We present the case of a 68-year-old woman with very severe kyphoscoliosis, who had failed treatment for advanced non-small cell lung cancer. She comes in with radiographic evidence of tumor progression.
On these images, we can appreciate very severe scoliosis, and tortuous trachea, making access to the airways with a rigid bronchoscope very challenging. There is tumor at the level of the carina obstructing both main stem bronchi, with complete right lung collapse.
(Thoracent)
The stent is made of nitinol wire, woven in a tubular mesh shape, and partially covered with silicone. A retrieval loop is threaded through the proximal part and is intended to help stent removal. There are radiopaque markers which help visualization under fluoroscopy.
The delivery system consists of a front handle, a safety lock, a stopper, a back handle, and two thumb rings, blue for right side. The two inner sheaths contain a central lumen that accommodates up to 0.035-inch guidewire.
The Y-stent comes in a variety of sizes to meet a range of patient’s airways anatomy. The outer diameter of the delivery system measures 8 mm, and the working length measures 650 mm. The stent can be inserted either through a rigid bronchoscope or through a large endotracheal tube.
The patient consented to have the procedure and was taken to the OR where she was intubated with an ETT size 9. Airways inspection with the FOB demonstrates tumor affecting the main carina and occluding the central airways.
Tumor debulking was performed, and we were able to restore airway patency on the left. On the right we were able to debulk the right mainstem bronchus. Then both airways were dilated to an appropriate diameter.
Using the flexible bronchoscope, the guidewires were inserted into the right main and the left main bronchus.
Once the guidewires were in place, we back loaded or advanced the inner sheaths over the guide wires, making sure the guidewire on the right goes into the blue inner sheath. The delivery system was advanced over the guidewires until the tip touched the carina. Because the carina was broad and diseased, we pulled back a bit to make sure the inner sheaths don’t get caught in the mucosa. While holding the back handle stationary, we loosened the safety lock, then retracted the front handle to expose the two distal branches of the stent, this allowed the branches to advance over the guidewires.
At that moment, we readvanced the whole catheter to allow a snug positioning over the carina, and we tightened the safety lock. We elected to remove the guidewires especially the right one, so it does not get caught beneath the stent after deployment. Otherwise, we could have left them in place until final stent deployment, we pulled the blue ring thumb to deploy the right branch,
then we pulled the other ring thumb to deploy the left branch of the stent.
And finally, we loosened the safety lock and the stopper and retracted all away back the front handle to release the entire stent, while keeping the back handle stationary. * It is important to mention when both branches are deployed, and while the delivery system is still inside the outer sheath, patient’s airways are obstructed. The delivery system was then gently pulled out of the airways.
Proper placement and deployment of the Y stent was confirmed with the flexible bronchoscope. Patient was successfully extubated in the operating room.
- Stent pictures (courtesy of Thoracent)
- Patient consented to radiographic and endoscopic pictures sharing for teaching purposes