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Biodegradable airway stents in infants - Potential life-threatening pitfalls
1Department of Otorhinolaryngology, Head and Neck Surgery, University of Szeged, Hungary.
Insights
Biodegradable polydioxanone stents for pediatric tracheobronchial obstruction can fragment, causing dangerous airway blockages. While initially improving breathing, these stents may lead to life-threatening complications requiring urgent intervention.
Area of Science:
- Pediatric Pulmonology
- Biomaterials Science
- Medical Device Engineering
Background:
- Severe tracheobronchial obstructions in children present significant clinical challenges.
- Biodegradable stents were explored as a less invasive, temporary solution to reduce interventions and complications.
- Polydioxanone (SX-ELLA) stents were investigated for treating pediatric tracheobronchial obstructions.
Observation:
- Initial improvements in breathing were noted post-stent placement in three pediatric patients.
- Stent degradation began around the 5th postoperative week.
- Degradation resulted in large intraluminar fragments causing significant airway obstruction.
Findings:
- One patient experienced fatal pneumonia, while another required emergency bronchoscopy due to stent fragments.
- The fragmentation process created sharp pieces that obstructed the airway, sometimes anchoring to the mucosa.
- Successful maintenance of the tracheal lumen was achieved in one case through repeated stent placements.
Implications:
- Biodegradable polydioxanone stents pose a significant risk of life-threatening airway obstruction in pediatric patients due to fragment formation.
- The fragmentation pattern, typically starting 4-6 weeks post-procedure, necessitates careful monitoring and potential repeat interventions.
- While potentially useful for specific conditions like tracheal collapse, the risks associated with fragment-induced obstruction limit the unambiguous advantage of these biodegradable stents in pediatric airways.
Objective:
The solution of severe tracheobronchial obstructions in early childhood means a great challenge. Biodegradable stents were intended to be a minimally invasive temporary solution which may decrease the number of interventions and limit the possible complications of stenting procedures. However, our first experiences have brought out a new, - especially in childhood - potentially life-threatening complication of this concept.
Methods:
Five SX-ELLA biodegradable polydioxanone stents was applied in three patients because of severe tracheobronchial obstruction: congenital tracheomalacia (7 day-old), acquired tracheomalacia (10 month-old), and congenital trachea-bronchomalacia (10 month-old).
Results:
The breathing of all children improved right after the procedure. We observed degradation of the stent from the 5th postoperative week which resulted in large intraluminar fragments causing significant airway obstruction: one patient died of severe pneumonia, the other baby required urgent bronchoscopy to remove the obstructing 'foreign body' from the trachea. In the third case repeated stent placements successfully maintained the tracheal lumen.
Conclusions:
Polydioxanone stents may offer an alternative to metallic or silastic stents for collapse or external compression of the trachea in children; however, large decaying fragments mean a potential risk especially in the small size pediatric airway. The fragmentation of the stent, which generally starts in the 4-6 postoperative weeks, may create large sharp pieces. These may be anchored to the mucosa and covered by crust leading to obstruction. As repeated interventions are required, we do not consider the application of biodegradable stents unambiguously advantageous.
