气管与主支气管良性狭窄金属支架植入后再狭窄及处理

Restenosis and its management after metallic stents implantation in benign tracheal and main bronchial stenosis

目的观察良性气管、主支气管狭窄金属支架植入后再狭窄的发生情况,评价球囊扩张、冷冻、高频电凝对再狭窄的疗效。方法对30例良性气管狭窄(A组)、35例支气管结核(EBTB)性主支气管狭窄(B组)者行金属支架植入术,随访观察再狭窄的发生情况,对再狭窄者行球囊扩张、冷冻和高频电凝联合治疗。评价治疗前及病情稳定后狭窄段气道内径、气促指数和肺通气功能。结果(1)A组发生再狭窄者6例,B组发生再狭窄者8例,再狭窄率分别为20%和22.86%。共植入国产支架30枚,6例发生再狭窄,再狭窄率为20%(6/30);共植入Ultraflex支架36枚,8例发生再狭窄,再狭窄率为22.2%(8/36)(P>0.05)。气管上段支架植入再狭窄率为4/9,中下段支架植入再狭窄率为9.09%(χ2=5.114,P<0.05,但χ2c=3.100,P>0.05)。纤维化期EBTB再狭窄率为16.67%,炎症反应期EBTB再狭窄率为60%(χ2=4.564,P<0.05,但χ2c=2.437,P>0.05)。(2)A组再狭窄治疗有效率为4/6,其中上段和中下段分别为2/4和2/2。B组再狭窄治疗有效率为7/8。(3)2组患者病情稳定后与治疗前相比,狭窄段内径均增加,气促指数均下降,肺活量均升高,第1秒钟用力呼气容积均上升。结论良性气管狭窄、结核性主支气管狭窄金属支架植入后有部分患者发生再狭窄。气管上段再狭窄发生率高于中下段,对这部分患者行金属支架植入术时应慎重。处于炎症反应期的EBTB再狭窄发生率高于纤维化期,应尽量避免对这部分患者行金属支架植入术。球囊扩张、冷冻和高频电凝是治疗支架植入后再狭窄的有效方法。

Objective To observe the occurrence of restenosis after metallic stents implantation in benign tracheal and main bronchial stenosis, and to evaluate the therapeutic effects of balloon dilatation, cryotherapy and electrocautery. Methods Thirty patients with benign tracheal stenosis and 35 patients with main bronchial stenosis caused by tuberculosis were treated with metallic stents implantation and a follow-up was carried out to observe the occurrence of restenosis. Combined balloon dilatation, cryotherapy and eletrocautery were used to manage the restenosis. The lumen of stenotic segment, dyspnea index and pulmonary function were measured before management and after the patient＇s condition became stable. Results Restenosis occurred in 6 of the 30 patients receiving tracheal stenting and in 8 of the 35 patients receiving bronchial stenting, the restenosis rates were 20% and 22. 86% , respectively. In total, 30 Chinesemade stents and 36 Ultraflex stents were implanted, and the restenosis rate was 20% and 22. 2%, respectively （P 〉 0. 05）. The restenosis rate was 4/9 in the upper segmental tracheal stents, and was 9. 09% in the middle-lower segmental stents （X^2 =5.114, P〈0.05, but X^2 =3.100, P〉0.05）. The restenosis rate was 16.67% in the fibrotic stage of endobronchial tuberculosis （EBTB） , and was 60% in the inflammatory reaction stage of EBTB （ X^2 = 4. 564, P 〈 0. 05, but X^2 = 2. 437, P 〉 0. 05）. The effective rate was 4/6 in the tracheal stenting restenosis patients, and was 2/4 and 2/2 in the upper and middle-lower segment groups, respectively. The effective rate was 7/8 in the bronchial stenting restenosis patients. After management, the lumen diameter of stenotic segment in the tracheal stenting restenosis patients increased from （ 3.33 ± 1.63 ） mm to （ 9.33 ± 3.98 ） mm （ P 〈 0. 02）, the dyspnea index decreased from （ 3.67 ± 0. 52） to （ 1.50 ± 1.64） （ P 〈 0. 02）, the vital capacity （VC） increased from （ 1.39 ± 0. 17 ） L to （2. 43 ± 0. 70） L （ P 〈0. 01 ） , the forced expiratory volume in one second （ FEVI ） increased from （ 1.02 ± 0. 15 ） L to （ 2. 00 ± 0. 72） L （ P 〈 0. 02）. After management, the lumen diameter of stenosis segment in the bronchial stenting restenosis patients increased from （ 3.00 ± 0. 76 ） mm to （ 7.38 ± 2. 00 ） mm （ P 〈 0. 001 ）, the dyspnea index decreased from （ 1.63 ± 0. 52 ） to （0. 50 ± 0. 76 ） （ P 〈 0. 005 ） , VC increased from （ 1.74 ± 0. 16）L to （2. 74 ±0.41）L （P〈0. 001）, FEV1 increased from （1.41 ±0. 19）L to （2. 56 ±0. 37）L （P〈 0. 001 ）. Conclusion Restenosis occurred in some patients with benign tracheal and tuberculous bronchial stenosis after metallic stent implantation. The restenosis rate was higher in the upper tracheal stenosis than that in the middle-lower tracheal stenosis. Caution should be taken when metallic stents are placed in this part of the trechea. The restenosis rate was higher in the inflammatory reaction stage of EBTB than in the fibrotic stage. Effort should be made to avoid placing metallic stents at this stage of the disease. Balloon dilatation, cryotherapy and eletrocautery are effective methods in managing restenosis after stent implantation.