REVIEW

CURRENT
OPINION Airway stent: what is new and what should
be discarded
Felix J.F. Herth and Ralf Eberhardt

Purpose of review
Patients with lung cancer often develop endobronchial disease, endobronchial tumor extension or airway
compression. Various nonmalignant diseases can also lead to severe central airway obstruction.
Since the early 1980s, technical advances of interventional bronchoscopic techniques have improved
symptom-free survival and quality of life for patients with lung cancer. Apart from other techniques, various
airway stents have been developed. Although interventional procedures are not definitive therapies, they
often relieve the strangling sensation produced by airway occlusion. There have been various new
developments and the authors review the available current literature on endobronchial stents
Recent findings
For patients with respiratory symptoms because of malignant airway obstruction, stent placement provides
symptom palliation and improved quality of life.
Summary
Various options for central airway obstruction are in development and will change our daily work. In
particular, coated stents have a large potential in minimizing stent complications.
Keywords
central airway obstruction, interventional pulmonology, stent placement

INTRODUCTION Since that time, the placement of airway stents is

The prognosis of lung cancer is still one of the worst one of the hot topics in interventional pulmonology
in oncology [1]. Despite all therapeutic efforts in the [11]. A variety of stent types and stent materials are
last 20 years, the 5-year survival at diagnosis is available but to date the ideal stent has not been
around 15%. A relevant number of patients develop developed yet [12].
symptoms caused by obstruction of the central air- The anatomy of the central airways as well as
ways in the course of their disease. A variety of their physiology is complex (different mechanical
therapeutic and endoscopic procedures are available peculiarities, such as rigidity, changes in shape
to alleviate those symptoms [2]. The techniques under lateral/circular compression, adaptation to
differ in terms of short and long-term success as high or low-pressure fluctuations). Therefore, com-
well as the complications [3]. plications after stent placement are not uncommon
Airway stents are commonly used to treat and may present as clogging of the stent with
patients with central airway obstruction (CAO) secretions, ingrowth of granulation or tumor tissue
because of a variety of malignant and benign dis- at the ends of the stent, migration or fracture of the
orders [4–6]. Although airway stents are effective in mesh structure of the stent [12] (Table 1).
reducing symptoms, complications are not uncom-
mon, especially in the long-term follow-up and in Department of Pneumology and Critical Care Medicine, Thoraxklinik,
&
benign disorders [7 ,8]. Translational Lung Research Center Heidelberg, German Center for
Lung Research (DZL), University of Heidelberg, Heidelberg, Germany
Reports of endoscopically implantable stents for
the airways date back to 1914 [9]. The Montgomery Correspodence to Professor Felix J.F. Herth, MD, PhD, FCCP, FERS,
Pneumology and Critical Care Medicine, Thoraxklinik, University of Hei-
T-tube, which was developed in 1960, was the first delberg, Röntgenstr. 1, D-69126 Heidelberg, Germany Tel: +49 6221
dedicated airway stent. The implantation of tracheal 396 1200; fax: +49 6221 396 1202;
stents in the lower parts of the airways was intro- e-mail: Felix.Herth@med.uni-heidelberg.de;
duced by Dumon in 1989 [10]. He started with the www.thoraxklinik-heidelberg.de
placement of silicone stents and opened up the field Curr Opin Pulm Med 2016, 22:252–256
of airway stenting. DOI:10.1097/MCP.0000000000000266

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 Airway stent: an update Herth and Eberhardt

The research group of Abdel-Rahman [15]

KEY POINTS reported on their long-term observation of metal

Coated stents stents after lung transplantation. In a period over
10 years, 435 patients underwent lung transplan-

Tailored stents tation in Israel. A total of 60 patients (12%) devel-

Three-dimensional printed stents oped a stenosis of the bronchial anastomosis site,
47 patients required a metal stent. Abdel-Rahman

