Perspective

Airway stents
Erik Folch, Colleen Keyes

Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonary, Massachusetts General Hospital, Harvard Medical School,
Boston, MA, USA
Correspondence to: Erik Folch. Division of Pulmonary and Critical Care Medicine, Section of Interventional Pulmonary, Massachusetts General
Hospital, Harvard Medical School, 55 Fruit Street, Boston, MA 02114, USA. Email: [email protected].

Stents and tubes to maintain the patency of the airways are commonly used for malignant obstruction
and are occasionally employed in benign disease. Malignant airway obstruction usually results from direct
involvement of bronchogenic carcinoma, or by extension of carcinomas occurring in the esophagus or the
thyroid. External compression from lymph nodes or metastatic disease from other organs can also cause
central airway obstruction. Most malignant airway lesions are surgically inoperable due to advanced disease
stage and require multimodality palliation, including stent placement. As with any other medical device,
stents have significantly evolved over the last 50 years and deserve an in-depth understanding of their true
capabilities and complications. Not every silicone stent is created equal and the same holds for metallic stents.
Herein, we present an overview of the topic as well as some of the more practical and controversial issues
surrounding airway stents. We also try to dispel the myths surrounding stent removal and their supposed use
only in central airways. At the end, we come to the long-held conclusion that stents should not be used as first
line treatment of choice, but after ruling out the possibility of curative surgical resection or repair.

Keywords: Airway stents; airway obstruction/therapy; tracheal neoplasms/therapy; prosthesis design; prosthesis
implantation; bronchi/pathology

Submitted Jan 19, 2018. Accepted for publication Feb 27, 2018.
doi: 10.21037/acs.2018.03.08
View this article at: http://dx.doi.org/10.21037/acs.2018.03.08

Introduction cases, particularly when it extends the lesion to >4 cm

in length, a commonly used limit for tracheal resection.
An airway stent is an endobronchial prosthesis of various
Furthermore, placement of an airway stent can create
materials that supports and maintains patency of the hollow
local inflammation and mucosal injury that may interfere
tubular airway structure (1). An airway stent may impede
with anastomotic healing following airway resection and
extension of a tumor into the airway, may help in the reconstruction (2). The most common indications for
healing or management of airway fistulas, or may support stenting include minimizing extrinsic compression from
the airway wall against collapse or external compression. tumors or lymphadenopathy, maintaining patency after
bronchoscopic tumor removal due to intrinsic obstruction,
Indications and contraindications for airway healing airway fistulas and anastomotic dehiscence post lung
stents transplantation and addressing very selected cases of benign
airway disease (3,4). It is important to note that in general,
Airway stenting is indicated in a variety of malignant and metallic stents are not considered first-line of therapy in
benign processes (Table 1). Independent of the indication, patients with benign airway obstruction and should only be
prior to any stent placement, the thoracic surgeon or used if everything else fails (5).
interventional pulmonologist must be sure that the patient The use of airway stents frequently elicits visceral
does not have any surgically curable airway disease. reaction from some thoracic surgeons and interventional
Stenting may complicate or preclude surgery in some pulmonologists. These reflexive responses are the result of

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(2):273-283
274 Folch and Keyes. Airway stents

Table 1 Indications for airway stenting Types of airway stents and materials

Indication: malignant disease The “ideal” stent has not yet been developed. In theory,
Malignant airway obstruction from extrinsic compression such an ideal stent should be stable, strong enough to
withhold the external compressive forces that compromise
Endobronchial tumor with residual obstruction after
multimodality thermal therapy the lumen patency, biocompatible (i.e., non-irritating),
available in all necessary sizes, resistant to migration, easily
Mixed endobronchial and extrinsic tumor
deployed and removed and can act as a barrier to inward
Loss of cartilage support from tumor destruction growth of tumor while being flexible enough to conform
Malignant tracheoesophageal fistula to the different luminal irregularities. However, the ideal
Indication: benign disease stent does not currently exist. At the time of writing of this
manuscript, the available airway stent materials include
Complex benign stricture or stenosis >4 cm in length
silicone, nitinol, stainless steel and hybrid stents. Recent
Benign stricture or stenosis in inoperable patient advances in 3-D printing may revolutionize stenting, but
Post-transplant airway stenosis medical-grade materials are in the development stage (8).
Tracheobronchomalacia: therapeutic trial before tracheoplasty

