Bifurcated Silicone Stents for the Management of Anastomotic Complications in Lung Transplanted Patients: Ten Years’ Experience

Abstract

<b><i>Background:</i></b> In lung transplantation (LT), the actual surgical practice is to cut the donor bronchus as short as possible in order to reduce anastomotic complications (AC). Consequently, the anastomosis is very close to the secondary carina. If AC occur, regular straight stents may be unsatisfactory and on-site modified bifurcated stents may represent an alternative. <b><i>Objectives:</i></b> This retrospective study sought to assess the short- and long-term outcomes of patients treated with customized bifurcated stent (CBS) for the management of AC following LT. <b><i>Methods:</i></b> Data from patients with AC following LT requiring CBS placement between June 2010 and June 2020 were analyzed. <b><i>Results:</i></b> Four hundred patients underwent lung transplant. AC requiring airway stenting occurred in 32 patients (8%), and CBS were inserted in 15 patients (3.5%). Indications were stenosis (<i>n</i> = 12; 80%) and bronchial dehiscence (<i>n</i> = 3; 20%). CBS were successfully deployed in 14 patients and failed in 1 patient. No migration was recorded during the follow-up. The median number of complication was 1 per patient (0–5). CBS could be removed in 11 patients (78.6%), and 3 died with their stents in place. AC recurrence or complications requiring new stenting occurred in 4/11 patients (36.3%), with a median time of 7 days (0–29). Seven patients (63.7%) had no AC recurrence, with a median follow-up of 925 days (118–3,249). <b><i>Conclusions:</i></b> The actual surgical anastomotic technique in LT provides new endoscopic challenges. CBS seem ideally positioned to address these difficulties safely and effectively but are associated with stent related complications requiring further endoscopic management.

Management of airway complications after lung transplantation: is there an ideal stent?

“…Thirtynine percent of covered SEMS have been placed in the right main bronchus, which may mean the authors either use very short devices with a high risk of migration; or temporarily cover the right upper lobe. Again, a recent report demonstrated in a limited cohort (n=15) the efficacy and safety of onsite customized silicone bifurcated stents in this setting (7). Also, the need for rigid bronchoscopy is reported as a pitfall of silicone stents, but complications of rigid bronchoscopy are extremely rare, and they represent a safe way to insert and manage potential immediate complications of stents (SEMS or silicone in our experience).…”

“…More than 80% of stents were placed in a main bronchus or the bronchus intermedius, so probably the treatment of smaller airways cannot explain the rate of mucus plugging. It is also not clear how the authors treat non-anastomotic stenoses that can involve the secondary carina and often requires a bifurcated device (7). Thirtynine percent of covered SEMS have been placed in the right main bronchus, which may mean the authors either use very short devices with a high risk of migration; or temporarily cover the right upper lobe.…”

“…In a randomized, controlled trial, Kraft et al showed that hyperbaric oxygen therapy does not reduce central airway stenosis severity or stenting (25). More recently, Guinde et al reported that the use of silicone customized bifurcated stent was a safe and efficient procedure to manage ACs after LT (7). Main reported series of ACs after LT from 2015 to present are presented in Table 1.…”

Advancements in airway stents: a comprehensive update

“…Stenting was successful in resolving the airway complication in 78% with the majority being able to have the stents removed. 64% had no further airway complications requiring new stents [24]. Using stents as component parts appears to be especially useful and effective but typical stent complications persist.…”