Both angiocatheters are inserted percutaneously, perpendicular to the stent and trachea to avoid perforation of the posterior wall of the trachea and prosthesis. Sutures are tied snuggly, but not tight enough to cause laceration of the anterior wall of the stent. We chose nonabsorbable, blue polypropylene (Prolene), or green braided polyester (Tevdek) sutures because of their known nonreactivity. In addition, these colors are easily discerned during videobronchoscopy fully generic allegra. The threader (Bodkin), an instrument originally designed to thread a bobber for fly fishing, makes suture manipulation and retrieval relatively simple. Diagrams depicting the specially designed instrument (Stent Introducer System) for stent placement and our method of external stent fixation are presented in Figure 2. Technical success was achieved in each case.
Symptoms resolved, none of the stents migrated, and quality of life was maintained, although granulation tissue formation or tumor overgrowth required repeat bronchoscopic intervention. None of our patients with cutaneous buttons developed skin infections. In one instance, however, the stent was sewn to a subcutaneously placed button (case 2). Indeed, successful subcutaneous fixation of laryngeal keels and stents has been previously reported. Our patient had a long-standing tracheotomy and recent peristomal infection. Not surprisingly, subcutaneous infection occurred, prompting us to fix all other buttons externally. A potential problem of this technique is skin infection or abscess formation due to maceration below the fixed button. Careful skin care, especially while shaving, is, therefore, essential. Another potential drawback of this technique is discomfort while swallowing because of unsatisfactory mobility of the button with the laryngotracheal complex during deglutition. None of our patients voiced this complaint. Theoretically, problems with deglutition could be avoided by suturing the stent to the outer wall of the trachea rather than to an externally fixed button. Emergent stent removal, however, would be cumbersome because a cutaneous incision and dissection are necessary to remove the buried suture.
Endoscopic management of tracheal stenosis, of which stent insertion has become an essential component, has become an attractive therapeutic alternative for many patients with high tracheal strictures. In many instances, subglottic stents provide palliation of dyspnea while preparing patients for open surgical resection. In others, stenting, sometimes associated with laser resection, is curative. Provided that bronchoscopic surveillance is maintained to detect and treat complications, we suggest that external fixation of an indwelling silicone stent also has a place, albeit a small one, among other modes of palliative therapy for patients with subglottic tracheal stenosis. In summary, this technique may be considered to prevent stent migration and provide symptomatic relief of dyspnea in carefully selected patients who have failed or who have refused other therapeutic measures.
Figure 2. Technique of external stent fixation after insertion into the upper trachea: (1) the stricture is gently dilated with the rigid tube; (2) the stent, which has been previously loaded into the hollow stent introducer, is expulsed through the rigid tube with the stent pusher; (3) the rigid tube is withdrawn carefully; (4) and its distal extremity is kept between the vocal cords; (5) the stent is grasped with rigid bronchoscopic forceps; (6) using sterile procedure, another operator inserts two angiocatheters through the anterior neck into the stent while the endoscopist continues observation through the rigid bronchoscope, and the needles are withdrawn once the angiocatheters are inside the stent; (7) the suture is placed through one of the angiocatheters, the threader (Bodkin) through the other; (8) the threader is used to pull the suture up through the second angiocatheter; and (9) the suture is secured over a silicone button, fixing the stent externally.