Airway Obstruction Type - Procedure

1. TrachealstenosisBronchoscopicalStentingF. StanzelAsklepios Clinics Munich-GautingGermany(Director: Prof. Dr. K. Haeussinger)

2. Airway ObstructionType - Procedure TypResectionAfterloading Stent(Laser,...) +++ Ø Ø ++ ++ + Ø + +++ Ø Ø +++ intraluminal mixed extraluminal Malacia

3. Stents - Indications • Airway obstruction by • extrabronchial compression • submucosal tumour growth • endoluminal growth after resection with relevant stenosis or repetitiv obstruction • scar stenosis, complex stenosis • Loss of stability • benign (malacia) or malignant • Sealing of fistula

4. Decision-makingBronchoscopy vs Surgery

5. Lung cancer Facts • 20 up to 30 % of lung cancer patients develop • complications (atelectasis, pneumonia) • symptoms (dyspnea, hemoptysis) • in endotracheal/-bronchial involvement • up to 40 % of deaths for loco-regional central involvement • treatment of central airway obstruction decisive in palliation

6. Stents – Different Types

7. Stent features adapt. Freitag 2002

8. Ideal airway stentMost important • inner diameter/wall thickness optimal • expansion force ↑, stable + dynamic, flexible • no migration + removable, manipulable • confectionable (or many sizes) • without secretion problems • without granulation tissue • fluoroscopically/radiologically visible • inexpensive

9. Airway StentWhich one to choose? • Dumon Stent • Dynamic Stent • others as Polyflex,… • Ultraflex • Alveolus AERO

11. Dumon Stent • „Dedicated“ airway stent • Straight silicone tube • Studds on surface • to reduce tissue compression • to prevent migration • Great experience • in Europe mostly used • since 1990 • Different length/diameters and Y-Stent available • Radiopaque vs. not visible • Special constructions, manipuliable

12. Stents – InsertionDumon-Stent

13. A B C nach M Noppen

14. Dumon-Stent - Insertion

15. StentsMark of stenosis edges

16. Benign Stenosis with Membrane

17. Malacia – Dumon Stent

18. Y-Stent (Bifurcation stent)

19. Dumon silicone stent : the gold standard Proven efficacy in the majority of tracheal, carinal and major bronchial stenoses. - easy to insert and remove - closed surface - relatively non-migratory, non-irritating, non-interfering with clearence, inexpensive - but straight tube, poor thickness/lumen ratio adapted from Noppen

20. Alternatives • reserve for special situations • “Vergnon“ Silicone Stent • short, benign stenosis • “Noppen“ Tygon Stent • moderate extrinsic compression

21. Alternativen • Reserve für spezielle Situationen • „Vergnon“ Silicone Stent • short, benign stenosis • „Noppen“ Tygon Stent • moderate extrinsic compression • Polyflex Stent (Polyester wires in Silicon cover) • variable diameters

23. Dynamic Y Stent (Freitag)

24. Dynamic Y Stent (Freitag) • Y stent, bifurcation stent • long tracheal branch • similiar to cross section of trachea • horseshoe-like metal buckles • high compression stability • membrane imitation improves mobilization of secretions • 3 sizes

25. StentinsertionTechniques

26. Tracheal Stenosis – Y-Stent

27. Tracheal Stenosis – Y-Stent

29. Metal Stents (Ultraflex, Wallstent) • thin wall, smooth • high adaptability • with (or without) covering • placement by catheter • simple placement • bad radiological visibility • difficult to remove • expensive

30. Covered Ultraflex

31. „Sealing of Fistula“ • curved airway, without stenosis!

32. Alveolus AERO™ Hybrid Pulmonary Stent • World’s first removable metal tracheobronchial stent • Fully covered, inside-out • Minimizes tumor in-growth and granulation tissue buildup. • Hydrophilic coating minimizes mucus adherence • Advance Removability Feature (suture) • Hybrid Stent • Has characteristics of both metallic and silicone stents

33. AERO DV™ OTE Pulmonary Delivery Device • Ergonomic single handed device for easy and precise stent delivery over target site. • Allows for direct visualization of proximal and distal ends of stenosis • Removes necessity for fluoroscopy

34. AERO DV™ OTE Pulmonary Delivery Device

35. New Metal StentAlveolus

36. Airway StentsResults • most experience in malignant disease • palliative • in selected patients high benefit • not as the last therapy-option • hardly to compare (pat.selection, stents) • less experience in benign disease • longer survival • more complicated • in combination with other methods • laser resection • dilatation • removable stents, mostly covered or not metal • especially malacia

37. malignant central airway obstruction no yes life threatening ? flexible bronchoscopy(+ TNM +CPR) rigid bronchoscopy no operable ? symptomatic or< 50% airway Ø ? yes yes no therapeutic endoscopy radiotherapy / chemotherapy surgery endobronchial recurrence adapted from Noppen

38. adapted from Marquette

39. AirwaystentsComplications I • Migration • depending on stent type • depending on stenosis type • depending on localization • Secretion retention, Mucostasis • mostly more a problem of the first days • repeated bronchoscopical cleaning up • consequent inhalations

40. Airway StentsComplications II • Stent obstruction • tumor growth/granulation tissue • interventional therapy • CAVE fire (flammable materials) • only cryotherapy and mechanical removal • Embedding/Perforation • Dumon-Stents; removal, longer stent • Stent defects • stent fractures in Ultraflex (Trachea) • membrane fissures in Freitag-Stents

41. Metal Stent - Complication

42. New stent – new complications

45. An indication for stent removal is often observed (25.6% in this series)!

46. What's up with stenting? • Significant improvement • dyspnea, other symptoms and QoL • Significant longer survival in selected patients • Significant lung function improvement • Significant impact on therapeutical options

47. Message • Ever consider surgery, first of all if benign! • Dumon stents are standard for ¾ of patients! • still gold standard • mostly best compromise • Other stents • special situations • 2nd choice! • Stenting with metal stents is easier, but • much more complicated over the long run • much more expensive • Alveolus AERO has a high migration rate! • Stenting is in flux, get the improvements

48. The ideal stent is still not available! Thank you!