Cutting Balloon Treatment for Resistant Benign Bronchial Strictures: Report of Eleven Patients
2010; Elsevier BV; Volume: 21; Issue: 5 Linguagem: Inglês
10.1016/j.jvir.2010.01.023
ISSN1535-7732
AutoresJin Hyoung Kim, Ji Hoon Shin, Ho-Young Song, Gi‐Young Ko, Dong Il Gwon, Hyun‐Ki Yoon, Kyu‐Bo Sung,
Tópico(s)Vascular Anomalies and Treatments
ResumoClinical outcomes of 11 patients who underwent cutting balloon treatment for the presence of benign airway strictures resistant to conventional balloon dilation are described. Cutting balloon treatment was technically and clinically successful in all 11 patients, with no major complications. During the mean 12.7-month follow-up period, there was recurrence in two patients, and the mean symptomatic improvement period was 23.1 months. The symptomatic improvement rates were 89% at 1 year and 59% at 2 years. Cutting balloon dilation can be a safe and effective therapeutic option for the treatment of benign bronchial strictures resistant to conventional balloon dilation. Clinical outcomes of 11 patients who underwent cutting balloon treatment for the presence of benign airway strictures resistant to conventional balloon dilation are described. Cutting balloon treatment was technically and clinically successful in all 11 patients, with no major complications. During the mean 12.7-month follow-up period, there was recurrence in two patients, and the mean symptomatic improvement period was 23.1 months. The symptomatic improvement rates were 89% at 1 year and 59% at 2 years. Cutting balloon dilation can be a safe and effective therapeutic option for the treatment of benign bronchial strictures resistant to conventional balloon dilation. BENIGN bronchial strictures that cause recurrent infections or dyspnea may occur after surgery, lung transplantation, trauma, external radiation therapy, or intubation, or as a complication of benign diseases (1Ferretti G. Jouvan F.B. Thony F. Pison C. Coulomb M. Benign noninflammatory bronchial stenosis: treatment with balloon dilation.Radiology. 1995; 196: 831-834PubMed Google Scholar, 2Sheski F.D. Mathur P.N. Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis.Chest. 1998; 114: 796-800Crossref PubMed Scopus (92) Google Scholar, 3Mayse M.L. Greenheck J. Friedman M. Kovitz K.L. Successful bronchoscopic balloon dilation of nonmalignant tracheobronchial obstruction without fluoroscopy.Chest. 2004; 126: 634-637Crossref PubMed Scopus (56) Google Scholar, 4Kim J.H. Shin J.H. Song H.Y. et al.Liquid [188]Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience.J Vasc Interv Radiol. 2008; 19: 406-411Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Iwamoto Y. Miyazawa T. Kurimoto N. et al.Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis.Chest. 2004; 126: 1344-1352Crossref PubMed Scopus (87) Google Scholar, 6Kapoor B.S. May B. Panu N. Kowalik K. Hunter D.W. Endobronchial stent placement for the management of airway complications after lung transplantation.J Vasc Interv Radiol. 2007; 18: 629-632Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar). Endoscopically or fluoroscopically guided balloon dilation has been an accepted initial therapy for benign bronchial strictures, primarily because balloon dilation is associated with lower morbidity and mortality rates than corrective surgery (1Ferretti G. Jouvan F.B. Thony F. Pison C. Coulomb M. Benign noninflammatory bronchial stenosis: treatment with balloon dilation.Radiology. 1995; 196: 831-834PubMed Google Scholar, 2Sheski F.D. Mathur P.N. Long-term results of fiberoptic bronchoscopic balloon dilation in the management of benign tracheobronchial stenosis.Chest. 1998; 114: 796-800Crossref PubMed Scopus (92) Google Scholar, 3Mayse M.L. Greenheck J. Friedman M. Kovitz K.L. Successful bronchoscopic balloon dilation of nonmalignant tracheobronchial obstruction without fluoroscopy.Chest. 2004; 126: 634-637Crossref PubMed Scopus (56) Google Scholar, 4Kim J.H. Shin J.H. Song H.Y. et al.Liquid [188]Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience.J Vasc Interv Radiol. 2008; 19: 406-411Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 5Iwamoto Y. Miyazawa T. Kurimoto N. et al.Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis.Chest. 2004; 126: 1344-1352Crossref PubMed Scopus (87) Google Scholar, 6Kapoor B.S. May B. Panu N. Kowalik K. Hunter D.W. Endobronchial stent placement for the management of airway complications after lung transplantation.J Vasc Interv Radiol. 