Management of tracheomediastinal fistula using self-expanding metallic Stents

Department of Pulmonary, Allergy, and Critical Care Medicine, Cleveland Clinic, Cleveland, Ohio 44195, USA.
The Annals of thoracic surgery (Impact Factor: 3.65). 06/2008; 85(5):1800-2. DOI: 10.1016/j.athoracsur.2007.11.045
Source: PubMed

ABSTRACT Tracheomediastinal fistula is a rare condition usually associated with a fatal outcome. We report the case of a 65-year-old man with a subcarinal mass causing total destruction of the carina and proximal mainstem bronchi. The mass was diagnosed as a large cell lymphoma, and the decision was made to undertake chemotherapy only after stabilization of the endobronchial tree. The endobronchial defects were successfully palliated with placement of three different types of self-expanding metallic stents using a flexible bronchoscope under conscious sedation. The unique properties of each stent were used for optimum clinical benefit, avoiding any morbidity.

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    QJM: monthly journal of the Association of Physicians 08/2012; 106(10). DOI:10.1093/qjmed/hcs170 · 2.46 Impact Factor
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    ABSTRACT: AIM: To investigate the clinical effectiveness, complications, and optimal duration of use of covered retrievable expandable metallic stents in the management of cuff-related tracheal stenosis. MATERIALS AND METHODS: Twenty-one patients with cuff-related tracheal stenosis, Meyer-Cotton grade II (29%) and III (71%), who underwent fluoroscopically guided placement of covered retrievable expandable metallic stents were studied. Sixty-four-section computed tomography (CT) and bronchovideoscopy were performed prior to stent insertion, 1 month after stent insertion, in the case of stent-related complications, and after stent removal. Clinical manifestations, Hugh-Jones classification, and forced expiratory volume in 1 s (FEV1) were used to evaluate respiratory function before and after stent insertion and removal. The diameter of the stricture and FEV1 changes before insertion and after removal were analysed using the paired samples t-test. A p-value of ≤0.05 was considered statistically significant. RESULTS: Twenty-one patients had 27 covered retrievable expandable metallic stents placed. Stents were electively removed from 20 patients. The median duration of stent placement was 5 months (range 4-12 months). One stent was not removed due to mucopolysaccharidosis type II (MPS II or Hunter syndrome) with tracheomalacia. After stent removal, airway dimensions increased and airway occlusion was symptomatically relieved in all patients. CT and bronchovideoscopy showed patent lumens with increased dimensions. Stent-related complications occurred in 19 (91%) patients, including granulation tissue formation (n = 18, 86%), stent migration and stent expectoration (n = 2, 10%), mucus plugging (n = 1, 5%), and halitosis (n = 6, 29%). Some patients experienced multiple complications, which were all managed effectively while the stent was still in place. There was a statistically significant difference in the diameter of the stricture and FEV1 between the time of stent insertion and removal. An improvement in Hugh-Jones classification of greater than one grade was seen in patients after stent removal. CONCLUSION: Temporary placement of a fully covered retrievable expandable metallic stent is safe and effective in cuff-related tracheal stenosis. The optimal duration of stent placement may be 4-8 months.
    Clinical Radiology 11/2012; DOI:10.1016/j.crad.2012.08.022 · 1.66 Impact Factor
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    ABSTRACT: During mediastinoscopy in a 38-year-old woman, there was uncontrolled bleeding that required a sternal split. One month later, chest and neck CT scan demonstrated tracheomediastinal fistula. The patient underwent urgent operation. Repair of the tracheal defect was accomplished using a pedicled right sternohyoid muscle; the right sternocleidomastoid muscle was used to separate the trachea from the innominate artery and the left pectoralis major muscle was used to fill the anterior mediastinal space. The postoperative course was uneventful. One month later, another CT scan demonstrated complete resolution. Careful use of coagulation during mediastinoscopy is of paramount importance to avoid thermal injury to the trachea. This case also underlines the importance of a good knowledge of the anatomy of the skeletal muscles of the chest wall and adjacent regions.
    The Thoracic and Cardiovascular Surgeon 03/2011; 59(6):364-6. DOI:10.1055/s-0030-1250481 · 1.08 Impact Factor

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