TRACHEO BRONCHIAL STENTING IN MALIGNANT AIRWAYS: a simple rapid trans nasal , fluoroscopic technique under local anaesthesia

1. TRACHEO-BRONCHIAL STENTING IN MALIGNANT
AIRWAYS: a simple rapid trans-nasal , fluoroscopic technique under
local anaesthesia
Affiliation and Institution: North eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong
Presenting Author: V M Joseph
Co-authors: A. Handique, D. Lynser, P.Phukan, C. Daniala, M. Sagar, S. Borah, G. Kumar, S. Paul, A. Chakraborty, L. Gupta, *KG
Lynrah, **Md Yunus, **Rajani Tabah, **Nari M Lyngdoh, Department of Radiology & Imaging, *KG Lynrah, Dept of General
Medicine, **Department of Anesthesia & Critical Care, North-Eastern Indira Gandhi Regional Institute of Health & Medical Sciences,
Shillong, Meghalaya, India

2. Interventional options in advanced
malignancy of aerodigestive tracts
Tracheostomy
and silicone
(Dumon)
stents
Tracheo-bronchial
stenting with
SEMS: Better
palliation and
improved quality
of life
Simple, Fast and Reliable
CT Based Planning
Transnasal approach
Solely under fluoroscopic guidance, Air
Column
Local Anesthesia, Even in severely
dyspneic patients
CT BASED
PLANNING

3. STUDY PERIOD: 2006 till date
No: of patients:
14 patients were treated
Advanced Esophageal Cancer infiltrating
trachea, 12 pts.
Malignant Infiltrative Node, unknown
primary, 2 pts.
Since late 2016, 6 patients, treated with
present technique
Earlier cases, additional bronchoscopy
No sedation
Supine, Sitting position if severe dyspnea
Nebulization with 2% Xylocaine & Salbutamol
Superior/ Recurrent laryngeal blocks if
necessary
Nasopharyngeal
Airway Tube, 7-8
mm (Romsons,
India) placed in a
nostril
Flexor® Balkin
Guiding Sheath, 6F
(Cook, USA)
Hydrophilic Wire,
035”, 150 cm
(Radiofocus,
Terumo, Japan)/
Amplatz extrastiff
wire 145 cm with J
tip (Cook, USA),
Exchange &
Sheath removal
Stent deployment,
Fluoroscopy,
Previous CT ,
Delivery System,
16-18 F (< 6mm)

4. 49 year old with
mediastinal mass and
dyspnea
Nasopharyngeal tube & Balkin Sheath
in position Stent Positioning Post deployment
High Tracheal Stenting Bronchial narrowings → 2 side by side stents

5. All Tracheo-Bronchial stents, 14 Pts., 15
stents
Stent Types No. of
Pts.
Covered tracheal stent (Comvii, Tawoong,
Korea, 7) & (Bravo, Ottomed, India, 4)
11
Bare stent, bronchial (Zilver, Cook, USA) 1
Two parallel bare stents b/l bronchial
disease (Zilver, Cook, USA)
1 (2
stents)
Bifurcated covered tracheo-bronchial Y
stent(Ottomed, India) Transoral route
1
Additional esophageal Stents 3
“Fluoro Only” Technique 6
❑ Ca Esophagus
Post CT-RT
❑ Significant
aspiration
after stent
placement
❑ High
Esophageal
stenting done
Covered esophageal stenting in Ca Esophagus with TOF. Came with
dyspnea after 4.5 months
Stent prolapse into
carina
Tracheo-Bronchial “Y” Stent
treatment

6. ✓ Technical Success,
✓ All patients
✓ Immediate relief of
dyspnea
✓ No stent migrations
during the follow up
✓ Post Procedure
Survival: 2-6 months
✓ Transnasal fluoroscopy
guided tracheo-bronchial
stenting is a simple, safe,
straightforward and rapid
technique
✓ Minimal Hardware
needed
✓ It avoids general
anesthesia and need of a
bronchoscope
✓ Always match ID of
nasopharyngeal tube to the OD of
Stent delivery system
✓ Fix Nasopharyngeal Tube,
Tendency to get Dislodged
✓ Balkin Sheath can also be used for
O2 delivery
1.Medhi J, Handique A, Goyal A, et al. Transnasal tracheobronchial stenting for malignant airway narrowing under local anesthesia: Our experience of treating three cases using this technique. Indian J
Radiol Imaging. 2016;26(1):103-7.
2.Breitenbücher A, Chhajed PN, Brutsche MH, Mordasini C, Schilter D, Tamm M. Long-term follow-up and survival after ultraflex stent insertion in the management of complex malignant airway stenoses.
Respiration. 2008;75:443–9. [PubMed]
3.Profili S, Manca A, Feo CF, Padua G, Ortu R, Canalis GC, et al. Palliative airway stenting performed under radiological guidance and local anesthesia. Cardiovasc Intervent Radiol. 2007;30:74–8. [PubMed]
4.Shin JH, Kim SW, Shim TS, Jung GS, Kim TH, Ko GY, et al. Malignant tracheobronchial strictures: Palliation with covered retrievable expandable nitinol stent. J Vasc Interv Radiol. 2003;14:1525–34.
[PubMed]
5.Shin JH, Song HY, Shim TS. Management of tracheobronchial strictures. Cardiovasc Intervent Radiol. 2004;27:314–24. [PubMed]
6.Conacher ID. Anaesthesia and tracheobronchial stenting for central airway obstruction in adults. Br J Anaesth. 2003;90:367–74. [PubMed]
7.Finlayson GN, Brodsky JB. Anesthetic considerations for airway stenting in adult patients. Anesthesiol Clin. 2008;26:281–91. vi. [PubMed]
8.Tanigawa N, Sawada S, Okuda Y, Sougawa M, Komemushi A, Kojima M, et al. Expandable metallic stent placement in upper tracheal stenosis: Value of laryngeal masks. AJR Am J Roentgenol.
2001;177:1423–6. [PubMed]
9.Rees CJ. In-office unsedated transnasal balloon dilation of the esophagus and trachea. Curr Opin Otolaryngol Head Neck Surg. 2007;15:401–4. [PubMed]
10.Verma SP, Smith ME, Dailey SH. Transnasal tracheoscopy. Laryngoscope. 2012;122:1326–30. [PubMed]