Filler R M, Forte V, Chait P
Department of Surgery, University of Toronto, and The Hospital for Sick Children, Ontario, Canada.
J Pediatr Surg. 1998 Feb;33(2):304-11. doi: 10.1016/s0022-3468(98)90452-3.
The authors report a 5-year experience of inserting the Palmaz stent into infants and children who had a variety of major airway obstructions.
From 1992 to 1997, 30 balloon expandable stents (Palmaz) were inserted in the trachea (n = 18) and bronchi (n = 12) of 16 infants, ages 1 week to 26 months (median, 9 months), suffering from three types of serious airway obstruction. In group 1, 10 stents were placed in eight children for tracheal or bronchomalacia. In group II, 11 stents were inserted in four infants for stricture at the site of surgical repair of stenosis. In group III, nine stents were placed to relieve airway compression from enlarged pulmonary arteries associated with severe congenital heart disease in three children and mediastinal lymphangioma in one. Tracheal stents were 30 mm long and were expanded to 8 to 10 mm at placement. Bronchial stents were 12 to 15 mm long and were expanded to 7 to 9 mm. The nonexpanded stents were placed on an inflatable balloon catheter and were inserted into the desired position in the airway through a bronchoscope or endotracheal tube using x-ray control. They were expanded and fixed in place by inflating the balloon to its rated diameter.
In group I, granulation tissue developed over the stents in five of eight cases. Obstructing granulations were removed by scraping or balloon compression in three and resulted in earlier than the planned removal in two. Stents have now been removed in six of eight cases. Major airway obstruction has not recurred. In group II, stents have been in place in all cases for 13 to 56 months after insertion, but in one child with three stents, two were removed for obstructive granulations 44 months after insertion. All are well. All group III patients could be extubated after stenting, but two with heart disease died after 3 and 12 months of palliation. During the course of follow-up, stents in the bronchi of two had migrated, and an additional stent was required. Autopsy in one showed full-thickness bronchial erosion but no perforation by the stent. A total 11 of 30 stents have been removed bronchoscopically in seven children without complications. Another child referred here for tracheal stent removal after laser resection of granulations died at attempted removal because the stent was "welded" into the tracheal wall by the inflammatory reaction. Manipulation of the stent completely occluded the airway.
Airway stents can be inserted easily and safely and left in-situ for prolonged periods to relieve major airway obstruction from a variety of causes. Tissue reaction may necessitate bronchoscopic manipulation and early stent removal, and adds to the difficulty of removal.
作者报告了将帕尔马兹支架植入患有各种严重气道阻塞的婴幼儿的5年经验。
1992年至1997年，对16名年龄在1周至26个月（中位数为9个月）的婴儿进行了30个球囊扩张支架（帕尔马兹）植入手术，这些婴儿患有三种严重气道阻塞类型。在第一组中，8名儿童因气管或支气管软化植入了10个支架。在第二组中，4名婴儿因狭窄手术修复部位的狭窄植入了11个支架。在第三组中，3名儿童因严重先天性心脏病相关的肺动脉扩大以及1名儿童因纵隔淋巴管瘤导致气道受压，植入了9个支架以缓解气道压迫。气管支架长30毫米，植入时扩张至8至10毫米。支气管支架长12至15毫米，扩张至7至9毫米。未扩张的支架放置在可充气球囊导管上，通过支气管镜或气管内导管在X线控制下插入气道的所需位置。通过将球囊充气至其额定直径使其扩张并固定在位。
在第一组中，8例中有5例支架上形成了肉芽组织。3例通过刮除或球囊压迫去除了阻塞性肉芽，2例导致支架比计划提前取出。目前8例中有6例已取出支架。主要气道阻塞未复发。在第二组中，所有病例的支架在植入后已放置13至56个月，但1名植入3个支架的儿童，其中2个在植入44个月后因阻塞性肉芽而取出。所有情况良好。第三组所有患者在植入支架后均可拔管，但2例患有心脏病的患者在姑息治疗3个月和12个月后死亡。在随访过程中，2例支气管内的支架发生移位，需要额外植入1个支架。1例尸检显示支气管全层糜烂，但支架未穿孔。7名儿童通过支气管镜取出了30个支架中的11个，无并发症。另1名因肉芽激光切除后转诊至此进行气管支架取出的儿童，在尝试取出时死亡，因为支架因炎症反应“焊接”到气管壁，操作支架完全阻塞了气道。
气道支架可以轻松、安全地插入并长时间留在原位，以缓解各种原因引起的主要气道阻塞。组织反应可能需要支气管镜操作和早期取出支架，并增加了取出的难度。