Benign tracheoesophageal fistula Is the material the most important factor? Silicone vs.
metallic vs. hybrid stents

The material of the stent is not the most important factor

catastrophic cases in the past, or deeply ingrained in their to consider when choosing an adequate stent. The selection
psyche by their mentors. When this occurs, it is important should be made based on the specific disease, anatomy and
to objectively analyze the specific case, the available options clinical situation. Likewise, the experience of the clinician
for that particular patient and the solid evidence behind the with a specific stent should not be the key factor deciding
biomaterials and engineering of current airway stents. In which stent to place. A rapid referral to a colleague is
other words, be evidence-based and not dogmatic. There better than a lengthy and complicated course. The ease
are only a few absolute contraindications to stent placement. of placement of metallic stents (i.e., without the absolute
In general, patients medically able to undergo surgical need for rigid bronchoscopy) has popularized their use in
interventions to cure benign or malignant conditions should malignant and benign disease (9). However, there has been
not have an artificial airway prosthesis placed (4). Also, very a significant shift towards the use of silicone stents in benign
severe impairment in functional capacity and very limited diseases. In 2005, the US Food and Drug Administration
survival expectancy should preclude stenting. However, (FDA) issued a warning stating that the use of metallic
recent advances in chemotherapy and radiation for lung stents should be avoided in benign diseases (5). This
cancer challenge our prior assumption (6). warning followed the reports of significant complications
If there is no viable lung tissue beyond the stenosis, in benign airway diseases, when stents were inevitably
stenting should also not be pursued (1). In most cases, careful susceptible based on a relatively longer patient life
review of the computed tomography and balloon dilation of expectancy and, therefore, longer endobronchial occupancy
the stenosis will reveal if distal airways are patent and thus periods compared to malignant disease indications. It is
worthy of reestablishing patency. Relative contraindications also important to remember that at the time of that FDA
include individuals unable to tolerate general anesthesia or recommendation, the available metallic stents had different
moderate sedation (7). In terms of preparation, the clinician biomechanical properties, were mostly uncovered, and,
should exercise self-restraint and consider if this is the right in some cases, repurposed from use in other organs such
setting for placement of an airway prosthesis. The most as the colon, esophagus or biliary tree. Nevertheless, the
experienced person who can place such a device should be recommendation stands true today, and should be explicitly
enlisted and a plan should be constructed for contingencies considered as follows:
such as airway obstruction during placement, bleeding, or  Use metallic tracheal stents in patients with benign
misplacement from the desired location. airway disorders only after thoroughly exploring all

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Annals of cardiothoracic surgery, Vol 7, No 2 March 2018 275

