Long-Term Success of Metal Endobronchial Stents in Lung Transplant Recipients

Abstract

Background Bronchial stenosis is a common complication following lung transplantation. We evaluated long-term associations of the use of self-expandable metal stents (SEMSs) with lung function tests, patient safety, and survival. Methods A retrospective chart review of 582 lung transplantations performed at our institution between January 2002 and January 2018. Fifty-four patients with SEMSs (intervention group) were matched one-to-one to patients without SEMSs (control group) using propensity score matching for age, sex, the year, and type of transplantation (unilateral/bilateral), and underlying disease. Data regarding long-term lung function and survival were compared between the groups. Results During a median follow-up of 54.8 months, the difference in survival between the study groups was not statistically significant (p = 0.2). Following 5, 7.5 and 10 years, values of mean forced expiratory volume in 1 second (FEV1) were comparable between patients with and without SEMSs as follows: 59.5 versus 62.6% (p = 0.2), 55.9 versus 55.0% (p = 0.4), and 63.5 versus 61.9% (p = 0.3), respectively. In the intervention group, a significant increase in the mean FEV1 was observed in 60 days after stent insertion (from 41.9 ± 12.8 to 49.5 ± 16.7% days, p < 0.001). Long-term complications following stent insertion included severe bleeding (1.8%), stent fractures (7.4%), stent stenosis (7.4%), stent collapse (3.7%), endobronchial pressure ulcer (1.9%), and stent migration (1.9%). Conclusion SEMS insertion is associated with a positive sustained effect on lung function, without increasing long-term mortality. Thus, airway stenosis after lung transplantation can be safely and successfully treated using endobronchial metal stenting, with tight bronchoscopic follow-up and maintenance.

Utility and safety of airway stenting in airway stenosis after lung transplant: A systematic review

“…Almost all studies indicated that stent insertion could immediately palliate stenosis symptoms such as dyspnoea, improve lung function ( 11 , 13 – 16 , 19 – 21 , 23 – 26 ), decrease the degree of stenosis ( 23 ) and successfully re-open the airways ( 16 ). Regarding long-term efficacy, most studies indicated that the survival time of post-stent patients was similar to that of patients without stents ( 3 , 11 , 20 , 24 , 25 ). However, Gottlieb et al ( 16 ) reported significantly lower survival rate in LTx recipients with stents than in the total LTx cohort.…”

“…Ma et al ( 21 ) found a statistically significant reduction in the number of bronchoscopies per month after stent removal compared to pre-stent placement for patients who ultimately could undergo stent removal. Regarding long-term lung function improvement for more than 3 months, some studies demonstrated that FEV 1 improved significantly after stent implantation ( 11 , 14 , 19 , 21 , 24 , 26 ). However, Izhakian et al ( 24 ) suggested that FEV 1 values were significantly lower in patients with stents than those without stents at 2.5 years post-transplantation but did not differ significantly between the two groups at 5, 7.5, and 10 years.…”

“…Regarding long-term lung function improvement for more than 3 months, some studies demonstrated that FEV 1 improved significantly after stent implantation ( 11 , 14 , 19 , 21 , 24 , 26 ). However, Izhakian et al ( 24 ) suggested that FEV 1 values were significantly lower in patients with stents than those without stents at 2.5 years post-transplantation but did not differ significantly between the two groups at 5, 7.5, and 10 years. Baljendra et al ( 19 ) showed that the statistically significant improvement in the FEV 1 value after stent implantation was transient, was sustained at 6 months post-stent implantation ( 19 ), and then (12 months) the changes in FEV 1 may return to baseline.…”

“…Almost all the 17 studies enrolled indicated that patients experienced immediate symptom relief and improved lung function. However, the follow-up results were controversial despite the majority of researchers identifying the long-term efficacy of stent therapy for post-transplantation airway stenosis ( 3 , 11 , 14 , 20 , 24 – 26 ). It cannot be ignored that some authors considered the improvement unsustainable.…”

Management of airway complications after lung transplantation: is there an ideal stent?

“…This technique is based on previous works which have demonstrated since 1997 in animals and then in humans the interest of using stented aortic matrices for airway replacement (21,22). Izhakian et al demonstrated that SEMS insertion was associated with a positive sustained effect on lung function without increasing long-term mortality (23). In addition, they established that bronchial stents were more likely to be colonized with pathologic bacteria and having pneumonia (24).…”