Refractory post-transplant airway strictures: successful management with wire stents

Objective: Bronchial stenosis, malacia and dehiscence are major airway comp lications of lung transplantation. Our success in managing this problem evo lved from the use of semi-rigid dilators, to balloon dilation and placement of a stent, which were initially silicone, thereafter win balloon-expandab le and finally wire self-expandable. Methods: From May, 1994 until July 199 7, we performed a total of 49 single and 58 bilateral lung transplants. Sym ptoms of shortness of breath, verified by a drop in the forced expiratory v olume in one second (FEV1), led to bronchoscopic inspection of the airway i n lung transplant patients. Eighteen patients (16%) suffered a severe form of airway complication (dehiscence or stenosis) in 24 of 151 airways at ris k (15.9%). These anastomotic strictures were recalcitrant to conventional t herapy. Intervention consisted of rigid bronchoscopy, dilation of the stric ture and placement of a stent. Flexible bronchoscopy and fluoroscopy were u sed for precise placement of the stent. As the initial stent, the Hood sili cone stent was placed five times in four patients and the Dumont studded st ent five times in four patients. The Palmaz wire stent was used as the init ial stent 10 times in seven patients and the Wallstent used eight times in seven patients. Four patients had multiple stents, Balloon inflation moulde d the wire stent to the airway. Results: There was no mortality resulting f rom the airway complication or any intervention. The most serious complicat ion was a perforation of the airway using the semi-rigid dilator that neces sitated immediate thoracotomy and re-anastomosis of the bronchus, Other com plications necessitated repeat interventions due to restenosis or failure o f the stents. The success of the stent placement was measured subjectively by the immediate ease of breathing enjoyed by each patient and objectively by the significant increase of the FEV1 from a pre-operative mean of 1.19 l (SD 0.64 l) to a post-operative mean of 2.06 l (SD 0.70 l) (P < 0001). The mean number of interventions according to the type of wire stent first use d was significantly fewer with Wallstent insertion (1.28 (SD 0.48)) than in those patients in whom a Palmaz stent was inserted (5.22 (SD 2.38)) (P < 0 008). Conclusion: The airway complication of stricture, broncho-malacia or dehiscence following lung transplantation can be managed effectively and ea sily with the use of balloon catheter dilation followed by precise placemen t of a self-expandable wire stent. The Wallstent is the superior stent for this application. (C) 1999 Elsevier Science B.V, All rights reserved.