ventilation to this lobe. The right upper lobe orifice is often variable in its position, so we have not found stents with pre-made orifices effective for use.
  6. While inserting silastic stents, we have found that it is important to place the hole for a lobar orifice corresponding to the print on the metallic applicator (Dumon-Harrell applicator: Bryan Corporation; Woburn, MA). This configuration allows for easy rotation of the stent (clockwise for right bronchial stents, counterclockwise for left bronchial stents) into the appropriate position as it is deployed. After stent deployment, we then often put a flexible bronchoscope through the rigid bronchoscope into the stent, while utilizing rigid forceps to manipulate the hole into its most optimal position.

Our experience has been that bronchoscopic surveillance and sequential “up-size” stenting for distal long-segment stenoses is an effective way to permanently increase luminal diameter over a long length of airway.

Footnotes

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References

  • Thistlethwaite PA, Yung G, Kemp A, Osbourne S, Jamieson SW, Channick C, Harrell J. Airway stenoses after lung transplantation: Incidence, management, and outcome. J Thorac Cardiovasc Surg. 2008;136:1569–1575. [PubMed]