Rare and fatal complication of Gianturco tracheobronchial stent

Systematic review comparing the efficacy and safety of covered and uncovered self-expanding metal stents in benign airway stenosis

BACKGROUND

Current United States Food and Drug Administration (FDA) guidelines established since 2005 recommend the usage of silicone stents over metal stents due to the risk of complications associated with the older generation of uncovered stents. Yet, with the advancement of technology, novel innovations of self-expanding metal stents (SEMS) have revolutionized the treatment of benign airway stenosis (BAS), where the insertion of SEMS is known to be easier than silicone stents.

AIM

To compare the efficacy and safety of covered SEMS against uncovered SEMS, and thereafter propose more direct trials comparing covered SEMS against silicone stents for consideration of revision of current FDA guidelines.

METHODS

A comprehensive literature review of MEDLINE and EMBASE was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Of 3002 articles, 64 publications met the eligibility criteria with a total of 900 patients (468 covered SEMS, 432 uncovered SEMS). The collected data were analyzed using Statistical Package for the Social Sciences version 11.5.

RESULTS

Covered SEMS showed a higher success rate of insertion (98.6% vs 88.2%) and lower complication rates of infection (1.3% vs 13.2%), restenosis (1.5% vs 10.6%), stent fracture (2.6% vs 7.4%), bleeding (0% vs 5.8%), and pneumothorax (0% vs 2.8%) compared to uncovered SEMS. However, covered SEMS compared to uncovered SEMS showed higher complication rates of stent migration (12.4% vs 6.9%) and granulation tissue formation (26.5% vs 20.1%).

CONCLUSION

Our study suggests that covered SEMS are an effective, safe, and viable option in the treatment of BAS. Thus, further consideration regarding the utilization of covered SEMS over other forms of stent types is appropriate.

A multidisciplinary approach for managing the infraglottic difficult airway in the setting of the Coronavirus pandemic

Management of a difficult airway caused by pathology below the glottis is high-risk and requires a shared approach to airway planning and surgical treatment. Access to the trachea requires a careful assessment of the airway since the end-point of laryngoscopy for infraglottic airway management is not visualization of the larynx for tube placement, but access to the laryngotracheal complex in cases where intubation may not be feasible or may preclude surgical access.

This work provides a common framework for creating multidisciplinary shared-airway management plans and presents devices and strategies that have in recent years improved airway management safety in this difficult patient group and may prove useful in the setting of the novel Coronavirus Disease 2019 (COVID-19).

Broncho-vascular fistulas from self-expanding metallic stents: A retrospective case review

To highlight a potentially fatal complication of broncho-vascular fistula arising from the self expanding metallic stent (SEMS) placement. We retrospectively analyzed five patients with benign and malignant airway diseases, who developed tracheo/broncho-vascular fistulas following SEMS placement in our tertiary care setting. All patients received either Wallstent or Ultraflex^® stent (Boston Scientific, Natick, MA) between 1999 and 2007. All patients had received adjunct therapy such as balloon bronchoplasty, laser therapy or electrocautery. Most patients presented with massive hemoptysis. A total of 483 SEMS were placed during this period. SEMS placement can be complicated by Broncho-vascular fistula formation. True incidence and precise time interval between the insertion of stent and onset of this complication is unknown. Additional therapeutic modalities to maintain stent patency may enhance the risk of fistula formation. SEMS should only be used in a select sub-group of patients, after exhaustive evaluation of other treatment options. These cases provide evidence that broncho-vascular fistulas can develop at any time following SEMS placement, suggesting the need for a more cautious approach, especially while using them for a long term management. In benign airway disease, the stent should be removed as soon as healing has taken place.

An instant rare complication: a fractured metallic pyloric stent

Metallic pyloric stenting (also termed as metallic enteral stenting) performed endoscopically, stands as first-line treatment for malignant gastric outlet obstruction. With reported evidence, these self-expandable metallic stents (SEMS) re-enable oral food intake, preventing patients having to face invasive techniques such as surgical gastroenterostomy. We report a patient having received a covered pyloric SEMS insertion following a tumour growth causing stenosis in the gastric antropyloric region. After 3 weeks, the patient presented with a fracture of the pyloric SEMS, a rare complication, resulting in a second pyloric SEMS insertion.

Incidence, anatomical location, and clinical significance of compressions and fractures in infrapopliteal balloon-expandable metal stents

PURPOSE

To investigate the incidence, anatomical location, and clinical impact of fractures and/or compression of infrapopliteal balloon-expandable metal stents implanted for critical limb ischemia (CLI) treatment.

METHODS

This prospective study included 63 CLI patients (45 men; mean age 71.3+/-9.5 years) who had been treated with infrapopliteal angioplasty and stent placement for 191 lesions in 84 limbs. In all, 369 stents (296 stainless steel and 73 cobalt-chromium alloy) were implanted; 239 were placed overlapping in tandem lesions. Mean length of the overall stented segment was 4.4+/-6.3 cm (range 1.6-14.0). Stents were located in the tibioperoneal (n = 34), anterior tibial (n = 195), posterior tibial (n = 63), and peroneal (n = 77) arteries. Follow-up consisted of digital subtraction angiography and infrapopliteal radiography imaging at 2 different angles. Evaluation of stents for the presence of fracture and/or compression was done after digital processing at the highest possible magnification. Stent fractures were defined according to published standards, whereas compression was classified as severe shape alteration and/or collapse of the stent mesh. Angiographic restenosis was based on a 50% threshold.

RESULTS

Mean follow-up was 15+/-11 months (range 6-60). Image analysis detected 1 (0.3%) severe stent fracture (complete separation and misalignment of stent struts) and 11 (3.0%) stent compressions. Infrapopliteal stent fracture and compressions were associated with increased artery restenosis [100% (12/12) versus 47.3% (169/357), p<0.001] and an increased rate of clinical deterioration and clinically-driven reinterventions [41.7% (5/12 limbs) versus 19.4% (14/72 limbs), p = 0.04]. The single fracture and most of the compressions were located in the distal third of the anterior tibial artery.

CONCLUSION

Stent fractures and compressions of infrapopliteal balloon-expandable metal stents are infrequent. However, they may be related to increased restenosis.