Biodegradable stents showed that 95% of these patients felt an immediate
improvement of their clinical symptoms. In the
follow-up period, the stent-treated group had a sig-
Despite all technical developments, the most nificantly increased number of bronchoscopies to
important question remains if the patient needs a handle stent related problems, without impact on
stent in the first place. Particularly, toward the end the survival. The group concludes that metal stents
stage of lung cancer, all options need to be discussed seem an acceptable option in case of a stenosis at
with the patient and ideally in a multidisciplinary the site of anastomosis, but the need for more
team. procedures in the follow-up must be accepted.
The balance between intervention and expected
complications should be considered and known in
CURRENT DEVELOPMENTS advance. In a recent publication from the AQUIRE
&&
database [16 ], 1115 interventional procedures on
&&
Marchese et al. [13 ] reported on their experience
with a fully covered self-expandable metal stent 947 patients were analyzed regarding the morbidity
(Novatec, La Ciotat, France). The stent was placed and the mortality of the interventional pulmonol-
in 52 patients; into the trachea (n ¼ 19), the main ogy procedure itself. The analysis showed significant
bronchi (n ¼ 21) as well as the distal bronchi differences among participating centers depending
(n ¼ 31). All deployments were successful with an on the type of anesthesia used (moderate vs deep or
immediate significant improvement of symptoms. general anesthesia), the possibility to perform rigid
The reported complications included migration bronchoscopy, the type of ventilation (jet vs volume
(7.6%), tumor overgrowth (15%), infection (5.7%), cycled), and last but not least the frequency of stent
granulation tissue formation (3.8%), and mucus placement in the different centers.
plug (3.8%). The group hence confirmed previous This resulted in an acceptable overall compli-
reports, that stents can improve the symptoms of cation rate of 3.9%, but with a large range
CAO rapidly, but in the follow-up a complication (0.9–11.7%). It was also shown that the urgency
rate of around 30% must be accepted. of the procedure, as well as the comorbidities of
the patients, is a significant risk factor. The 30-day
&&
The paper by Mahmood et al. [14 ] assessed
53 patients with CAO and focused particularly on mortality was 14.8%, again with a wide range
the clinical improvement after stent placement. (7.7–20.2%). Interestingly, a risk factor for increased
Six to eight weeks after bronchoscopy and stent 30-day mortality was stent placement.
placement, a significant increase in the forced vital The results of this database analysis showed an
capacity and forced expiratory volume at 1 s was acceptable morbidity and mortality regarding stent
noted. placement, clearly depending on the local factors
The Shortness of Breath Questionnaire score such as experience and interventional possibilities
improved as well as the Short Form 36 Health Survey at the centers.
questionnaire (SF-36) in almost all domains; Unfortunately, clear structural and quality-
benefits were seen independent of the underlying based recommendation for interventional pulmo-
disease. nology centers currently do not exist. Especially
from the patient’s perspective there is a clear need
for this, but that is a political question, which is
unsolved for several other technologies as well.
Table 1. Complications of stenting Leading on from this, the success of stenting has
&&

Major long-term complications of stenting Percentage

been shown to depend on experience [16 ], and
experience starts with training. The definition of
Migration 5–20% competency in different training programs in inter-
Granulation 15–20% ventional pulmonology is very variable. In an Expert
&&

Mucus plugging 10–20% Panel Report [17 ], drafted questions in a PICO

Stent fracture 10% (population, intervention, comparator, outcome)
format as well as MEDLINE data through PubMed

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Interventional pulmonology

(a)

(b)
FIGURE 1. Metallic Y-shaped stent in place.

and the Cochrane Library are presented and describe

the actual requirements and needs for the future.
Unfortunately, there is a lack of clearly structured
nation-wide programs in interventional pulmonol-
ogy. It is up to the national professional societies
and certifying agencies to move away from a
volume-based system to a standardized skill acqui-
sition and knowledge-based competency assess-
ment for trainees.
Over the years, more and more stents have
become available. Companies offer patient tailored
stents as well as metallic Y-shaped stents. Gompel-
&&
mann et al. [18 ] reported on 43 patients treated
with a metallic Y stent (Fig. 1). A total of 90% had
CAO because of malignant disease. In all patients,
the stent was placed without any complications. A
longitudinal follow-up was possible in 32 of the 43
patients; 11 patients died within 6 weeks following FIGURE 2. Bioabsorbable stent (a) immediately after
stent insertion. On follow-up, 45% tolerated the placement and (b) 8 weeks later.
stent without problems, 11% required further stent-
ing and 33% developed complications, such as operations. These stents seem to be well tolerated
increased secretions, cough, dyspnea, or granula- by the tracheal mucosa, maintain their biomechan-
tion tissue formation. The author showed that ical strength for 6 weeks, and dissolve completely
&&
placement of a metallic Y stent in symptomatic after 3–4 months (Fig. 2). Fuehner et al. [19 ]
CAO relieves symptoms, but as with other stents, reported on a larger case series with biodegradable
complications are not rare. stents in patients after lung transplantation.
Options to overcome the complications in the A total of 11 stents were inserted and all patients
follow-up period are being developed. In attempting reported a relief of their clinical symptoms and
to address some of the drawbacks mentioned above, improvement of their pulmonary function test.
biodegradable stents have been developed as a Patency was achieved in 9/11 stenoses at 1-year
temporary option in managing CAO. Biodegradable follow-up. Complete degradation of the stents was
stents are mostly based on polydioxanone, a observed after 3 months in all cases. No patient
material used to suture anastomoses during required further airway intervention after 6 months.