2007; 18: 629-632Abstract Full Text Full Text PDF PubMed Scopus (53) Google Scholar, 7Kim J.H. Shin J.H. Song H.Y. et al.Tracheobronchial laceration after balloon dilation for benign strictures: incidence and clinical significance.Chest. 2007; 131: 1114-1117Crossref PubMed Scopus (45) Google Scholar, 8Carre P. Rousseau H. Lombart L. et al.Balloon dilatation and self-expanding metal Wallstent insertion for management of bronchostenosis following lung transplantation The Toulouse Lung Transplantation Group.Chest. 1994; 105: 343-348Crossref PubMed Scopus (100) Google Scholar). However, in many cases, there is recurrence after balloon dilation, and it has been reported to occur in 30%–80% of patients (1Ferretti G. Jouvan F.B. Thony F. Pison C. Coulomb M. Benign noninflammatory bronchial stenosis: treatment with balloon dilation.Radiology. 1995; 196: 831-834PubMed Google Scholar, 5Iwamoto Y. Miyazawa T. Kurimoto N. et al.Interventional bronchoscopy in the management of airway stenosis due to tracheobronchial tuberculosis.Chest. 2004; 126: 1344-1352Crossref PubMed Scopus (87) Google Scholar, 8Carre P. Rousseau H. Lombart L. et al.Balloon dilatation and self-expanding metal Wallstent insertion for management of bronchostenosis following lung transplantation The Toulouse Lung Transplantation Group.Chest. 1994; 105: 343-348Crossref PubMed Scopus (100) Google Scholar, 9Lee K.W. Im J.G. Han J.K. Kim T.K. Park J.H. Yeon K.M. Tuberculous stenosis of the left main bronchus: results of treatment with balloons and metallic stents.J Vasc Interv Radiol. 1999; 10: 352-358Abstract Full Text PDF PubMed Scopus (35) Google Scholar, 10Lee K.H. Ko G.Y. Song H.Y. Shim T.S. Kim W.S. Benign tracheobronchial stenoses: long-term clinical experience with balloon dilation.J Vasc Interv Radiol. 2002; 13: 909-914Abstract Full Text Full Text PDF PubMed Scopus (45) Google Scholar). Recently, placement of nonretrievable metallic stents or temporary implantation of retrievable metallic or silicone stents has been reported to be a safe and useful therapy for benign bronchial stricture resistant to balloon dilation (11Thornton R.H. Gordon R.L. Kerlan R.K. et al.Outcomes of tracheobronchial stent placement for benign disease.Radiology. 2006; 240: 273-282Crossref PubMed Scopus (70) Google Scholar, 12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar, 13Ryu Y.J. Kim H. Yu C.M. Choi J.C. Kwon Y.S. Kwon O.J. Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis.Eur Respir J. 2006; 28: 1029-1035Crossref PubMed Scopus (54) Google Scholar, 14Kim J.H. Shin J.H. Song H.Y. Lee S.C. Kim K.R. Park J.H. Use of a retrievable metallic stent internally coated with silicone to treat airway obstruction.J Vasc Interv Radiol. 2008; 19: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar). However, stent placement for benign bronchial stricture has the disadvantages of frequent stent migration, granulation tissue formation, and mucous retention (11Thornton R.H. Gordon R.L. Kerlan R.K. et al.Outcomes of tracheobronchial stent placement for benign disease.Radiology. 2006; 240: 273-282Crossref PubMed Scopus (70) Google Scholar, 12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar, 13Ryu Y.J. Kim H. Yu C.M. Choi J.C. Kwon Y.S. Kwon O.J. Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis.Eur Respir J. 2006; 28: 1029-1035Crossref PubMed Scopus (54) Google Scholar, 14Kim J.H. Shin J.H. Song H.Y. Lee S.C. Kim K.R. Park J.H. Use of a retrievable metallic stent internally coated with silicone to treat airway obstruction.J Vasc Interv Radiol. 2008; 19: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 15Gildea T.R.Murthy Sc Sahoo D. Mason D.P. Mehta A.C. Performance of a self-expanding silicone stent in palliation of benign airway conditions.Chest. 2006; 130: 1419-1423Crossref PubMed Scopus (68) Google Scholar). The cutting balloon features three or four microtomes fixed longitudinally on the surface of a noncompliant balloon (16Shin J.H. Song H.Y. Kim J.H. et al.Cutting balloon treatment for recurrent benign bronchial strictures.AJR Am J Roentgenol. 2008; 190: W130-W132Crossref PubMed Scopus (4) Google Scholar). Cutting balloon dilation is believed to provide more intraluminal patency than conventional balloon dilation as it creates microsurgical incisions before dilation, thereby facilitating dilation and permitting controlled and localized damage (17Cejna M. Cutting balloon: review on principles and background of use in peripheral arteries.Cardiovasc Intervent Radiol. 2005; 28: 400-408Crossref PubMed Scopus (33) Google Scholar, 18Wu C.C. Lin M.C. Pu S.Y. Tsai K.C. Wen S.C. Comparison of cutting balloon versus high-pressure balloon angioplasty for resistant venous stenoses of native hemodialysis fistulas.J Vasc Interv Radiol. 