stents interventionel bronchoscopy airway stenting interventionel bronchoscopy airway stenting fjf...
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StentsStents
Interventionel Bronchoscopy
Airway stenting
Interventionel Bronchoscopy
Airway stenting
FJF HerthFJF Herth
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StentsStents Rigid bronchoscopyRigid bronchoscopy
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• adequate space• optimal view• secured ventilation• best possible manipulation
• limited space• limited view• limited manipulation• restricted ventilation
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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
HistoryHistory
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StentsStents IndicationsIndications
• Tumor stenosis by
• exophytic tissue
• compression
• fistula
• Benign stenosis
• Malacia
• scar stenosis
• complex stenosis
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Indication malignant327
• Tu-compression 110/34%
• Tu-infiltration 118/36%
• Tu-fistula 99/30%
Herth et al., WCB, 2002
StentsStents Strategical ConsiderationsStrategical Considerations
• urgency of treatment
• prognosis of disease
• quality of life
• endoscopical alternatives
• risk of treatment
• cost - effectiveness
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short time effect long time effect
mechanical procedures
Laser, APC
Stent
HDR, PDT
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• desobliteration• dilatation (diameter should be large
size, beware of stent dislocation)
• safe respiration / ventilation • safe placement and fixation• safe handling of complications
basicsbasics
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before intervention
StentsStents Coring outCoring out
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StentsStents Argon-Plasma-CoagulationArgon-Plasma-Coagulation
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After laser
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No worry ! stent placement is quiet simple…
These are doing always the beginners
StentsStents Stent typesStent types
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Metall Stents
• Ultraflex
• Wall Stent
Polymer Stents
• Dumon Stent
• Polyflex Stent
Hybrid Stents
• Dynamic Stent
Stent typesStent types
StentsStents Silicone StentSilicone 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
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Silicone stents
• Y- Stent (Freitag-Stent)• Dumon-Stent
• fixed diameter• problems with transport
of secretion• easy replacement
Silicone StentSilicone Stent
StentsStents Dumon Stent – PlacementDumon Stent – Placement
StentsStents Dumon Stent – PlacementDumon Stent – Placement
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StentsStents Dynamic StentDynamic Stent
• Introduced by Freitag
• Y- shaped silicone stent with U-shaped metal reinforcements
• Flexible posterior membrane
• Rigid bronchoscopy
• Practice needed
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• Available in different diameters
• Cut lengths as needed
• Good imitation of tracheal anatomy
• Excellent cover of carinal abnormalities
• Minimal migration risk
Dynamic StentDynamic Stent
StentsStents Dynamic StentDynamic Stent
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metallic meshwork stents
• Wall-stent• Nitinol-stent
• dynamical diameter• easy application• overgrowing by granulation
tissue
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StentsStents Alveolus-StentAlveolus-Stent
• Nitinolstent
• self expanding
• complete coating
• hydrophile surface
StentsStents AlveolusAlveolus
StentsStents AlveolusAlveolus
StentsStents AlveolusAlveolus
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After stent placement
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Pre Intervention Post Intervention
StentsStents Metal Stents SummaryMetal Stents SummaryPro
• 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
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experience in rigid bronchoscopy
10 stents under supervision
10 Stents / year
experienceexperience
ERS/ATS Statement, Eur Respir J, 2002
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uncovered stent by exophytic tumor
bridging ventilated lung area
contra indicationscontra indications
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• retreat of the bronchosope
• Laser measurement
• CT
Stents should be longer than
the stenosis (~ 5mm at both ends)
LengthLength
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Experience
Maximum
Cave: Dislocation
DiameterDiameter
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StentsStents complicationscomplications
• dislocation
• mucostasis
• granulation tissue
• fracture
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complication malignant
• granuloma 3%
• dislocation 18%
• rec. Infection 8%
• others 3%
Cavaliere et al., Chest, 1996
StentsStents Ultraflex®-StentUltraflex®-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
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Dislocation
• Silicone 3-13 %• metalic stents 0-17 %
rareoften in benigne stenosismost in follow-up
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StentsStents DislocationDislocation
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Mucostasis/(Infection)
• Silicone 6-50 %• metalic stents 18-39 %
pneumonia not publishedpurulent bronchitisstinking respiration
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Granulation tissue• Silicone 0-6 %• metalic stents 5-30 %
Major granulations
= removal necessary
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fractures
• Silicone 0 %• metalic stents 0-6 %
raremost without any consequences
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Fx 3 +4
fistulafistula
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• 44 (97 %) sealed
• 26 (58 %) tracheal stent
• 14 (33 %) esophageal stent
• 4 (9 %) double stenting
• 5 (11 %) additional stent
• survival 14 - 476 days
N=45Herth et al., ERS 2001
fistulafistula
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• 65 (58 %) tracheal stenting
• 37 (37 %) esophageal stenting
• 10 (9 %) double stenting
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Success Non Success
Survival 237 d 39 d
30 day
Mortality 5 % 33 %
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102
88
134
56
0
20
40
60
80
100
120
140
160
180
before after
sucessfulnon-sucessful
P < 0,001
QoL (EORTC QoL-C30 / LC13)
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It´s a scandal!Until now, nobodyproved the lethaleffect of a decapitation in a double blinded, randomised trial
StentsStents Evidence-basedEvidence-based
metallic: 7x prospective
Silicone: 1x prospective
Wallstent: 1x prospective
Comparison: 2x retrospective
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• survival Ultraflex
• 206 days, R 5-683
• survival Dumon Stent
108 days
1Becker et al., WCB, 20022Cavaliere et al., Chest, 1996
StentsStents recommondation HDrecommondation HD
Temporary stenting:• Dumon Stent• Polyflex Stent
Permanent stenting:• Dumon Stent• Ultraflex /Alveolus Stent (curve)
StentsStents SummarySummarySummarySummary
• 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