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 Airway stent: an update Herth and Eberhardt

In a recently published review article Dutau et al. external airway splints. After the implanation, the
&&
[20 ] presented the available literature on the use of infants did not have any life-threatening airway
biodegradable stents in animal and humans trials. problems and the long-term follow-up shows con-
The group summarized the main indication clearly tinued growth of the primary airways. Thus patient-
being a benign, symptomatic CAO with a need for specific three-dimensional printed device pro-
temporary rather than permanent stenting. The duction seems feasible. More data on such options
current literature provides case sampling rather than are certainly needed but may prove to be an exciting
evidence, but it seems that the use of such stents possibility for a patient-specific approach to the vari-
could circumvent long-term complications experi- able shapes and causes of CAO.
enced with regular stents. The literature also shows
that biodegradable stents are not without safety
issues. Toxicity of their degradation products and CONCLUSION
the degradation-related, premature failure of the Stents are an effective treatment for patients with
implant are reported issues. The majority of the CAO. After the implantation, most of the symptoms
stents are synthetic and the degradable polymers are rapidly improved. Based on the underlying dis-
are polyesters. It has to be shown that alternative ease, long-term complications are common, especi-
structures, such as polyanhydrides, polyphospha- ally in nonmalignant disease. Owing to the lack of
zenes, polyamides, polycarbonates, or magnesium, an ideal stent, further technical developments
may be able to compete with the polyesters in the are needed. The first generation of biodegradable
future. Prospective studies are desperately needed to stents is available, drug coated or delivering stents
answer open questions regarding these stents. are on the way to our armentarium and three-
Different groups are currently working on vari- dimensional printing of an optimized stent may
able types of coating of the stent [drug-eluting stents be the future. It would appear that in interventional
(DES)]. This aims to reduce the fibroblast growth, pulmonology, a personalized medicine approach is
resulting in a reduction of formation of granulation soon to be expected.
tissue. But, beside all technical improvement, there is a
Chinese researchers developed a paclitaxel- clear need for a quality-based definition of interven-
eluting tracheal stent with sustained and slow tional pulmonology/stent centers as well as for
&&
paclitaxel release [21 ], which could inhibit the structured training programs.
formation of granulation tissue. They measured
the in-vitro paclitaxel dilution and were able to Acknowledgements
show that a coating proportion of 0.1% (w/v) pacli- None.
taxel and 2% (w/v) polylactic acid-coglycolic acid
resulted in paclitaxel released from the DES at thera- Financial support and sponsorship
peutic levels. The release of paclitaxel was sustained None.
in excess of 40 days. Coating seems therefore
possible and human trials have already started. Conflicts of interest
&&
Kruklitis et al. [22 ] reported on the use of the
There are no conflicts of interest.
stent as a way to transport therapeutic agents to the
mucosa. They impregnated the stent with viral gene
vectors for local gene delivery to the bronchial REFERENCES AND RECOMMENDED
epithelium. In their studies, murine and human READING
Papers of particular interest, published within the annual period of review, have
nonsmall cell lung cancer cells were successfully been highlighted as:
transfected with reporter genes in vitro. In a pilot & of special interest
&& of outstanding interest
in-vivo part of the study, they presented data sup-
porting the concept that therapeutic genes could 1. Pirker R. Novel drugs against nonsmall-cell lung cancer. Curr Opin Oncol
2014; 26:145–151.
also be delivered with this technology. 2. Gompelmann D, Eberhardt R, Herth FJ. Advanced malignant lung disease:
Apart from the mentioned designing, coating what the specialist can offer. Respiration 2011; 82:111–123.
3. Boyd M, Rubio E. The utility of interventional pulmonary procedures in
and eluting variables of the stents, technical devel- liberating patients with malignancy-associated central airway obstruction
opments in other areas have brought about the from mechanical ventilation. Lung 2012; 190:471–476.
4. Wood DE, Liu YH, Vallières E, et al. Airway stenting for malignant and benign
possibility of three-dimensional printing of new tracheobronchial stenosis. Ann Thorac Surg 2003; 76:167–172; discussion
airways or airway sleeves. 173–174.
&& 5. Mroz RM, Kordecki K, Kozlowski MD, et al. Severe respiratory distress caused
In a first report, Morrison et al. [23 ] present 3 by central airway obstruction treated with self-expandable metallic stents.
infants with severe bronchomalacia, who were not J Physiol Pharmacol 2008; 59 (Suppl 6):491–497.
6. Breitenbucher A, Chhajed PN, Brutsche MH, et al. Long-term follow-up and
weanable because of their malacia. The team implan- survival after Ultraflex stent insertion in the management of complex malignant
ted patient-specific three-dimensional printed airway stenoses. Respiration 2008; 75:443–449.

