The incidence of bronchial stenosis after lung transplantation ranges from 1.6% to 32% and is the most common transplant airway complication. The stenosis may occur two to nine months after transplantation at the anastomotic site or distal to the anastomoses. Post-transplant bronchial stenosis are often treated with balloon bronchoplasty and silicone stent insertion, but in severe cases, may require surgical intervention.
A 61 year old male with a history of right single lung transplantation for severe COPD developed dyspnea with an associated decline in his spirometry 3 months post transplantation. Flexible bronchoscopy showed an 80% occlusive stenosis in the bronchus intermedius, immediately distal to the right upper lobe orifice. The right upper lobe bronchus also had an approximately 20% stenosis. Balloon bronchoplasty was performed with a CRE balloon, with immediate improvement in his dyspnea and spirometry; however he developed rapid recurrence of dyspnea. A rigid bronchoscopy was then performed with a repeat balloon bronchoplasty, rigid dilation, and silicone stent placement in the bronchus intermedius. The patient’s symptoms were immediately improved with an increase in his spirometry to baseline, but within one week, he returned with recurrent symptoms and a decrease in his spirometry. A repeat bronchoscopy revealed proximal dislodgement of his stent obstructing the right upper lobe entrance and worsening of the right upper lobe stenosis. The patient underwent another rigid bronchoscopy with the insertion of a silicone Y stent in the right main stem/right upper lobe/bronchus intermedius. All three limbs of the Y stent were shortened prior to insertion via rigid bronchoscope. After deployment of the stent, the flexible bronchoscope was used as a guide wire into the right upper lobe, concomitant with advancement of the stent with the rigid forceps into proper position. The patient’s symptoms subsequently improved and his spirometry returned to baseline. At three months follow-up he remained asymptomatic, he had a surveillance bronchoscopy which dislodged his stent and was removed. A similar sized Y stent was reinserted in the same position within the week without complications.
Silicone stents are the preferred stent in the non-malignant airway. They offer the benefits of decreased granulation tissue, ease, and safety of removal. However silicone stents carry the risk of migration from the target location. The silicone Y stent may reduce migration by having an additional third limb to stabilize its position. The silicone Y silicone stent is used primarily for lower tracheal and main stem bronchus airway patency. To our knowledge, this is the first description of a silicone Y stent being used in the secondary carina for a post-transplant airway. This patient had a silicone Y stent in the secondary carina twice without complications during insertion. He maintained stable spirometry at the three months follow-up time point. In this case, the patient had additional distal stenosis beyond the anastomotic site; importantly a single silicone Y stent was able to maintain patency of two separate sites of bronchial stenosis.
Silicone Y stents can be placed safely in a secondary carina for post-ansastamotic stenosis and may reduce stent migration complications.
Hans Lee, No Financial Disclosure Information; Product/procedure/technique that is considered research and is NOT yet approved for any purpose. Insertion of a silicone Y stent into the secondary carina.