After the required number of rings was exposed, the remaining constrained portion of the stent was secured by hand. Using straight sharp-sharp iris scissors, the stent was slowly cut using the end of the outer sheath as a guide. The cut was placed between the exposed rings and the constrained portion of the stent. This provided a “window” that allowed cutting the hydrophilic coating and several long axis nitinol connectors. The now fully expanded, severed distal end of the stent was removed and discarded (Figs. 4C, 5D).
The outer sheath was now slowly readvanced over the space left by the discarded stent. It was reapproximated to the distal tip of the stent deploying device. The remaining nondeployed stent was now completely enclosed by the sheath (Fig. 4D). This allowed insertion of the stent in a usual fashion through the oropharynx and trachea, and the positioning of the modified stent within the bronchial tree was uncomplicated (Fig. 6).
BPF and APF are dreaded complications of a multitude of thoracic procedures and diseases because of the difficulty in management and poor outcomes. Although not formally tested, factors associated with poor outcomes include fistula size, time of onset from surgery, bronchial stump length, and etiology of stump failure. On the basis of these factors, certain therapeutic options may be favored over the others.
Surgical approaches for management of BPF include thoracoplasty, chest wall fenestration, and omental wrapping by a variety of techniques, although these procedures carry significant morbidity and mortality themselves. Surgical therapy for a postresection APF is rarely indicated.4,11,19 Isolated lung ventilation strategies, chest tube management, and high-frequency ventilation have all been attempted with variable success.
Because of the paucity of randomized, controlled trials in APF treatment techniques, small case series and anecdotal experience provide limited options to bronchoscopists.
In our patient, the massive volume loss through the APF complicated her underlying interstitial disease process. The patient experienced a rapidly progressive hypoxemic respiratory failure. Because of the concern of exacerbating tidal volume loss through the fistula, we did not use positive pressure ventilation. Similarly, independent lung ventilation was not an option as demonstrated by temporary occlusion of the RMS with a bronchial blocking balloon. Finally, the patient was clinically unsuitable to tolerate thoracoscopy after a tenuous operative course to place her 3 chest tubes. We, therefore, elected to seal the fistula with a covered SEM stent. Because of limitations in stent size in our institution and other local centers, we made the decision to attempt length modification rather than abandon the attempt to close the air leak and stabilize the patient. We were afraid that without this maneuver, the additional length of the stent would have blocked the lower trachea and the left main bronchus. A silicone “Y” stent was not considered, as it was not safe to perform a rigid bronchoscopy.
To our knowledge, the length modification of an SEM stent has not been performed previously. We describe a strategy for the predeployment length modification of covered SEM airway stents. This method allows for the emergent management of a rapidly deteriorating patient when essential stent sizes are unavailable. Although long segments of stenosis can be managed with nesting of short stents, a stent that is too long usually offers no benefit. Inappropriately long stents will occlude the distal airways or will project into the trachea. Stents with significant projection into the trachea can partially occlude or severely compromise the tracheal lumen or contralateral mainstem bronchus. Furthermore, the stent may cause mucosal injury to the tracheal wall, particularly with cough. With the above method of modification, an Aero stent can be shortened by 5-mm increments to the appropriate length.
In our patient, this stent modification technique allowed the desired portion of the stent to remain in the constrained position and subsequently be safely deployed. The stent remained stable after deployment with continued occlusion of the RUL fistula. There was no recurrence of right-sided fistula leakage over the remainder of the patient's course, although the patient expired 10 days later from a contralateral tension pneumothorax.
We believe that the best option is to always place the appropriate length stent without modification. If an emergent indication is present and the available stents are too long, this technique can be used to fit the stent to the patient. It would be our recommendation that as soon as feasible, the stent be replaced with the correct size.
Length modification of the Aero stent before deployment is possible. The modification of this SEM stent can be considered when a proper length stent is not available in an urgent or emergent situation. Further evaluation is required to determine the long-term safety and stability of such an approach.
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