American Journal of Respiratory and Critical Care Medicine

Treatment of airway complications after lung transplantation depends on iterative balloon dilatations and stent implantation. Self-expandable metallic stents (1) are the most widely used in this situation; they can relieve stenosis, and uncovered models can close dehiscences by the granulation tissue they induce. Silicone stents also have good results for this purpose (2). Despite progress made in customizing stents (3, 4), airway stenoses are sometimes difficult to manage because of complex anatomy, in particular those involving the bronchial anastomosis after lung transplantation (5, 6). We herein report on a patient suffering from complete stenosis of the bronchus intermedius (BI) with partial dehiscence of the bronchial anastomosis after lung transplantation. The complex anatomy excluded the use of conventional airway stents (Video 1). An OKI stent dedicated to the right primary carina can be discussed in such cases, but we believe this stent would have been less suitable owing to the complex anatomy of the right main bronchi, the particular angle between the upper right lobe and the BI, and the difference in caliber between a thin BI (7 mm) and the right main bronchi (15 mm). Furthermore, this stent would not cover the dehiscence. Computer-assisted segmentation of the airways of the patient was realized from a computed tomography scan. We virtually relieved the stenosis, closed the dehiscence, and designed a three-dimensional stent and mold (VGStudioMAX 3.0 software; Volume Graphics GmbH, Heidelberg, Germany). Numerical data were entered in a three-dimensional computer numerical control machine (RolandDG MDX 40A; Roland DG Corporation, Hamamatsu, Japan) to produce the Ertacetal POM C mold (Ertacetal POM C, Tielt, Belgium; AnatomikModeling SAS, Toulouse, France). A dedicated silicone stent (PN40000) was then made from this mold (Groupe Sebbin SAS, Boissy-l’Aillerie, France) (Figure 1). Under rigid bronchoscopy, the BI was progressively dilated. The stent was then inserted through the rigid tracheoscope and placed in the right main bronchus using a rigid forceps; it showed very precise congruence within the airway anatomy (Figure 2, Video 2) and allowed recannulation of the whole right-lung bronchial tree (Figure 3). The patient reported an immediate and dramatic improvement in dyspnea, quality of life, and functional parameters (peak expiratory flow increasing from 2.27 to 3.78 L/min) 7 days after the procedure. He still derives benefit (Day 75) with the maintenance of improvement in pulmonary symptoms and quality of life and no complication associated with the procedure. This world premiere computer-aided design application in airway stenting in a therapeutic impasse situation constitutes a strong proof of concept for the use of patient-specific devices in other complex airway diseases. Other indications will be evaluated in an ongoing study (NCT02889029).

Video 1. Bronchoscopic view of the limited dehiscence and complete bronchus intermedius obstruction before balloon bronchoplasty and stenting.

Video 2. Endoscopic result of the airways after dilatation of the stenosis and stenting showing great congruence of the device with the anatomically complex airways.

1. Mughal MM, Gildea TR, Murthy S, Pettersson G, DeCamp M, Mehta AC. Short-term deployment of self-expanding metallic stents facilitates healing of bronchial dehiscence. Am J Respir Crit Care Med 2005;172:768771.
2. Dutau H, Cavailles A, Sakr L, Badier M, Gaubert J-Y, Boniface S, Doddoli C, Thomas P, Reynaud-Gaubert M. A retrospective study of silicone stent placement for management of anastomotic airway complications in lung transplant recipients: short- and long-term outcomes. J Heart Lung Transplant 2010;29:658664.
3. Miyazaki T, Yamasaki N, Tsuchiya T, Matsumoto K, Takagi K, Nagayasu T. Airway stent insertion simulated with a three-dimensional printed airway model. Ann Thorac Surg 2015;99:e21e23.
4. Guibert N, Moreno B, Plat G, Didier A, Mazieres J, Hermant C. Stenting of complex malignant central-airway obstruction guided by a three-dimensional printed model of the airways. Ann Thorac Surg (In press)
5. Awori Hayanga JW, Aboagye JK, Shigemura N, Hayanga HK, Murphy E, Khaghani A, D’Cunha J. Airway complications after lung transplantation: contemporary survival and outcomes. J Heart Lung Transplant 2016;35:12061211.
6. Chhajed PN, Malouf MA, Tamm M, Spratt P, Glanville AR. Interventional bronchoscopy for the management of airway complications following lung transplantation. Chest 2001;120:18941899.

*These authors contributed equally to this work.

Funded by ADERSPOT (Association pour le Développement de l'Enseignement, de la Recherche et des Soins en Pneumo-Oncologie de Toulouse) and AnatomikModeling.

Author Contributions: Conception and design: N.G., A.D., B.M., C.H., and J.M.; analysis and interpretation: N.G., A.D., B.M., C.H., and J.M.; drafting the manuscript for important intellectual content: N.G., A.D., B.M., L.B., G.P., C.H., and J.M.; responses to the major revisions of the manuscript: N.G., B.M., L.M., C.H., and J.M. Recovery of additional data requested by reviewers and drafting of revised version: L.M.

The uncompressed videos are accessible from this article’s supplementary material page.

Originally Published in Press as DOI: 10.1164/rccm.201611-2361IM on February 16, 2017

Author disclosures are available with the text of this article at www.atsjournals.org.

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