2008; 19: 877-883Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar). Cutting balloons have been used to dilate tight, resistant strictures in blood vessels, the ureter, the biliary system, and the esophagus (17Cejna M. Cutting balloon: review on principles and background of use in peripheral arteries.Cardiovasc Intervent Radiol. 2005; 28: 400-408Crossref PubMed Scopus (33) Google Scholar, 18Wu C.C. Lin M.C. Pu S.Y. Tsai K.C. Wen S.C. Comparison of cutting balloon versus high-pressure balloon angioplasty for resistant venous stenoses of native hemodialysis fistulas.J Vasc Interv Radiol. 2008; 19: 877-883Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 19Canaud L. Alric P. Berthet J.P. Marty-Ane C. Mercier G. Branchereau P. Infrainguinal cutting balloon angioplasty in de novo arterial lesions.J Vasc Surg. 2008; 48: 1182-1188Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar, 20Atar E. Bachar G.N. Bartal G. et al.Use of peripheral cutting balloon in the management of resistant benign ureteral and biliary strictures.J Vasc Interv Radiol. 2005; 16: 241-245Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar, 21Wilkinson A.G. MacKinlay G.A. Use of a cutting balloon in the dilatation of caustic oesophageal stricture.Pediatr Radiol. 2004; 34: 414-416Crossref PubMed Scopus (10) Google Scholar). However, cutting balloon therapy for benign airway strictures has been reported in only a very small number of patients (N = 3) with limited follow-up (16Shin J.H. Song H.Y. Kim J.H. et al.Cutting balloon treatment for recurrent benign bronchial strictures.AJR Am J Roentgenol. 2008; 190: W130-W132Crossref PubMed Scopus (4) Google Scholar). Therefore, the purpose of this study is to report the clinical results of cutting balloon treatment for benign bronchial strictures resistant to balloon dilation in 11 patients. Written informed consent was obtained from each patient, and our institutional review board approved this retrospective review of prospectively collected data. From August 2006 to December 2008, 11 patients underwent cutting balloon treatment for benign airway strictures. Among the patients included were three described in our previous report (16Shin J.H. Song H.Y. Kim J.H. et al.Cutting balloon treatment for recurrent benign bronchial strictures.AJR Am J Roentgenol. 2008; 190: W130-W132Crossref PubMed Scopus (4) Google Scholar). The inclusion criteria were documented chronic and fibrotic benign bronchial strictures as established by histologic diagnosis of bronchoscopic biopsy samples, strictures resistant to conventional balloon dilation, and focal ( 3 cm) bronchial strictures, acute strictures, or ongoing infection. Patient characteristics are summarized in the Table. Strictures in all patients were resistant to conventional balloon dilation (performed one to five times; mean of 1.5 times ± 1.2). The length of the strictures ranged from 1 to 2.5 cm (mean, 1.6 cm ± 0.5). The Hugh-Jones classification was used in all patients to evaluate improvement in respiratory function before and 1–3 days after the procedure (14Kim J.H. Shin J.H. Song H.Y. Lee S.C. Kim K.R. Park J.H. Use of a retrievable metallic stent internally coated with silicone to treat airway obstruction.J Vasc Interv Radiol. 2008; 19: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar).Tabled 1Summary of Patient Characteristics and Clinical OutcomesPt. No.Age (y)/SexCause of StrictureObstruction SiteObstruction Length (cm)Hugh-Jones GradeComplicationsBefore TreatmentAfter Treatment134/FTuberculosisLMB1.531—262/FTuberculosisRMB2.531—343/FTuberculosisRMB/RLLB2.5/2.542—410/FTuberculosisRMB231Blood-tinged sputum536/MTuberculosisLMB131—652/FRadiationLMB153Blood-tinged sputum737/FTuberculosisLMB1.831—842/FTuberculosisLMB1.531—927/FTuberculosisLMB1.531—1055/FTuberculosisRMB1.541—1171/MPostoperativeAnastomosis153Cutting balloon ruptureNote.—LMB = left main bronchus; RLLB = right lower lobar bronchus; RMB = right main bronchus. Open table in a new tab Note.