Expandable stents.

Expandable metallic stents are effective in selected patients with malignant or benign airway stenoses. When used for malignant lesions, the primary purpose of the stent is to improve the quality of life; stents are usually chosen for palliation of symptoms in recognition of the low likelihood of success for other therapy. For patients with benign stenoses, the stents provide a permanent source of structural support to alleviate the narrowed segment. The advantages of the expandable metallic stents are as follows: (1) they can be inserted through an endotracheal tube or under local anesthesia with relative simplicity under fluoroscopic guidance; (2) they do not impair the drainage of sputum because ciliary movement is not interrupted; (3) over a period of a few weeks, the meshwork is gradually covered with mucosa as the stent becomes incorporated into the airway wall; (4) ventilation usually is not impaired if the metallic mesh stent covers another nonstenosed bronchus, because the interstices of the stent are nonobstructive; and (5) they are dynamic and continue to expand over time, particularly if concurrent treatment achieves an effect on the lesion that caused stenosis. Disadvantages of the expandable stent include (1) they often are only temporarily effective for tracheobronchial stenosis due to intraluminal tumor or granulation tissue, both of which can grow between the wires; (2) they are considered permanent stents because removal is difficult; and (3) they can be poorly positioned during placement or can become displaced by progressive migration after placement, and they cannot be repositioned. A relative contraindication to insertion is an inflammatory process or infection that can predispose to granulation formation, particularly at the points of maximal contact pressure of the stent to the airway mucosa. In the presence of inflammation, it may be better to use a silicone prosthesis until the inflammatory process subsides and fibrosis occurs. Granulation tissue is less likely to occur in areas of established scar than in areas of acute inflammation. In circumstances in which it is essential that a stent remain only temporarily, an expandable stent should not be inserted in favor of a silicone stent, which can be removed. In the future, expandable stents may have silicone coverings or may be constructed of materials that facilitate removal. Until that time, expandable stents should be considered permanent and nonremovable. Subtle differences exist among the available stents. Standard is low-profile expandable construction from wire mesh. A relatively minor difference is the slightly wider expansibility of the Gianturco stent, a quality that makes it the best suited of the three stents for lesions that involve tracheomalacia. Perhaps the only major difference between the Wallstent and the Gianturco and Palmaz stents is its better ability to conform to tortuous lesions. In an acutely angled stricture, a Wallstent offers a better opportunity for successful placement than other stents. The filamentous meshwork of the Wallstent allows it to bend and conform better to distorted airways. The Gianturco and Palmaz stents have little longitudinal elasticity, which makes them less effective in a tortuous or highly angulated airway stenosis. Expandable stents have demonstrated their efficacy and exposed their limitations in the treatment of airway stenoses. Refinements in design should help to lessen specific disadvantages and problems. Covered expandable stents, a realistic prospect, have specific advantages over standard expandable stents; they will be removable and prevent tumor ingrowth. Current investigative work with such prostheses for the vascular system may provide the foundation for their investigative use in the airway. In essence, two categories of expandable stents are evolving, covered and uncovered, each having unique features adaptable to the specific clinical needs.