Percutaneous dilation tracheostomy in a patient with tracheal stent

Abstract

We reported the case of a patient with obstruction of tracheal stent, deployed previously for anaplastic thyroid carcinoma. The extension of malignant stricture above and below the stent and close to the vocal folds made unfeasible the stent recanalization and/or its replacement with another longer. Thus, tracheostomy was the only option to assure ventilation. After partial air-way recanalization with rigid bronchoscope, tracheostomy cannula was inserted through the stenosis using percutaneous dilatation tracheostomy technique.

Obstruction of airway stent by tumour ingrowth is a life-threatening clinical condition, needing an emergent treatment [1, 2].

INTRODUCTION

Obstruction of airway stent by tumour ingrowth is a life-threatening clinical condition, needing an emergent treatment [1, 2]. We reported percutaneous dilatation tracheostomy (PDT) with Ciaglia Blue Rhino technique for palliation of respiratory distress in a patient with self-expandable metallic stent, which was deployed previously for malignant tracheal stenosis due to anaplastic thyroid carcinoma.

CLINICAL CASE

Last November 2020, a 63-year-old male, smoker and receiving anticoagulant therapy for cardiac disease, was referred to our attention for the management of severe respiratory distress. Five months before, he underwent insertion of self-expandable metallic stent (length: 60 mm; size: 18 mm) in the upper trachea for management of malignant stricture due to anaplastic thyroid cancer. Then, he underwent resection of tumour through a cervicotomy, but only a debulking was performed due to local extension of disease. The postoperative clinical course was unremarkable. Patient then received radiotherapy (45 Gy dose) followed by chemotherapy (docetaxel 75 mg/m² and cisplatin 75 mg/m² every 4 weeks for 6 courses). At the time of the present admission, chest computed tomography scan (Fig. 1A) showed that tumour grew above and below the stent and severely compromised airway. Patient underwent an emergent rigid bronchoscopy to restore airway patency (Video 1). Endoscopic view confirmed the presence of malignant stricture above the proximal end of the stent and close to the vocal folds (Fig. 1B). Mechanical dilatation by bronchoscope and resection of tumour with laser allowed obtaining a partial recanalization of subglottic space. Then, bronchoscope was gently moved through the stent forward to the tracheal bifurcation. The distal end of the stent was obstructed by tumour ingrowth (Fig. 1C), which firmly attached the stent to tracheal wall, making unfeasible to withdraw the stent and to replace it with another longer. Thus, a partial recanalization was carried by forceps. The stenosis extended below and above the ends of the stent and close to the vocal folds, and there was no room to add additional stents for covering all the stenosis. Then, the bronchoscope was positioned just below the vocal folds and displaced anteriorly the trachea. A guide wire was introduced between the cricoid cartilage and the first tracheal ring and inserted into the stent; the dilator was then advanced over the guide wire to create the stoma (Fig. 2A). An 8.50-mm extra-long armoured tracheostomy cannula was inserted into the trachea and then gently moved forward to the tracheal bifurcation through the stent (Fig. 2B). Following, a video bronchoscope passed through the tracheostomy tube and ensured that the cannula was laid over the stent in normal airway. A complete resolution of respiratory distress was obtained, and endoscopy and radiology examinations showed the proper position of tracheostomy tube (Fig. 2C). Patient was discharged 2 days later. At 2 months after the procedure, tracheostomy was well tolerated and patient started a targeted therapy.

Figure 1:

Chest computed tomography scan (A) and endoscopy (B and C) showed the malignant stricture above and below the ends of the stent.

Figure 2:

Introduction of dilatator (A) and of tracheostomy cannula (B); cannula through the stent (C).

DISCUSSION

The management of the present case was particularly challenging because of previous treatments, as stent recanalization or its removal and replacement with another longer stent [3] was unfeasible due to the compromised airway. In addition, more invasive options such as stent removal and replacement under Extracorporeal Membrane Oxygenation (ECMO) or tracheal resection were considered inadequate in this case where a palliative solution was more suitable [4]. Because of the high risk of bleeding from the anticoagulant therapy and the previous cervical incision, the decision was made to perform PDT rather than open tracheostomy. Only another similar case has been reported in literature before. In the Madden’s report [5], the stent was placed in the middle trachea for tracheomalacia, while in our case it was deployed in more proximal position, rendering tracheostomy deployment much more difficult for the concomitant presence of malignant subglottic stenosis.

The use of rigid bronchoscope was crucial for the success of the procedure. It restored airway patency above and below the stent, facilitating the cannula insertion. During the introduction of dilatator and of cannula, the bronchoscope lifted the anterior wall of the trachea and prevented its collapse. Furthermore, the aspiration of large amount of blood maintained the airway free, assuring an optimal view and ventilation at all times. Technically, before performing PDT, the rigid bronchoscope should be positioned just below the vocal folds to prevent it from accidently damaging the stent or becoming an obstacle for the insertion of cannula.

In conclusion, our technique is an additional tool for physicians to offer an immediate palliation of respiratory distress in case of airway stent obstruction by tumour ingrowth.

REVIEWER INFORMATION

Interactive CardioVascular and Thoracic Surgery thanks Philipp Jungebluth and the other, anonymous reviewer(s) for their contribution to the peer review process of this article.