other treatment options (such as tracheal surgical occur as well as from granulation tissue growth at the
procedures or placement of silicone stents). Using proximal or distal ends (Figure 2B,C). In addition, ignition
metallic tracheal stents as a bridge to other therapies during other endobronchial treatments (i.e., laser therapy)
is not recommended, because removal of the metallic is possible. The three most common silicone stents are the
stent can result in serious complications; Montgomery T-tube, the tubular stent and the Y-stent.
 If a metallic tracheal stent is the only option for a Complications include migration with a rate of 9.5% and
patient, insertion should be done by a physician trained obstruction due to secretions with a rate of 3.6% (15,16).
or experienced in metallic tracheal stent procedures;
 If removal is necessary, the procedure should be
Metallic and hybrid stents
performed by a physician trained or experienced in
removing metallic tracheal stents; Metallic stents may be subdivided into self-expandable
 Always review the labelling before using the device, metallic stents (SEMS) and fixed-diameter stents that
especially the indications for use, warnings and require balloon dilatation. Metal stents are available in
precautions. Select patients carefully. covered and uncovered varieties. The initial uncovered
Table 2 shows the characteristics of the individual stents. metallic stents (i.e., Gianturco, Wallstent, Palmaz) were
repurposed models designed for use in the gastrointestinal
and the vascular fields, and probably accounted for the early
Silicone stents
reports of serious complications (17). Most of these initial
Silicone is a synthetic material created of silicone elastomers metallic stents (i.e., Gianturco, Palmaz, etc.) with their
or polydimethylsiloxane. Silicone has firmness, stability at sharp ends are now rarely used. Metallic stents have many
high temperatures and elicits minimal tissue reactivity (10). attractive advantages. They can be inserted with topical
It is easily molded and can give various degrees of anesthesia and moderate sedation via flexible bronchoscopy,
firmness and flexibility. Reinforcement of the silicone When compared to silicone stents, metallic stents have;
with polypropylene, polyamide and carbon fiber fibers can a better internal-to-external diameter ratio, resulting in a
confer greater mechanical strength and resistance to the larger airway lumen; are radio-opaque, making them easy
silicone matrix (11). Silicone stents are comparatively less to spot on radiographic films; and have a lower incidence
expensive, well tolerated, and have the sufficient firmness of migration (18,19). Uncovered stents have the additional
to resist extrinsic compression. In addition, they can be benefits of not creating obstruction across bronchial lobar
easily modified by cutting a portion of the stent, allowing orifices and, in theory, do not interrupt the mucociliary
customization to the airway anatomy prior to deployment clearance (13).
(Figure 1). In general, rigid bronchoscopy is needed for On the other hand, uncovered metallic stents can be
deployment as well as general anesthesia; however, insertion difficult to remove, and tumor or granulation tissue may
using the flexible bronchoscope has been described (12). grow through the mesh/stent orifices (Figure 3). Serious
Once deployed, they can be repositioned or removed using complications have been reported, including airway or
the rigid grasping forceps. vascular perforation (20). Also concerning is the fact
Silicone stents come in various lengths, shapes, that complications of metallic stents tend to occur more
diameters and durometers (hardness of polymers and frequently in benign diseases, for reasons previously
elastomers). Custom prostheses can be ordered from several described. Currently, the role of uncovered metallic stents
manufacturers (Table 2). “Y”-shaped stents are useful in is limited, however, there are specific indications for
cases of bilateral bronchial involvement, to maintain patency their use, such as anastomotic dehiscence following lung
at the main carina, or to prevent migration of a distal transplantation (21-23).
silicone tracheal stent. The significant advantages of silicone The new generation stents are made from alloys. The
stents are the ability to be easily repositioned and removed most popular composition is nitinol (titanium and nickel
as well as the possibility of customization by making orifices alloys); a super-elastic biomaterial that may undergo large
in the desired location. However, tubular silicone stents deformations in size and shape. Nitinol-made stents have
have a higher risk of migration, and repeated bronchoscopic “shape memory” that decreases risk of airway perforation,
procedures may be needed for repositioning (Figure 2A) because they do not change in length once expanded,
(9,13,14). Obstruction from accumulated secretions may and are flexible enough to change in shape with cough

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(2):273-283
 Table 2 Types of airway stents
Type of stent (material) Manufacturer Placement technique Sizes available (OD vs. length) Anti-migration mechanism 276
Tubular silicone (silicone) Hood Laboratories, Rigid Bronchoscopy Wide range from 9 mm × 20 mm External silicone studs and direct
Pembroke MA, USA to 20 mm × 80 mm pressure on the wall
Boston Medical Products,
Westborough MA, USA
Bryan Corporation/Lymol
Medical, Woburn MA, USA
Montgomery T-tube (silicone) Boston Medical Products, Tracheostomy and umbilical Pediatric: 6–9 mm vertical limb Horizontal limb prevents migration
Westborough MA, USA tape or Kelly technique and 6 or 8 mm horizontal limb
Adult: 10–16 mm vertical limb
and 8 or 11 horizontal limb
The length of all limbs can be
customized
Silicone Y-stent (silicone) Novatech, Grasse, France Rigid Bronchoscopy Wide range in diameters of The Y shape prevents migration
tracheal-bronchial-bronchial
Bryan Corporation/Lymol Direct laryngoscopy with “pull

© Annals of Cardiothoracic Surgery. All rights reserved.

