1. Non-anastomostic Bronchial Stenoses after Lung Transplantation: Outcome of Endobronchial Stent Placement Geltner C. 1, Stein M. 1, Tagger M. 2, Bucher B. 1, Jamnig H.1, Müller L LKH Natters, Dept. of Pulmonology, 6161 Natters, Austria 2 LKH Natters, Dept. Of Anesthesiology, 6161 Natters, Austria 3 Dept. of Cardiac Surgery, University Innsbruck, Austria
Intermediusstenosis pre and post dilatation und stent placement (Pat 3)
Stenosis of left lower lobe and bronchomalacia pre and post dilatation and stent placement (Pat 2)
Stenosis of bronchus intermedius due to bronchomalacia (Pat 10)
Left lower lobe with MRSA and aspergillosis (Pat 4)
Left lower lobe and left upper lobe stenosis (Pat 6)
Lung transplantation (LuTx) has become a successful treatment for end-stage pulmonary disease with five years survival now approaching 70%. Endobronchial complications commonly occur within the first weeks after surgery and were reported in up to 30% of cases a decade ago. They predominantly involve the anastomosis and present with dehiscence or various degrees of necrosis of the graft bronchus during the early period and later on with chronic infections at the anastomotic site and/or stenosis. Inadequate bronchial vascularization is accepted to be the main cause, however, surgical technique, immunological and infectious processes may also be involved. Despite technical improvements with regard to the suture technique including coverage of the anastomosis with well vascularized recipient derived soft tissue, coverage with fibrin glue and meticulous revascularization of the bronchial arteries, bronchial anastomotic complication remain a significant problem. Recent publications show a reduction of the rate of anastomotic complications to less than 20%. Chronic infections of the anastomotic site and in cases of anastomotic dehiscence of the mediastinum or in case of stenosis in the dependent post stenotic bronchial areas remain difficult to treat conditions and therefore, these complications need to be seriously addressed. Various treatment options have been developed including endobronchial laser therapy, radiation brachytherapy (afterloading) and endobronchial stent placement has been reported to be successful. Nevertheless, these complications have the potential to lead to graft failure or death and surgery and retransplantation remain as last resorts if the above therapies fail.
Of note, endobronchial complications also may rarely involve the recipient airways and more commonly the more distal parts of the graft. Bronchial stenoses and bronchomalacia distal to the anastomotic region may lead to central bronchial obstruction, bronchial strictures and bronchiomalacia. Whereas ample experience with stent placement or other bronchoscopic techniques to manage endobronchial stenoses involving the main stem bronchi and the anastomotic region has been collected, for distal endobronchial complications only little data is available. Most series and case reports emphasize the usefulness of endobronchial stent placement after lung transplantation. The aim of this retrospective study was to review our series of 130 consecutive LuTx from 1993 to 2006 with regard to serious endobronchial complications. The success rate of all endobronchial stents that were placed in this patient cohort was the primary endpoint. A secondary endpoint was to determine the rate, type, management and significance of infectious complications prior to stent placement and during follow up.
Demografic of patients
Stents were placed according to standard placement recommendations using rigid bronchsoscopy and general anaesthesia in most cases. The procedures were performed in our bronchoscopy suite using standard instruments (WOLF rigid bronchoscopes) and OLYMPUS or Fujinon flexible videoscopes. Rüsch Polyflex stents were deployed using the standard application catheter. Boston ultraflex stents were placed using a guide wire and in some cases a bronchoscopic or fluoroscopic imaging to guide the procedure. The stents were deployed after measurement of the central airways by flexible bronchoscope. Rüsch Tracheobronchial Stent was intruded in the central airways by using the standard forceps described by Freitag e.a. All stents were routinely controlled within one to four days after procedure. For the study all stents that stayed in place more than 24 hours were included.
In cases where removal of the stent was necessary a wide range of techniques using different types of forceps either with flexible or with rigid scopes was used. Some stents could only be removed in parts especially in cases with severe granulation tissue ingrowth into the lumen of the stent.
Results:
A total of 44 stents were placed in 13 patients after lung transplantation. 12 patients had bilateral lung transplant including two retransplant, 1 received a left single lung transplant. All patients were initially transplanted between October 1995 and April Demografic data see table 1. Within this period a total of 130 lung transplants were performed at our institution. 13/130 patients developed severe bronchoconstriction and malacia requiring interventional bronchoscopy and stent placement (10%). All patients of the study were transplantated because of end stage COPD and emphysema, one had homocygotic alpha 1 antitrypsin deficiency. No patient that was transplanted for other diagnosis required a stent or another bronchoscopic intervention. In our study the problem of chronic bronchomalacia seems to occur only in chronic bronchitis and emphysema.
Mostly self expandable metal stent (SEMS) were placed (40/44). There were two tracheobronchial bifurcation stents and two silicon stents (Rüsch Polyflex) implanted. Type and location of stents are listed in table 2. 2 of the 13 patients had concomitant anastomosis necrosis and stenosis that was treated simultaneously. Mean time from transplant to first stent implantation was 644 days (range 33 to 2371)
Mean duration of stent maintenance was 469 days with range from 1 to 1883 days. At the end of the observation the evaluation reported 13 stent failures (migration, granulation or device brokage), 24 stents were in place, 7 had to be removed surgically or were in place whilst a surgical lobectomy was performed. By the end of the study period 24 stents were in place and functioned well. 2 of these were removed electively. 16 were in place and the patients died due to other reasons that were not stent related (this occure xx days after stent implantation) and the procedure were not causal. 1 device was explanted with the lung during pulmonary retransplant procedure, 1 was causal involved in the death of the patient due to letal haemoptysis and the others were still in place in well doing patients.
Table: Characteristic of patients and stents
Conclusion:
Endobronchial stent placement is an effective treatment for bronchial stenoses that are not related to the bronchial anastomoses. Complications occurred in about 40% of all stents.