—LMB = left main bronchus; RLLB = right lower lobar bronchus; RMB = right main bronchus. Before the procedure, the severity and length of the strictures were evaluated by chest radiography, computed tomography (CT) including three-dimensional reconstructions, and bronchoscopy. The pharynx and larynx were routinely anesthetized topically with an aerosol spray, followed by intravenous administration of midazolam for conscious sedation and monitoring of oxygen saturation. Under bronchoscopic guidance, a 0.035-inch exchange guide wire (Terumo, Tokyo, Japan) was inserted across the stricture and into the distal portion of the trachea or bronchus. The bronchoscope was removed and, with fluoroscopic guidance, a straight, 5-F graduated catheter (Cook, Bloomington, Indiana) was passed over the guide wire into the distal part of the stricture. Then, approximately 5 mL of contrast medium (iopromide [Ultravist 300, Bayer Healthcare, Wayne, New Jersey]) was injected through the catheter to evaluate the degree and length of the stricture. The 0.035-inch exchange guide wire was then exchanged for a 0.018-inch guide wire (Terumo) to allow placement of an 8-mm-diameter, 2-cm-long cutting balloon catheter (Peripheral Cutting Balloon, Boston Scientific, Natick, Massachusetts) with four blades across the stricture. When the bronchial stricture was so tight that the cutting balloon catheter could not pass through it, 4-mm balloon dilation was preceded by cutting balloon dilation with the assistance of a 9-F guiding sheath (Flexor Check-Flo introducer; Cook) that is typically used for transjugular intrahepatic portosystemic shunt procedures. The cutting balloon was then inflated with diluted contrast medium at pressures as high as 10 atm for 30 seconds under fluoroscopic guidance. The 0.018-inch guide wire was then exchanged for the 0.035-inch guide wire to perform conventional balloon dilation (10- or 12-mm-diameter, 4-cm-long balloon catheter), which was fully dilated for 1 minute. Bronchoscopy was performed immediately after the procedure to evaluate the degree of dilation of the stenotic segment and any possible complications. Patients were followed up with clinical examination, chest radiography, or bronchoscopy to evaluate the treatment efficacy at 1–3 days, 1 month, 2 months, 3 months, and then every 3 months thereafter. Follow-up CT including three-dimensional imaging was performed 2, 6, or 12 months after the cutting balloon treatment to evaluate improvements in the stricture. Patients were told to visit our hospital if their symptoms recurred. If a patient did not return to our institution, the patient or a member of his/her family was contacted by telephone at the end of this study to obtain information concerning his/her respiratory status. Technical success was defined as successful full dilation of the cutting and subsequent conventional balloons with passage of the adult bronchoscope (22Abi-Jaoudeh N. Francois R.J. Oliva V.L. et al.Endobronchial dilation for the management of bronchial stenosis in patients after lung transplantation: effect of stent placement on survival.J Vasc Interv Radiol. 2009; 20: 912-920Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar). Clinical success was defined as an improvement of more than one grade on the Hugh-Jones classification scale. The symptomatic improvement period after the procedure was calculated according to the Kaplan-Meier method. Recurrence was defined as return of the patient's obstructive symptoms similar to those experienced before the procedure. Cutting balloon treatment was technically successful in all 11 study patients (100%; Figure 1, Figure 2). Three patients required 4-mm-diameter balloon dilation and the assistance of a guiding sheath before the cutting balloon treatment because severe stricture precluded the passage of the cutting balloon catheter through the stricture. The cutting balloon ruptured after dilation in one patient, but there were no subsequent problems and the strictures were successfully dilated in this patient. Blood-tinged sputum was seen in two patients, but it disappeared within 4 hours. There were no other immediate complications in any of our study patients. After the cutting balloon therapy, all patients showed at least 1 grade improvement on the Hugh-Jones classification scale (Table). Therefore, clinical success was achieved in all patients (100%).Figure 2Images from a 71-year-old man (patient 11) with an anastomotic bronchial stricture detected 4 months after left lower lobectomy. (a) Chest radiograph shows total collapse of the left lung. (b) Selective bronchogram shows complete occlusion of the left main bronchus anastomotic area (arrow). (c) Bronchoscopic image shows hard scar tissue (arrow). (d) A conventional balloon could not be dilated because of the tight, severe stricture. (e) The 8-mm cutting balloon catheter could be almost completely dilated (arrow). Conventional 10-mm balloon dilation was then performed (not shown). (f) Bronchoscopic image obtained immediately after