Interventionel Bronchoscopy Airway stenting FJF Herth

Rigid bronchoscopy

limited space limited view limited manipulation restricted ventilation adequate space optimal view secured ventilation best possible manipulation

first description dentist C.R. Stent 1907: Killian metalicprothesis History 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

Tumor stenosis by exophytic tissue compression fistula Benign stenosis Indications Tumor stenosis by exophytic tissue compression fistula Benign stenosis Malacia scar stenosis complex stenosis

Indication malignant 327 Tu-compression 110/ 34% Tu-infiltration 118/36% Tu-fistula 99/ 30% Herth et al., WCB, 2002

endoscopical alternatives risk of treatment cost - effectiveness Strategical Considerations urgency of treatment prognosis of disease quality of life endoscopical alternatives risk of treatment cost - effectiveness

mechanical procedures Laser, APC Stent HDR, PDT short time effect long time effect

dilatation (diameter should be large basics desobliteration dilatation (diameter should be large size, beware of stent dislocation) safe respiration / ventilation safe placement and fixation safe handling of complications

before intervention

Coring out

Argon-Plasma-Coagulation

After laser

No worry ! stent placement is quiet simple… These are doing always the beginners

Stent types

Metall Stents Ultraflex Wall Stent Polymer Stents Dumon Stent Stent types Metall Stents Ultraflex Wall Stent Polymer Stents Dumon Stent Polyflex Stent Hybrid Stents Dynamic Stent

Silicone material with studded surface Need for rigid bronchoscopy 4/23/2017 Silicone 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 1989 marseille – current gold standard

Silicone stents Y- Stent (Freitag-Stent) Dumon-Stent fixed diameter problems with transport of secretion easy replacement

Dumon Stent – Placement

Dumon Stent – Placement

Y- shaped silicone stent with U-shaped metal reinforcements Dynamic Stent Introduced by Freitag Y- shaped silicone stent with U-shaped metal reinforcements Flexible posterior membrane Rigid bronchoscopy Practice needed

Dynamic Stent Available in different diameters Cut lengths as needed Good imitation of tracheal anatomy Excellent cover of carinal abnormalities Minimal migration risk

Dynamic Stent

metallic meshwork stents Wall-stent Nitinol-stent dynamical diameter easy application overgrowing by granulation tissue

Nitinolstent self expanding complete coating hydrophile surface 4/23/2017 Alveolus-Stent Nitinolstent self expanding complete coating hydrophile surface

Alveolus

Alveolus

Alveolus

After stent placement

Pre Intervention Post Intervention

Easily placed, effective Adapting well to airway dynamics 4/23/2017 Metal Stents Summary Pro 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

experience in rigid bronchoscopy 10 stents under supervision 10 Stents / year ERS/ATS Statement, Eur Respir J, 2002

uncovered stent by exophytic tumor bridging ventilated lung area contra indications uncovered stent by exophytic tumor bridging ventilated lung area

retreat of the bronchosope Laser measurement CT Length retreat of the bronchosope Laser measurement CT Stents should be longer than the stenosis (~ 5mm at both ends)

Diameter Experience Maximum Cave: Dislocation

4/23/2017

complications dislocation mucostasis granulation tissue fracture

complication malignant granuloma 3% dislocation 18% rec. Infection 8% Dumon-Stent complication malignant granuloma 3% dislocation 18% rec. Infection 8% others 3% Cavaliere et al., Chest, 1996

complication malignant 96/327 granuloma 31/10% fracture 5 / 2% Ultraflex®-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

Dislocation Silicone 3-13 % metalic stents 0-17 % rare often in benigne stenosis most in follow-up

4/23/2017 Dislocation

Mucostasis/(Infection) Silicone 6-50 % metalic stents 18-39 % pneumonia not published purulent bronchitis stinking respiration

Granulation tissue Silicone 0-6 % metalic stents 5-30 % Major granulations = removal necessary

fractures Silicone 0 % metalic stents 0-6 % rare most without any consequences

fistula Fx 3 +4

44 (97 %) sealed 26 (58 %) tracheal stent 14 (33 %) esophageal stent fistula 44 (97 %) sealed 26 (58 %) tracheal stent 14 (33 %) esophageal stent 4 (9 %) double stenting 5 (11 %) additional stent survival 14 - 476 days N=45 Herth et al., ERS 2001

65 (58 %) tracheal stenting 37 (37 %) esophageal stenting 10 (9 %) double stenting

Success Non Success Survival 237 d 39 d 30 day Mortality 5 % 33 %

P < 0,001 QoL (EORTC QoL-C30 / LC13)

It´s a scandal! Until now, nobody proved the lethal effect of a decapitation in a double blinded, randomised trial

metallic: 7x prospective Silicone: 1x prospective Evidence-based metallic: 7x prospective Silicone: 1x prospective Wallstent: 1x prospective Comparison: 2x retrospective

pre - dilatation yes, but how ? survival rates 1,5 – 10,5 Mo Evidence-based immediate effects pre - dilatation yes, but how ? survival rates 1,5 – 10,5 Mo 30 day mortality ~20 % fistula: QoL  No selection criterias described

survival Dumon Stent 108 days survival Ultraflex 206 days, R 5-683 survival Dumon Stent 108 days 1Becker et al., WCB, 2002 2Cavaliere et al., Chest, 1996

Ultraflex /Alveolus Stent (curve) recommondation HD Temporary stenting: Dumon Stent Polyflex Stent Permanent stenting: Ultraflex /Alveolus Stent (curve)

Not one stent fits all needs Most needs can be accommodated 4/23/2017 Summary 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 Very successful Needs to be in hands of full service facility Use surgery if indicated What should be done vs what can be done Deal with problems as they arise Rigid bronchoscopy is mandatory for interventionalists