Fully covered self-expandable metal y stent is a treatment option for tracheo-mediastinal fistula

SESSION TITLE: Procedures Case Report Posters 7 SESSION TYPE: Case Report Posters PRESENTED ON: 10/11/2023 12:00 pm - 12:45 pm INTRODUCTION: Tracheal defects and tracheo-mediastinal fistulas are rare complications occurring in patients with lung cancer and are often fatal. Treatment options are stenting, patch closure or muscle flap closure. Our case describes a fully covered self-expandable metal Y (SEM-Y) stent via flexible bronchoscopy (FB) under fluoroscopic guidance in a patient with tracheo-mediastinal fistula secondary to metastatic non-small cell lung cancer (NSCLC). CASE PRESENTATION: A 60-year-old female with history of tobacco use and stage IV right lung NSCLC presented with complaints of dyspnea. She completed her first round of chemotherapy with carboplatin, paclitaxel and pembrolizumab 3 days prior. CT chest showed a decrease in the size of her mediastinal mass, multifocal pneumonia and pneumomediastinum with a new defect of posterior tracheal wall with no esophageal mucosal defect. She was admitted with septic shock secondary to pneumonia and mediastinitis, hypoxic respiratory failure and tested positive for SARS-COV-2. Patient was started on broad spectrum antibiotics, remdesivir and steroids. She was treated with non-invasive positive pressure ventilation but eventually required mechanical ventilation.The patient was transferred to our hospital and underwent flexible bronchoscopy (FB). Upon inspection, a posterior distal tracheal wall defect just proximal to the main carina was visualized. Using a therapeutic 6.8 mm outer diameter bronchoscope, 2 guidewires were advanced into the right lower lobe and left lower lobe under fluoroscopic guidance. The tracheobronchial stent delivery catheter was advanced over the 2 guidewires into the 9.0 mm endotracheal tube under fluoroscopic guidance. The right and left limbs of the stent were deployed followed by the tracheal portion of the stent under fluoroscopic guidance. The stent covered the defect entirely on both ends with improvement of pneumomediastinum. Unfortunately, 5 days later, her family pursued comfort care due to patient's wishes of not wanting tracheostomy or aggressive care. DISCUSSION: Bronchial tree fistulas can communicate with the esophagus, pleura and mediastinum. These can result from trauma, tumors, lung resection or iatrogenic causes and increase mortality and morbidity. Treatment options include surgery or stents. Insertion of stents is a viable treatment option for patients who are not surgical candidates. Silicone Y stents require placement with rigid bronchoscopy (RB) which is not always feasible. SEM-Y stents have an advantage over silicone stents as they can be done via FB, utilize guidewires and are deployed under direct fluoroscopic visualization to ensure proper placement. CONCLUSIONS: SEM-Y stents are a minimally invasive approach to treat patients with bronchial tree fistulas including tracheo-mediastinal and tracheo-esophageal fistulas in patients who are not surgical candidates. REFERENCE #1: Cao M, Zhu Q, Wang W, Zhang TX, Jiang MZ, Zang Q. Clinical Application of Fully Covered Self-Expandable Metal Stents in the Treatment of Bronchial Fistula. Thorac Cardiovasc Surg. 2016;64(6):533-539. doi:10.1055/s-0034-1396681 REFERENCE #2: McManigle JE, Fletcher GL, Tenholder MF. Bronchoscopy in the management of bronchopleural fistula. Chest. 1990;97(5):1235-1238. doi:10.1378/chest.97.5.1235 REFERENCE #3: Pertzov B, Gershman E, Izhakian S, Amor SM, Rosengarten D, Kramer MR. Placement of self-expanding metallic tracheobronchial Y stent with laryngeal mask airway using conscious sedation under fluoroscopic guidance. Thorac Cancer. 2021;12(4):484-490. doi:10.1111/1759-7714.13782 DISCLOSURES: No relevant relationships by Suchitra Pilli No relevant relationships by Patryk Purta