Letter to the Editor
To the Editor:
The removal of self-expanding metallic stents (SEMS) is becoming a more common clinical challenge. Recently, Food and Drug Administration warnings have been issued to warn against the use of these prostheses unless no other options are tenable, specifically in nonmalignant diseases.1 The ease of implantation and other physical characteristics of the SEMS have, in some cases, led to its inappropriate use.2 Reported complications include stent fracture, migration, difficult repositioning, or removal after deployment owing to ingrowth with either tumor or granulation tissue.3–6 Particularly, in patients with benign diseases, long-term complications are as frequent as 25% to 50% requiring removal by 16 months.7,8 Stent-related granulation is particularly difficult to manage.9,10 The reported difficulties of stent removal or replacement present unique constellations of procedure complications, episodes of primary disease relapse, treatment failure, or even death.11
To facilitate endoscopic removal of SEMS, we adopted a new technique to help free the stent from its mucosal attachments with the following approach: first, we assess the patient for location of proposed stent removal. Fully epithelialized stents generally require multimodality techniques, including rigid bronchoscopy and thermal treatments, to clear the mucosa. In the event the stent is only partially epithelialized, a stent removal may be performed under conscious sedation. In all cases, the patients' airway is entered via the oral route. Using a flexible bronchoscope and endoscopic forceps, we meticulously attempt to pull wires free of the mucosa to create a narrow “surgical plane” along the full length of the stent such that a potential space between the airway wall and the stent can be created. Then, a controlled radial expansion balloon dilatation catheter (Boston Scientific, Boston, MA) is passed through the scope and placed between the airway mucosa and the outer surface of stent. The balloon size selected is slightly smaller than the stent diameter. The stent is then separated from the airway mucosa by controlled incremental expansion of the balloon. This procedure is repeated in different areas across the perimeter to free as much of the stent from the adherent airway mucosa as possible before attempting to pull the stent. Care needs to be taken if the stent completely collapses and causes obstruction of the involved airway, the balloon must be repositioned inside the lumen of the stent and the stent lumen restored. Third, opposing walls of the metallic stent or the silk suture, if present, is then grasped with alligator or rat-toothed forceps and a gentle continuous traction is applied to pull the stent out of the airway. The actual extraction can be performed with either flexible or rigid bronchoscopic instruments. This technique allowed for successful removal of the stent intact in most cases.
We find that this technique is safer and cleaner than the described technique of grabbing and twisting the stent free of the mucosa with rigid instruments.12 Depending on several factors, most importantly the clinical stability of the patient and the degree to which the stent is incorporated into the airway wall, the described technique may be performed with conscious sedation without an endotracheal tube in an incompletely epithelialized stent.
We hope this approach will be a useful addition to the few existing studies that have assessed the best methods of stent removal.
Reyadh Salman, MD
Michael S. Machuzak, MD
Thomas R. Gildea, MD
Department of Pulmonary Allergy, and Critical Care Medicine Cleveland Clinic, Cleveland, OH
1. Food and Drug Administration. FDA public health notification: complications from metallic tracheal stents in patients with benign airway disorders. 2005.
2. Noppen M, Van Renteerghem D, Vanderstraeten P. The wrong stent at the wrong time: a cautionary tale. Respiration. 2003;70:313–316.
3. Mehta AC, Dasgupta A. Airway stents. Clin Chest Med. 1999;20:139–151.
4. Ernst A, Feller-Kopman D, Becker HD, et al. Central airway obstruction. Am J Respir Crit Care Med. 2004;169:1278–1297.
5. Bolliger CT. Airway stents. Semin Respir Crit Care Med. 1997;18:563–570.
6. Freitag L, Eicker K, Donovan TJ, et al. Mechanical properties of airway stents. J Bronchol. 1995;2:270–278.
7. Noppen M, Stratakos G, D'Haese J, et al. Removal of covered self-expandable metallic airway stents in benign disorders: indications, technique, and outcomes. Chest. 2005;127:482–487.
8. Schmidt B, Olze H, Borges AC, et al. Endobronchial balloon dilatation and stent implantation in benign stenoses. Ann Thorac Surg. 2001;71:1630–1634.
9. Gaissert HA, Grillo HC, Wright CD, et al. Complication of benign tracheobronchial strictures be self-expanding metal stents. J Thorac Cardiovasc Surg. 2003;126:744–747.
10. Jantz MA, Silvestri GA. Silicone stents versus metal stents for management of benign tracheobronchial disease: pro; metal stents. J Bronchol. 2000;7:177–183.
11. Prasad M, Bent JP, Ward RF, et al. Endoscopically placed nitinol stents for pediatric tracheal obstruction. Int J Pediatr Otorhinolaryngol. 2002;66:155–160.
12. Lunn W, Feller-Kopman D, Wahidi M, et al. Endoscopic removal of metallic airway stents. Chest. 2005;127:2106–2112.