Michael J. Wallace.

Chusilp Charnsangavej, MD Kenji

#{149} Ogawa, MD #{149}
C. Humberto Carrasco, MD
#{149}
Kenneth C. Wright, PhD Robert
#{149} McKenna, MD #{149}
Marion McMurtrey, MD
#{149}
Cesare Gianturco, MD

Tracheobronchial Tree:
Expandable Metallic Stents Used in
Experimental and Clinical Applications’
Work in Progress

An expandable stainless steel stent N ECESSITY to maintain the integri- the stents
length, 2.5
was
cm.
2 cm
Stents
and 4 cm and
were used
their
individ-
was formulated for use in the treat- ty of the airway in patients
ually, or two stents were connected by a
ment of tracheobronchial stenosis, with tracheobronchial stenosis, tra-
wire strut and inserted together. With
tracheomalacia, and airway collapse cheomalacia, and airway collapse fol-
centripetal pressure, the stent was placed
following tracheal reconstruction. lowing tracheal reconstruction has
first in a cartridge made of i2-F Teflon
The stents were placed through an stimulated the search for an adequate tubing. The cartridge was connected to a
endotracheal tube into the trachea stent (1-10). The expandable stainless Teflon delivery catheter of the same di-
and bronchi of 11 healthy dogs. The steel stent for intravascular use de- ameter, and the stent was pushed
stents expanded over time, substan- vised by Gianturco and reported by through the catheter into the tracheo-
tially increasing the diameter of the Wright et al. seemed appropriate for bronchial tree using a flexible cable.
lumen. Slight migration occasional- further investigation in the tracheo-
ly occurred, while an inflammatory bronchial tree (11). We report our ex-
Experimental Studies
reaction was noted in each animal. perimental studies with placement of
The stents were successfully used in stents in the trachea and bronchi of An endotracheal tube was placed in the
proximal trachea of eight mongrel dogs
the treatment of two cancer patients dogs and the initial clinical applica-
(weight, 15-25 kg) under general anes-
to dilate a postoperative bronchial tion in two patients.
thesia. With fluoroscopic guidance, a 12-F
stenosis that caused pneumonia and
Teflon catheter was passed through the
to support a tracheal graft that col- MATERIALS AND METHODS endotracheal tube into the trachea or
lapsed with respiration. Because of bronchi. The tip of the catheter was locat-
Expandable Stent
the stent migration in experimental ed at the site at which the stent was to be
studies, designs are being tested to The stents were constructed of 0.018- deposited. When the stent arrived at the
develop stents with greater stabil- inch stainless steel wire formed in cylin- tip of the catheter, the “pusher” catheter
ity. These stents may be effective in drical zig-zag configuration of five to ten was held in place while the outer catheter
overcoming stenosis caused by scar- bends (Fig. 1). The relaxed diameter of was withdrawn, exposing the stent. As

ring, extrinsic compression, and col-

lapse of reconstructed tracheobron-
chial structures.

Index terms: Bronchi, stenosis, 671.741 Tra-

#{149}
chea, diseases Trachea,
#{149} intubation, 671.456.
Trachea, stenosis

Radiology 1986; 158:309-312

‘From the Departments of Diagnostic Radi-

ology (C.C., K.O., C.H.C., K.C.W., C.G.) and
Surgery (R.M., MM.) and the John S. Dunn
Summer Student Grant Program (M.J.W.), Uni-
versity of Texas, M.D. Anderson Hospital and
Tumor Institute, Houston. Received July 23,
1985; accepted and revision requested Septem-
ber 4; revision received September 23. This
work was supported in part by the John S.
a. b.
Dunn Research Foundation and the George A.
Cook Memorial Fund. Figure 1. Expandable stainless steel stent. (a) Stent in a 12-F Teflon cartridge. (b) Fully ex-
C RSNA, 1986 panded stent after release from the cartridge.

309
long as the stent remained partially with- Only slight changes in peristalsis tis) was noted at the sites of stent
in the outer catheter, its position could be were noted in the esophagus in one placement in each animal of the first
altered. However, once released, only animal. group. Despite the use of procaine
slight adjustment could be accomplished.
Moderate coughing without he- penicillin in the second group, the
The animals were monitored every 2
moptysis was experienced by all 11 mucosal inflammation was the same.
weeks by radiographic examination for
animals, but they were otherwise The stents that had remained in place
changes in size and position of the stents
and by clinical assessment for cough, he- normal and active. for 4-6 weeks were partially covered
moptysis, respiratory compromise, and by mucosal proliferation.
difficulty in swallowing or eating. After Multiple sections were taken
Pathologic Examination
4-10 weeks of observation, the dogs were alongside and beneath the arms of
killed, and the trachea, bronchi, and During autopsy, the tracheobron- the stent. Microscopically, some of
esophagus were examined grossly and chial tree was removed and opened the sections were covered by pseu-
histologically.
on its posterior aspect. Mucosal in- dostratified, ciliated, columnar epi-
After the first group of eight animals
flammation (tracheitis and bronchi- thelium, characteristic of the respira-
was studied, stents were placed in the tra-
cheobronchial tree of a second group of
three dogs with the addition of intramus-
cular antibiotics (penicillin C procaine,
150,000 units/day for 4 days before and
300,000 units every other day for 3 weeks
after the stent placement). These dogs
were followed for 5-8 weeks, killed, and
evaluated in a similar manner.