14-10-10 to 18-14-14
Medical, Woburn, MA, USA technique”
Modified laryngoscopy and
¶
“push technique”
Dynamic or Freitag stent (Silicone outer Boston Scientific, Natick Direct laryngoscopy with “pull 3 sizes: 11×8×8, 13×10×10, The Y shape prevents migration
construction with C-shaped stainless MA, USA technique” 15×12×12 with tracheal lengths
steel support struts and BA+ sulfate of 110 and R-bronchial 25 mm
Modified laryngoscopy and
impregnation for increased radiopacity) ¶ and L-bronchial 40 mm
“push technique”
Ultraflex stent (woven nitinol or nickel- Boston Scientific, Natick Flexible bronchoscopy with Wide range from 8 mm × 20 mm In the uncovered stent, pressure
titanium alloy structure with or without a MA, USA wire-guided fluoroscopy to 20 mm × 80 mm on the wall and granulation tissue
polyurethane cover) prevents migration. In the covered
Rigid bronchoscopy with
stent, the proximal and distal 5mm

www.annalscts.com
direct visualization
are uncovered to prevent migration
Merit Endotek or Alveolus (laser-cut nitinol Merit Medical Systems, Flexible bronchoscopy with Wide range from 8 mm × 15 mm Anti-migration fins that embed in
or nickel-titanium alloy structure with South Jordan, Utah, USA direct visualization to 20 mm × 80 mm the airway mucosa
polyurethane cover) Flexible bronchoscopy with
wire-guided fluoroscopy
Rigid bronchoscopy with
direct visualization
Bona stent (woven nitinol wire structure EndoChoice, Alpharetta, GA, Flexible bronchoscopy with Wide range from 10×30 to Direct pressure on the wall
with silicone cover) USA wire-guided fluoroscopy 20–80 mm
Rigid bronchoscopy with
direct visualization
Polyflex stent (polyester mesh structure Boston Scientific, Natick, Rigid bronchoscopy Wide range from 8 mm × 20 mm Direct pressure on the wall
on outer stent and silicone) MA, USA to 22 mm × 80 mm
Balloon-expanding stents (fully Atrium iCast, Maquet Flexible bronchoscopy; the Wide range from 5 mm × 16 mm Direct pressure on the wall
covered stainless steel in two layers of Getinge, Hudson, NH, USA balloon and stent fit through a to 10 mm × 38 mm
polytetrafluoroethylene) 2.8-mm working channel
¶
, techniques described in “Kazakov J, Khereba M, Thiffault V, et al. Modified technique for tracheobronchial Y-stent insertion using flexible bronchoscope for stent guidance. J Thorac
Cardiovasc Surg 2015;150:1005-9.”.

Ann Cardiothorac Surg 2018;7(2):273-283

Folch and Keyes. Airway stents
Annals of cardiothoracic surgery, Vol 7, No 2 March 2018 277

(1,24). With the idea of incorporating the benefits and

minimizing the drawbacks of silicone and bare metal
stents, the “hybrid stents,” or covered metallic stents, were
created. These stents incorporate the polymer and metal
alloy technology previously elucidated. Covered metallic
stents have the advantage of minimal tissue ingrowth and
easier manipulation. Polyurethane, polytetrafluoroethylene
(PTFE) and silicone have been used as the covering
material for hybrid stents. Degradation of the polyurethane
membrane by respiratory secretions has been described (25).
PTFE is more chemical resistant; however, a 13% rate of
Figure 1 Customized silicone stent.
PTFE separation from the stent at the site of polyurethane

A B C

Figure 2 Common complications of silicone stents. (A) Silicone stent migration; (B) granulation at distal end of the stent; (C) mucus
plugging in stent.