cutting balloon dilation shows four directions of laceration (arrows) corresponding to the four microtomes of the cutting balloon catheter. (g) Four-month follow-up chest radiograph shows complete left lung aeration. (Available in color online at www.jvir.org.)View Large Image Figure ViewerDownload Hi-res image Download (PPT) During the follow-up period of 17 days to 30 months (mean, 12.7 months ± 9.4), one patient (patient 6) died of septic shock induced by acute renal failure unrelated to the procedure 17 days after cutting balloon treatment. Two patients (18%) experienced recurrence of their dyspnea 6 and 17 months, respectively, after cutting balloon treatment. They both underwent a second cutting balloon treatment for the recurrent stricture, and no further recurrence was seen by the time the study ended (11 and 13 months, respectively, after the second cutting balloon therapy). The mean symptomatic improvement period was 23.1 months ± 3.6 (95% CI, 16.1–30.3 months; Fig 3). The symptomatic improvement period rates were 89% at 1 year and 59% at 2 years. Treatment of frequently recurring or very tight benign bronchial strictures is troublesome because they usually do not respond well to the existing therapeutic options and therefore usually eventually require surgical treatment. These tight strictures may develop as a result of the overabundance of fibrotic change caused by chronic inflammation or frequent, previous treatments such as balloon dilation, laser treatment, or stent placement (4Kim J.H. Shin J.H. Song H.Y. et al.Liquid [188]Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience.J Vasc Interv Radiol. 2008; 19: 406-411Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 18Wu C.C. Lin M.C. Pu S.Y. Tsai K.C. Wen S.C. Comparison of cutting balloon versus high-pressure balloon angioplasty for resistant venous stenoses of native hemodialysis fistulas.J Vasc Interv Radiol. 2008; 19: 877-883Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar, 21Wilkinson A.G. MacKinlay G.A. Use of a cutting balloon in the dilatation of caustic oesophageal stricture.Pediatr Radiol. 2004; 34: 414-416Crossref PubMed Scopus (10) Google Scholar). By cutting the most rigid area in a stricture and subsequently facilitating the propagation of balloon pressure along the incisions, cutting balloon treatment seems to be suitable for treating resistant benign bronchial strictures. Lacerations made by cutting balloon treatment may be important for widening the lumen of the stenotic segment and thereby improving airway patency. For example, a recent study (7Kim J.H. Shin J.H. Song H.Y. et al.Tracheobronchial laceration after balloon dilation for benign strictures: incidence and clinical significance.Chest. 2007; 131: 1114-1117Crossref PubMed Scopus (45) Google Scholar) found that the group of patients (n = 64) with tracheobronchial lacerations showed better cumulative airway patency (median patency duration, 24 months vs 4 months, respectively) and a lower recurrence rate (32% vs 40%) than the group (n = 60) without tracheobronchial laceration after conventional balloon dilation. Recently, temporary implantation of a retrievable metallic or silicone stent has been reported to be a good alternative option for benign bronchial stricture that is resistant to balloon dilation (12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar, 13Ryu Y.J. Kim H. Yu C.M. Choi J.C. Kwon Y.S. Kwon O.J. Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis.Eur Respir J. 2006; 28: 1029-1035Crossref PubMed Scopus (54) Google Scholar, 14Kim J.H. Shin J.H. Song H.Y. Lee S.C. Kim K.R. Park J.H. Use of a retrievable metallic stent internally coated with silicone to treat airway obstruction.J Vasc Interv Radiol. 2008; 19: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar). Kim et al (12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar) reported the clinical outcome after temporary placement of a metallic stent for 2–6 months in 24 patients with benign tracheobronchial strictures resistant to conventional balloon dilation. During the follow-up period (mean, 24 months) after temporary stent placement, the mean maintained airway patency time was 25.2 months ± 5.9. The maintained patency rates were 50% at 1 year and 32% at 3 years after temporary stent placement (12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar). However, the high incidence of complications such as stent migration and the high recurrence rate mainly as a result of granulation tissue formation or mucous retention make it difficult to recommend the use of stent placement rather than other types of therapy for the treatment of benign tracheal or bronchial strictures (12Kim J.H. Shin J.H. Song H.Y. Shim T.S. Yoon C.J. Ko G.Y. Benign tracheobronchial strictures: long-term results and factors affecting airway patency after temporary stent placement.AJR Am J Roentgenol. 