1. Interventionel Bronchoscopy
Airway stenting
FJF Herth

3. Rigid bronchoscopy

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

5. 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

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

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

12. 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

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

14. 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

15. before intervention

16. Coring out

18. Argon-Plasma-Coagulation

19. After laser

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

21. Stent types

22. 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

23. 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

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

25. Dumon Stent – Placement

26. Dumon Stent – Placement

28. 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

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

30. Dynamic Stent

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

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

35. Alveolus

36. Alveolus

37. Alveolus

38. After stent placement

39. Pre Intervention
Post Intervention

40. 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

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

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

45. 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)

46. Diameter
Experience
Maximum
Cave: Dislocation

48. 4/23/2017

50. complications
dislocation
mucostasis
granulation tissue
fracture

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

52. complication malignant 96/327 granuloma 31/10% fracture 5 / 2%
Ultraflex®-Stent
complication malignant 96/327
granuloma 31/10%
fracture / 2%
dislocation 28/ 9%
complication during
bronchoscopy 5 / 2%
rec. Infection 23/ 8%
others / 2%
Herth et al., WCB, 2002

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

57. 4/23/2017
Dislocation

58. Mucostasis/(Infection)
Silicone %
metalic stents %
pneumonia not published
purulent bronchitis
stinking respiration

59. Granulation tissue
Silicone %
metalic stents 5-30 %
Major granulations
= removal necessary

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

63. fistula
Fx 3 +4

64. 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 days
N=45
Herth et al., ERS 2001

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

66. Success Non Success
Survival d d
30 day
Mortality % %

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

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

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

70. 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

71. 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

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

73. 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