A B C

Figure 3 Ultraflex partially covered stent after successful removal. (A) Covered nitinol stent with proximal string for removal; (B) covered
nitinol stent showing granulation tissue that penetrates the uncovered segment of the stent preventing migration but causing obstruction; (C)
covered nitinol stent with granulation tissue that penetrates the uncovered segment.

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278 Folch and Keyes. Airway stents

temperatures, while regaining its original shape at higher or

body temperatures (18,27).

Polyflex stent (Boston Scientific, Natick, MA, USA)

The Polyflex stent is a hybrid self-expanding stent made
from a polyester-fiber wire mesh covered by silicone (28).
It is deployed under rigid bronchoscopy using a special
delivery device. It is available as a straight stent in various
diameters and lengths. Migration rates have been described
to be as high as 69%, and a 25% rate of significant mucous
retention has been reported (29). In a separate prospective
Figure 4 Merit Endotek nitinol stent with anti-migration fins study at 5-centers, researchers reported their experience
(arrows) that may cause trauma during cough or attempted removal. with 27 Polyflex stents for malignant airway obstruction,
where the migration rate was 3% (28).

attachment was seen in this study. Stents have been Merit Endotek or alveolus stent (Merit Medical Systems,
designed with external or internal covering. The external South Jordan, Utah) (Figure 4)
cover does not allow the stents to incorporate into the Alveolus is a fully covered hybrid stent with a dedicated
tissue, leading to a migration rate estimated between 18% deployment device and specially designed airway
and 22% (25). Internally covered stents, on the other hand, measurement device. It may be placed using fluoroscopic
are less susceptible to migration from friction and anchor guidance, as well as rigid bronchoscopy. Limited data has
of the bare metal outside of the stent in contact with the been published on its use (30). The initial publications
airway. A recent study showed a 4% migration rate with the reported a significant risk of migration, prompting a design
use of an internal silicone-covered stent. modification that included “non-migration” fins. These
Some of the covered metallic stents have, at the proximal appendages become more prominent as pulling forces
end, a small loop for manipulation that once grasped, will are exerted on the stent. As a result, the “anti-migration”
subsequently create a partial collapse of the stent to allow fins sink deeper into the mucosa effectively preventing
removal (Figure 3A). Among its disadvantages, the stent migration (see detail in Figure 4). Unfortunately, this
cover may facilitate sputum retention and obstruction, as is may cause significant mucosal injury at the time of stent
the case with silicone stents (13). Recently, self-expanding removal. In unique circumstances, our group has experience
Y-stents became available outside of the United States. with customizing the length of this stent, by trimming rows
The initial experience in 38 patients with 3-month follow- of struts prior to deployment.
up using rigid and flexible bronchoscopy placement is
considered preliminary (26). Here, we present some of the The dynamic (Freitag) stent (Boston Scientific, Natick,
most common metallic and hybrid stents used. MA, USA)
The Freitag “Y” silicone stent with bands of stainless steel
Ultraflex stent (Boston Scientific, Natick, MA, USA) (horseshoe-shaped) incorporated with silicone, along the
Ultraflex is a nitinol (nickel-titanium alloy) stent designed anterior and lateral surface of the cylindrical tube to mimic
with a polyurethane cover to prevent tumor or granulation tracheal cartilages. Thus, the posterior membrane is flexible
tissue ingrowth. It is deployed by a guide-wire technique and mimics the motion of the posterior tracheal wall during
or flexible bronchoscopy and is self-expandable (7). respiration (18,31). The rigidity of the dynamic Y stent
Some experts also deploy it through rigid bronchoscopy. precludes its use in conventional rigid stent deployers,
The Ultraflex stent comes in a compressed state and is and actually requires removal of the rigid bronchoscope
delivered to the desired area by gradually removing a suture for placement under direct laryngoscopy. It can also be
that secures the stent in place. It has “shape memory”; deployed under suspension laryngoscopy. These stents
it self-adjusts to changes in the bronchial size without are mostly useful in cases of tracheobronchomalacia and
any shortening after deployment, and it deforms at cold malignant airway disease involving the main carina.