1070-5287 Copyright ß 2016 Wolters Kluwer Health, Inc. All rights reserved. www.co-pulmonarymedicine.com 255

Copyright © 2016 Wolters Kluwer Health, Inc. All rights reserved.

Interventional pulmonology

7. Beaudoin EL, Chee A, Stather DR. Interventional pulmonology: an update for 17. Ernst A, Wahidi MM, Read CA, et al. Adult bronchoscopy training: current
& internal medicine physicians. Minerva Med 2014; 105:197–209. && state and suggestions for the future: CHEST Expert Panel Report. Chest
Good overview about the available technologies. 2015; 148:321–332.
8. Akulian J, Pathak V, Lessne M, et al. A novel approach to endobronchial Recent published expert opinion about training requirements.
closure of a bronchial pleural fistula. Ann Thorac Surg 2014; 98:697–699. 18. Gompelmann D, Eberhardt R, Schuhmann M, et al. Self-expanding Y stents in
9. Killian G. The Semon Lecture on suspension laryngoscopy and its practical && the treatment of central airway stenosis: a retrospective analysis. Ther Adv
use: delivered before the University of London. Br Med J 1914; 1:1181– Respir Dis 2013; 7:255–263.
1182. First larger experience with a metallic Y-shaped stent.
10. Dumon JF. A dedicated tracheobronchial stent. Chest 1990; 97:328–332. 19. Fuehner T, Suhling H, Greer M, et al. Biodegradable stents after lung
11. Wahidi MM, Herth FJ, Ernst A. State of the art: interventional pulmonology. && transplantation. Transpl Int 2013; 26:e58–e60.
Chest 2007; 131:261–274. First report about a bidegradable stent.
12. Casal RF. Update in airway stents. Curr Opin Pulm Med 2010; 16:321–328. 20. Dutau H, Musani AI, Laroumagne S, et al. Biodegradable airway stents:
13. Marchese R, Poidomani G, Paglino G, et al. Fully covered self-expandable && bench to bedside: a comprehensive review. Respiration 2015; 90:512–
&& metal stent in tracheobronchial disorders: clinical experience. Respiration 521.
2015; 89:49–56. Actual review about ‘biodegradable airway stents’.
Actual series about metallic stent and the clinical experience. 21. Kong Y, Zhang J, Wang T, et al. Preparation and characterization of paclitaxel-
14. Mahmood K, Wahidi MM, Thomas S, et al. Therapeutic bronchoscopy && loaded poly lactic acid-co-glycolic acid coating tracheal stent. Chin Med J
&& improves spirometry, quality of life, and survival in central airway obstruction. (Engl) 2014; 127:2236–2240.
Respiration 2015; 89:404–413. Bench work on the possibility to coat stents.
Actual trial about different clinical changing after stenting. 22. Kruklitis RJ, Fishbein I, Singhal S, et al. Stent-mediated gene delivery for site-
15. Abdel-Rahman N, Kramer MR, Saute M, et al. Metallic stents for airway && specific transgene administration to the airway epithelium and management of
complications after lung transplantation: long-term follow-up. Eur J Cardio- tracheobronchial tumors. Respiration 2014; 88:406–417.
thorac Surg 2014; 45:854–858. First report about ‘stent-mediated gene therapy’.
16. Ost DE, Ernst A, Grosu HB, et al. Complications following therapeutic 23. Morrison RJ, Hollister SJ, Niedner MF, et al. Mitigation of tracheobroncho-
&& bronchoscopy for malignant central airway obstruction: results of the AQuIRE && malacia with 3D-printed personalized medical devices in pediatric patients.
Registry. Chest 2015; 148:450–471. Sci Transl Med 2015; 7:285ra64.
Largest database about stent related complications. Three-dimensional printing as an option for interventional pneumology.

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