We present the case of a 68-year-old woman with severe kyphoscoliosis who had previously failed treatment for advanced non-small cell lung cancer. She presented with radiographic evidence of tumor progression.
The images reveal severe scoliosis and a tortuous trachea, significantly complicating access to the airways with a rigid bronchoscope. There is a tumor located at the level of the carina, obstructing both mainstem bronchi and causing complete collapse of the right lung.
(Thoracent)
The stent is composed of nitinol wire, woven into a tubular mesh structure, and partially covered with silicone. A retrieval loop is threaded through the proximal end to facilitate stent removal. Radiopaque markers are incorporated to enhance visualization under fluoroscopy.
The delivery system includes a front handle, a safety lock, a stopper, a back handle, and two thumb rings, with the blue ring indicating the right side. The two inner sheaths contain a central lumen capable of accommodating a guidewire up to 0.035 inches in diameter.
The Y-stent is available in a variety of sizes to accommodate different airway anatomies. The delivery system has an outer diameter of 8 mm and a working length of 650 mm. The stent can be inserted either via 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