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Annals of cardiothoracic surgery, Vol 7, No 2 March 2018 279

Table 3 Complications of airway stents Comparative data in the lab

Stent migration A recent publication comparing three different tracheal

Stent malposition stents made of steel, nitinol and nitinol drug-eluting
compounds demonstrated the highest granuloma
Granulation formation
formation and overall proliferative reactivity with steel,
Tumor ingrowth followed by drug-eluting nitinol and finally nitinol being
Mucoid impaction least reactive (34).
Infection

Stent fracture Comparative data in clinical research

Bronchovascular fistula
To date, there are no comparative trials of stents in the
Airway rupture bronchoscopy literature. Retrospective studies, with their
Halitosis shortcomings, have shown different risks of complications
for different airway stents. In one such study, 172 patients
with 195 stents showed Merit Endotek (former Aero)
stents had an increased risk of infection (HR 1.98; 95% CI,
Stents for tracheoesophageal or
1.03–3.81) and silicone tube stents had increased risk of
bronchoesophageal fistulas
migration (HR 3.52; 95% CI, 1.41–8.82). Silicone stents
Stents have been used to seal fistulas between the and lower respiratory tract infections were associated with
respiratory and digestive tracts when surgical correction increased risk of granulation tissue (35).
is contraindicated. In cases where an esophageal stent has
been placed, perforation and migration can be prevented
Complications of stents
by a tracheal stent. In fact, for the treatment of large
tracheoesophageal fistulas, stenting of both the trachea and Airway stents have been associated with significant
the esophagus seems to be superior over single stenting complications. The most important complications are
of either tract (3,32,33). Collaboration with a surgeon is associated with human error in placement, sizing and
advised to determine the most appropriate remedy for this perhaps overextended placement. The initial stents and
complicated condition. tubes (i.e., Montgomery T-tube) required a tracheostomy
for placement. Thereafter, the rigid bronchoscope was used,
and, in the last two decades, self-expanding metallic stents
Airway stents in lung transplantation
have been placed with rigid or flexible bronchoscopy. The
Bronchial anastomotic dehiscence after lung complications associated with airway stents can derive from
transplantation is a potentially catastrophic airway the following factors: the material; covering, or lack thereof;
complication, seen typically within 1 to 5 weeks after continuous movement; infection; mucociliary inhibition;
the implantation. Fortunately, the incidence of severe or biomechanical properties of the stent. The original
dehiscence is low (23). The management depends on complications associated with metallic stents were the result
the symptoms and severity of the presentation. Therapy of repurposing of colon, biliary or vascular stents for airway
may involve observation for mild cases, versus surgical use. Their high radial force and traumatic borders were
or endoscopic management for high-grade dehiscence. responsible for catastrophic complications and clinicians
Mughal et al. described the successful management of were forced to abandon their use or attempt sizing trickery
severe dehiscence in seven patients using airway stents (21). to minimize migration and other complications. However,
In this series, Ultraflex uncovered stents were used as a complications still occur. Table 3 describes common and
platform for dehiscence healing. They took advantage of uncommon complications of airway stents.
the uncovered metallic stents “complication” of excessive Some investigators consider that prompt removal of
granulation tissue to heal the dehiscence. airway stents after remodeling of the airway has occurred,

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280 Folch and Keyes. Airway stents

