stents interventionel bronchoscopy airway stenting interventionel bronchoscopy airway stenting fjf...

StentsStents

Interventionel Bronchoscopy

Airway stenting

Interventionel Bronchoscopy

Airway stenting

FJF HerthFJF Herth

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StentsStents Rigid bronchoscopyRigid bronchoscopy

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• adequate space• optimal view• secured ventilation• best possible manipulation

• limited space• limited view• limited manipulation• restricted ventilation

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first description dentist C.R. Stent

1907: Killian metalicprothesis

1915: Brüning gum prothesis

1933: Canfield silver prothesis

1965: Montgomery Stent

1965: Anderson Silicone stent (surgical)

1978: Totj Nd:YAG Laser

1990: Dumon-Stent

1992: Nitinol-Stent

1992: Dynamic Stent

HistoryHistory

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StentsStents IndicationsIndications

• Tumor stenosis by

• exophytic tissue

• compression

• fistula

• Benign stenosis

• Malacia

• scar stenosis

• complex stenosis

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Indication malignant327

• Tu-compression 110/34%

• Tu-infiltration 118/36%

• Tu-fistula 99/30%

Herth et al., WCB, 2002

StentsStents Strategical ConsiderationsStrategical Considerations

• urgency of treatment

• prognosis of disease

• quality of life

• endoscopical alternatives

• risk of treatment

• cost - effectiveness

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short time effect long time effect

mechanical procedures

Laser, APC

Stent

HDR, PDT

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• desobliteration• dilatation (diameter should be large

size, beware of stent dislocation)

• safe respiration / ventilation • safe placement and fixation• safe handling of complications

basicsbasics

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before intervention

StentsStents Coring outCoring out

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StentsStents Argon-Plasma-CoagulationArgon-Plasma-Coagulation

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After laser

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No worry ! stent placement is quiet simple…

These are doing always the beginners

StentsStents Stent typesStent types

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Metall Stents

• Ultraflex

• Wall Stent

Polymer Stents

• Dumon Stent

• Polyflex Stent

Hybrid Stents

• Dynamic Stent

Stent typesStent types

StentsStents Silicone StentSilicone Stent

• Introduced in 1989 as a continued development from T- tube (Dumon stent)

• Silicone material with studded surface

• Need for rigid bronchoscopy

• Affordable

• Removable

• Other brands with slightly different designs available

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Silicone stents

• Y- Stent (Freitag-Stent)• Dumon-Stent

• fixed diameter• problems with transport

of secretion• easy replacement

Silicone StentSilicone Stent

StentsStents Dumon Stent – PlacementDumon Stent – Placement

StentsStents Dumon Stent – PlacementDumon Stent – Placement

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StentsStents Dynamic StentDynamic Stent

• Introduced by Freitag

• Y- shaped silicone stent with U-shaped metal reinforcements

• Flexible posterior membrane

• Rigid bronchoscopy

• Practice needed

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• Available in different diameters

• Cut lengths as needed

• Good imitation of tracheal anatomy

• Excellent cover of carinal abnormalities

• Minimal migration risk

Dynamic StentDynamic Stent

StentsStents Dynamic StentDynamic Stent

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metallic meshwork stents

• Wall-stent• Nitinol-stent

• dynamical diameter• easy application• overgrowing by granulation

tissue

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StentsStents Alveolus-StentAlveolus-Stent

• Nitinolstent

• self expanding

• complete coating

• hydrophile surface

StentsStents AlveolusAlveolus

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StentsStents AlveolusAlveolus

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After stent placement

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Pre Intervention Post Intervention

StentsStents Metal Stents SummaryMetal Stents SummaryPro

• Easily placed, effective

• Adapting well to airway dynamics

• Good inner/ outer diameter ratio

Con

• Granulation/ Breakage

• Removal problematic

• Stent shortening with placement

• Anatomical adaptation not yet optimal

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experience in rigid bronchoscopy

10 stents under supervision

10 Stents / year

experienceexperience

ERS/ATS Statement, Eur Respir J, 2002

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uncovered stent by exophytic tumor

bridging ventilated lung area

contra indicationscontra indications

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• retreat of the bronchosope

• Laser measurement

• CT

Stents should be longer than

the stenosis (~ 5mm at both ends)

LengthLength

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Experience

Maximum

Cave: Dislocation

DiameterDiameter

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StentsStents complicationscomplications

• dislocation

• mucostasis

• granulation tissue

• fracture

StentsStents Dumon-StentDumon-Stent

complication malignant

• granuloma 3%

• dislocation 18%

• rec. Infection 8%

• others 3%

Cavaliere et al., Chest, 1996

StentsStents Ultraflex®-StentUltraflex®-Stent

complication malignant 96/327

• granuloma 31/10%

• fracture 5 / 2%

• dislocation 28/ 9%

• complication during

bronchoscopy 5 / 2%

• rec. Infection 23/ 8%

• others 3 / 2%

Herth et al., WCB, 2002

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Dislocation

• Silicone 3-13 %• metalic stents 0-17 %

rareoften in benigne stenosismost in follow-up

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StentsStents DislocationDislocation

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Mucostasis/(Infection)

• Silicone 6-50 %• metalic stents 18-39 %

pneumonia not publishedpurulent bronchitisstinking respiration

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Granulation tissue• Silicone 0-6 %• metalic stents 5-30 %

Major granulations

= removal necessary

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fractures

• Silicone 0 %• metalic stents 0-6 %

raremost without any consequences

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Fx 3 +4

fistulafistula

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• 44 (97 %) sealed

• 26 (58 %) tracheal stent

• 14 (33 %) esophageal stent

• 4 (9 %) double stenting

• 5 (11 %) additional stent

• survival 14 - 476 days

N=45Herth et al., ERS 2001

fistulafistula

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• 65 (58 %) tracheal stenting

• 37 (37 %) esophageal stenting

• 10 (9 %) double stenting

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Success Non Success

Survival 237 d 39 d

30 day

Mortality 5 % 33 %

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102

88

134

56

0

20

40

60

80

100

120

140

160

180

before after

sucessfulnon-sucessful

P < 0,001

QoL (EORTC QoL-C30 / LC13)

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It´s a scandal!Until now, nobodyproved the lethaleffect of a decapitation in a double blinded, randomised trial

StentsStents Evidence-basedEvidence-based

metallic: 7x prospective

Silicone: 1x prospective

Wallstent: 1x prospective

Comparison: 2x retrospective

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• survival Ultraflex

• 206 days, R 5-683

• survival Dumon Stent

108 days

1Becker et al., WCB, 20022Cavaliere et al., Chest, 1996

StentsStents recommondation HDrecommondation HD

Temporary stenting:• Dumon Stent• Polyflex Stent

Permanent stenting:• Dumon Stent• Ultraflex /Alveolus Stent (curve)

StentsStents SummarySummarySummarySummary

• Not one stent fits all needs

• Most needs can be accommodated

• Stent choice needs to be individualized

• Airway stenting is generally safe in experienced hands (airway centers)

• Long term follow-up in large series for is rare available

• Stent design is in continuous development