RESULTS

Radiographic Examination
In the first group of dogs, multiple
stents were placed in the trachea and
bronchi in all eight, in the bronchus
in six, lower trachea in six, midtra-
chea in four, and upper trachea in 2.
The stent placed in the bronchus did
not migrate in five of the six animals,
while in the remaining dog, the stent
moved 9.5 cm up into the trachea
during the last 4 weeks of the 8-week
follow-up after an episode of cough-
ing. The stents in the lower trachea
migrated in five of the six animals,
ranging from 2.0 cm up to 4.3 cm
a.b. C.
down the trachea and frequently
Figure 2. Endotracheal stent in a dog. (a) Two stents joined by a wire strut immediately af-
straddling the bifurcation. The stents
ter placement in the trachea. (b) Stent, 1 week later. (c) Note progressive expansion of stent 1
positioned in the midtrachea moved
month later.
in all four dogs, from 0.7 cm up to 3.0
cm down the trachea. In the two dogs
in which the stent was deposited in
the upper trachea, the downward mi-
gration was 1.5 cm and 2.7 cm.
The tracheobronchial tree expand-
ed at each site where the stent was
placed. The bronchus dilated 0.7-1.3
cm, while the trachea enlarged
0.6-1.9 cm (Figs. 2, 3).
The esophagus, as studied during
barium examination, exhibited
slowed or impaired penistalsis and
appeared more flaccid in three of the
eight animals. The overexpanded
segments of the trachea at the stent
sites impinged on the esophagus, cre-
ating areas of relative narrowing
with dilatation above.
In the second group, which re-
ceived antibiotics, stent migration oc-
curred in two of the three dogs, mov-
ing upward 1.5 cm and 3.5 cm. The a. b.
trachea expanded 0.7-1.4 cm, while Figure 3. Combined endotracheal and endobronchial stent in a dog, immedi-
the bronchus dilated 0.5-0.7 cm. ately after placement (a) and 1 month later (b).

310 Radiology
#{149} February 1986
filled with necrotic debris was noted, poorly differentiated carcinoma of the The stainless steel stent can be
presumably caused by a strut of the distal trachea with mediastinal extension. fashioned as to expansile properties,
stent. Treatment was instituted by surgical de- length, and diameter to suit the spe-
bulking in an attempt to alleviate the pa- cific requirements. In our animal ex-
Comment tient’s complaints. The distal trachea was
peniments, overdistention was done
partially resected just above the origin of
The experimental data showed that purposefully to demonstrate the pro-
the right main-stem bronchus. Recon-
it was possible to place stents in the struction was accomplished with a myo- gressive expansion caused by the
tracheobronchial tree of dogs. At the cutaneous flap. Postoperatively, the tra- stents. This progressive expansion
site of the stents, the trachea and chea collapsed at the graft site with each should be effective in overcoming
bronchi had been gradually dilated inspiration, necessitating the assistance of stenotic areas caused by scar forma-
to a diameter approximately one- a positive pressure respirator. The superi- tion, extrinsic compression of the tra-
or vena caval syndrome persisted in the chea and bronchi, and collapse of the
third greater than before stenting. In
areas drained by the superior vena cava. reconstructed tracheobronchial struc-
the dogs, we were not able to avoid a
With the patient under general anes-
localized inflammatory reaction us- tunes.
thesia and with fluoroscopic guidance, a
ing procaine penicillin. The displace- While tracheitis occurred at the
12-F Teflon catheter was placed through
ment of the stents indicated the need stent site in all dogs, infection did
the tra.cheostomy tube with the tip rest-
for better fixation. ing just above the tracheal bifurcation not complicate the stent site in our
It was also obvious that the clinical and the reconstructed site. A single stent, two patients. These patients were re-
use of these intratracheal and intra- 4 cm by 2.5 cm, was deposited at the site ceiving similar antibiotic coverage as
bronchial devices was justified to of the graft. The stent furnished support part of their overall treatment. In ad-
to this area, immediately relieved the pa- dition, there were no symptoms or
maintain or reestablish an adequate
tient of respiratory distress, and obviated signs of tracheal irritation in the two
airway. This was the case in the fol-
the need for the respirator. In addition to patients. Although minimal stent mi-
lowing two clinical reports. the tracheal stent, stents were placed in
gration occurred in the patients, it
the superior vena cava. In the following
did not cause any clinical problems.
days, the swelling secondary to venous
CLINICAL EXPERIENCE Because the stents migrated in the
compression disappeared. After these en-
Case 1.-A 75-year-old man with squa- couraging results, the patient underwent dogs, we are testing stent designs
mous cell carcinoma of the upper lobe of chemotherapy but succumbed to toxicity that should result in greaten stability
the right lung was treated by a sleeve re- 3 weeks later. of these devices. U
section. The anastomosis of the right At postmortem examination, there was
main-stem bronchus and the bronchus in- no evidence of tracheitis. The tracheal Acknowledgments: The authors wish to ac-
knowledge the assistance and guidance of Ra-
termedius was complicated by a stenosis, stent remained in situ, and the superior
quel Collins and Irene Szwarc.
0.5 cm in diameter, and chronic pneu- vena cava was patent.
monitis beyond the obstruction (Fig. 4). Send correspondence and reprint requests to:
Bouginage and balloon dilatation were DISCUSSION Chusilp Charnsangavej, M.D., Department of
performed with no significant improve. Diagnostic Radiology, University of Texas, M.
ment (12).
Tracheal stenosis has resulted from D. Anderson Hospital and Tumor Institute,
With the patient under general anes- vehicular accidents, prolonged tra- 6723 Bertner Avenue, Houston, TX 77030.
thesia, a bronchoscope was placed with cheal intubation, extensive burns,
the tip positioned above the tracheal bi- and tumor resection. Extrinsic com- References
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about the stent with mucosal overgrowth.
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The patient died of cerebral metastases struction of the canine trachea with urinary
pandable metallic stent may provide
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312. Radiology February 1986