2007; 188: 1033-1038Crossref PubMed Scopus (69) Google Scholar, 13Ryu Y.J. Kim H. Yu C.M. Choi J.C. Kwon Y.S. Kwon O.J. Use of silicone stents for the management of post-tuberculosis tracheobronchial stenosis.Eur Respir J. 2006; 28: 1029-1035Crossref PubMed Scopus (54) Google Scholar, 14Kim J.H. Shin J.H. Song H.Y. Lee S.C. Kim K.R. Park J.H. Use of a retrievable metallic stent internally coated with silicone to treat airway obstruction.J Vasc Interv Radiol. 2008; 19: 1208-1214Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 15Gildea T.R.Murthy Sc Sahoo D. Mason D.P. Mehta A.C. Performance of a self-expanding silicone stent in palliation of benign airway conditions.Chest. 2006; 130: 1419-1423Crossref PubMed Scopus (68) Google Scholar, 23Madden B.P. Loke T.K. Sheth A.C. Do expandable metallic airway stents have a role in the management of patients with benign tracheobronchial disease?.Ann Thorac Surg. 2006; 82: 274-278Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar). On the contrary, in our study we achieved 100% technical and clinical success with cutting balloon dilation in patients with benign bronchial strictures refractory to conventional balloon dilation, and there were no significant immediate or delayed complications after cutting balloon treatment. The mean symptomatic improvement period was 23.1 months ± 3.6 after cutting balloon treatment during the follow-up period (17 days to 30 months; mean, 12.7 months). The symptom-free rates were 89% at 1 year and 59% at 2 years, and the recurrence rate was 18% (two of 11). Insertion of a guide wire and balloon catheter is an essential step in successful balloon dilation. In some instances, the strictures are too stenotic to allow passage of a guide wire or even liquid contrast material, thus essentially obliterating the lumen and making further intervention impossible (24de S.A. Keal R. Hudson N. Leverment J. Spyt T. Use of expandable wire stents for malignant airway obstruction.Ann Thorac Surg. 1994; 57: 1573-1577Abstract Full Text PDF PubMed Scopus (34) Google Scholar, 25Egan A.M. Dennis C. Flower C.D. Expandable metal stents for tracheobronchial obstruction.Clin Radiol. 1994; 49: 162-165Abstract Full Text PDF PubMed Scopus (26) Google Scholar). In addition, to introduce a cutting balloon catheter, a thinner wire (eg, 0.018-inch) should be used, which also makes cannulation of a tight stricture more difficult. In the present study, we encountered three patients whose strictures were too severe to allow passage of a cutting balloon catheter. We dilated these strictures with a 4-mm-diameter balloon, after which a cutting balloon catheter could be passed through the stricture with the assistance of an angled sheath typically used for transjugular intrahepatic portosystemic shunt procedures. We used these sheaths because the angle of the guiding sheath used for transjugular intrahepatic portosystemic shunt creation can be similar to the angle between the trachea and the bronchus and the stiffness of the guiding sheath may prevent backward curving of the guide wire or balloon catheter (26Shin J.H. Song H.Y. Yoon C.J. et al.Bronchial catheterization with a TIPS dilator after failure of conventional technique.AJR Am J Roentgenol. 2006; 187: W299-W301Crossref PubMed Scopus (1) Google Scholar). In summary, cutting balloon dilation can be a safe and effective therapeutic option for the treatment of benign bronchial strictures that are resistant to conventional balloon dilation. Future comparative studies with other therapeutic options such as stent placement are warranted, and a combination therapy such as drug-eluting (27Cremers B. Speck U. Kaufels N. et al.Drug-eluting balloon: very short-term exposure and overlapping.Thromb Haemost. 2009; 101: 201-206PubMed Google Scholar) or radiation-eluting (4Kim J.H. Shin J.H. Song H.Y. et al.Liquid [188]Re-filled balloon dilation for the treatment of refractory benign airway strictures: preliminary experience.J Vasc Interv Radiol. 2008; 19: 406-411Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar) cutting balloon treatment may further improve the clinical outcomes in patients with resistant benign bronchial strictures.
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