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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
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Dumon JF. A dedicated tracheobronchial stent. Chest 1990;97:328–32.
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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
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• Manual debridement / debulking
• Electrocautery, argon
• Cryotherapy
• Laser ablation (CO2, ndYAG)
• Photodynamic therapy
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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
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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
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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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• 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
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Tracheal Replacement
• Transplantation
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Questions?