or after adequate response to chemotherapy or radiation, lymphoma or small cell lung cancer). In these cases,
may minimize these complications. Furthermore, the use and in absence of the final pathology, it is reasonable
of scheduled follow-up with computed tomography or to place a palliative stent that may be removed at a
bronchoscopy to identify and address early complications is later procedure;
recommended (36).  Airway stent(s) placed for airway dehiscence after lung
transplantation. As previously described, these are rare
situations where creating a scaffold for granulation
The case for lobar and segmental stents
and re-epithelization is warranted. After a few weeks,
Traditionally, stent placement has been only recommended careful removal of the stent is carried out.
for central airways (trachea, mainstem bronchi) for two
reasons: first, the available silicone stents had a 1 mm or
How to remove stents
1.5 mm wall, conferring a disadvantage in the internal-to-
external diameter ratio, and; second, the idea that lobar The literature on stent removal is scant and mostly describes
or segmental salvage was not necessary given the limited the complications related to inappropriate stent placement.
survival of lung cancer. In the recent years, progress in The removal of silicone stents in general is straightforward.
lung cancer survival and technological improvements in the It involves rigid bronchoscopy and the use of rigid forceps
manufacturing process of airway stents has challenged these to simultaneously twist-and-pull the stent into the barrel
assumptions. A growing group of experts are using small of the rigid bronchoscope while maintaining continuous
metallic stents either in balloon expanding or self-expanding visual contact with the stent. Twisting is thought to prevent
formats with encouraging results (37,38). tearing of the stent generated from single-plane pulling. In
the case of Montgomery T-tubes, the removal just requires
gentle yet firm tugging from the horizontal limb; caudally
When the stent is temporary
at first, to release the proximal limb, and then cephalad to
A rarely discussed situation in the airway stent literature remove the remaining distal limb.
is the use of temporary stents. In selected situations, the The difficulty in removing metallic stents was initially
clinician may encounter a significant airway obstruction described with the use of biliary stents adapted to the
that requires stent placement with subsequent removal a airway (41). Every effort should be made to remove the
few weeks later, example situations include: stent in one piece. This minimizes the risk of leaving stent
 Temporary stent trial for evaluation of the potential fragments and also decreases the length of the procedure.
clinical benefit of surgical tracheoplasty for We described our experience in removing metallic stents by
tracheobronchomalacia. Our group and others have using cryoablation, Jackson dilators or Fogarty balloons and
used short-term (1–2 weeks) trials with silicone Y-stents rigid bronchoscopy (42). The removal of metallic stents in
and uncovered nitinol stents in an attempt to identify the first 2 months is relatively simple. However, after that
those patients who are more likely to benefit from interval, the degree of difficulty and experience necessary
surgical tracheoplasty (39,40). It is imperative to have increases.
a pre-procedural agreement with the patient that the An important factor to consider is the specific type of
stent(s) will only remain in place for 1–2 weeks given metallic stent. Laser-cut fully covered stents (i.e., Merit-
the potential complications of airway stents in benign Endotek) will have less tumor ingrowth, but the anti-
disease. After completing subjective and objective migration fins will likely cause significant mucosal injury
evaluation of its benefit, the stent(s) are removed, and bleeding. After separating them from the wall with
where any low-grade granulation or irritation that may Jackson dilators or Fogarty balloon, these stents should
have occurred can be expected to resolve within days be removed by rigid forceps in a twist-and-turn fashion
to weeks. Thereafter, those patients who responded similar to silicone stents. Braided nitinol stents (i.e.,
may undergo surgical tracheoplasty; Ultraflex) should also be freed from the wall with Jackson
 Airway stent(s) placed for tumors at the time of initial or Fogarty balloons first. Thereafter, identify the proximal
diagnostic bronchoscopy. In rare cases, the tumor circumferential suture and pull from that point in order
causing the obstruction will have a dramatic initial to purse-string the proximal end of the stent and facilitate
response to chemotherapy or radiotherapy (e.g., removal (Figure 3). Failure to do so may result in piecemeal

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Annals of cardiothoracic surgery, Vol 7, No 2 March 2018 281

consultant for Boston Scientific and Medtronic. Dr. Keyes

has no conflicts of interest to declare.

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Conflicts of Interest: Dr. Folch has served as a scientific 13. Makris D, Marquette CH. Tracheobronchial stenting

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(2):273-283
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Practical and Legal Considerations. Respiration

Cite this article as: Folch E, Keyes C. Airway stents.

Ann Cardiothorac Surg 2018;7(2):273-283. doi: 10.21037/
acs.2018.03.08

© Annals of Cardiothoracic Surgery. All rights reserved. www.annalscts.com Ann Cardiothorac Surg 2018;7(2):273-283