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Tracheal Stenosis

Gary Schwartz, MDDepartment of Thoracic Surgery and Lung Transplantation

Baylor University Medical Center

Endoscopic & Surgical Management

No disclosures

• Simple vs. complex / “web-like”

• Location– glottic

– subglottic

– cervical trachea

– mediastinal trachea

• Extent – Cotton’s Classification– I: < 70%

– II: 70%-90%

– III: > 90%

– IV: complete obstruction

Tracheal Stenosis

• Pressure ulceration

• Healing:

– granulation

– cicatrization

– contraction

Tracheal Stenosis

Ann Surg 1969;169:334-348

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• Rigid bronchoscopy

• Flexible bronchoscopy w/ balloon dilation

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Montgomery WW. T-Tube Tracheal Stent. Arch Otolaryngol 1965 Sep; 82:320-321

Tracheal Stenosis

Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:328–32.

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Tracheal Stenosis

A 47 year-old female has a metallic tracheal stent implanted for post-tracheostomy tracheal stenosis. Regarding patients with trachealstents:

(a) Anti-platelet therapy is required for metallic stents but not silicone stents

(b) Should only be intubated by awake, fiber-optic intubation

(c) Do not require knowledge of exact stent location prior to attempted intubation

(d) Typically require repeated interventions for long-term efficacy

Tracheal Stenosis

A 47 year-old female has a metallic tracheal stent implanted for post-tracheostomy tracheal stenosis. Regarding patients with trachealstents:

(a) Anti-platelet therapy is required for metallic stents but not silicone stents

(b) Should only be intubated by awake, fiber-optic intubation

(c) Do not require knowledge of exact stent location prior to attempted intubation

(d) Typically require repeated interventions for long-term efficacy

• Complications (5-15%):

• Migration

• Granulation

• Stent Fracture

• Mucous plugging

• Patient intolerance

• Respiratory infections

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Future potential:• Biodegradable absorbable

• Polydioxanone

• Drug-eluting• Mitomycin, Cisplatin

• Custom-made• Acrylic• SILMET®: self-

expanding nitinol stent made of nitinol

• 3-D printing

Tracheal Stenosis

• Manual debridement / debulking

• Electrocautery, argon

• Cryotherapy

• Laser ablation (CO2, ndYAG)

• Photodynamic therapy

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Tracheal Stenosis

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Surgical planning

– Cervical incision

• upper vs. full sternotomy, right thoracotomy

– 2-3 cm / 4-6 rings safely resected and primarily anastomosed

– Release maneuvers: annular ligament, suprahyoid, infrahyoid, intrathoracic tracheal, inferior pulmonary ligament

Tracheal Stenosis

The preferred method of ventilation during tracheal resection is:

(a) Transtracheal jet ventilation

(b) Cross table ventilation

(b) Extracorporeal membrane oxygenation

(c) Cardiopulmonary bypass

Tracheal Stenosis

The preferred method of ventilation during tracheal resection is:

(a) Transtracheal jet ventilation

(b) Cross table ventilation

(b) Extracorporeal membrane oxygenation

(c) Cardiopulmonary bypass

Tracheal Stenosis

Tracheal Stenosis

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• 503 pts, 521 resections (residual + restenoses)• Mean tracheal resection length 3.3 cm• Outcomes measures:

• Good: normal daily activities, intact bronchoscopic airway• Satisfactory: normal daily activities but exercise stress,

bronchoscopic vocal cord issues or stenosis• Failure: tracheostomy

• Failure rate:• Tracheo-tracheal anastomosis 2.2%• Crico-tracheal and thyrotracheal: 6-8%

• Mortality 2.4%

Tracheal Stenosis

Tracheal StenosisEnd-stage tracheal stenosis is amenable to tracheal replacement utilizing a:

(a) Human allograft trachea

(b) Synthetic, non-viable tissue

(c) Tissue-engineered trachea

(d) Autogenous tissue transfer

(e) None of the above

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Tracheal StenosisEnd-stage tracheal stenosis is amenable to tracheal replacement utilizing a:

(a) Human allograft trachea

(b) Synthetic, non-viable tissue

(c) Tissue-engineered trachea

(d) Autogenous tissue transfer

(e) None of the above

Tracheal Stenosis

Tracheal Replacement

• Foreign material

• Nonviable tissue

• Autogenous tissue

• Tissue engineering

• Transplantation

Tracheal Stenosis

Tracheal Replacement

• Foreign material

1950 Oct;38(150):200-5.

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Tracheal Replacement

• Nonviable tissue

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Tracheal Replacement

• Nonviable tissue

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Tracheal Replacement

• Autogenous tissue

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Tracheal Replacement

• Autogenous tissue

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Tracheal Replacement

• Tissue engineering

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Tracheal Replacement

• Transplantation

Tracheal Stenosis

Tracheal Replacement

• Transplantation

Tracheal Stenosis

Questions?