these patients may develop dyspnea , stridor , intractable cough , hemorrhage , atelectasis , or postobstructive pneumonia , or a combination of the aforementioned manifestations because of tracheobronchial tumor extension ( 1 ) .
these patients are poor surgical candidates judged on the basis of either physiological or oncological criteria .
the optimal management of patients with central airway obstruction includes radiotherapy , laser therapy , photodynamic therapy , cryotherapy and airway stenting , which can be done either with or without bronchoscopic guidance .
airway stent can especially achieve immediate and durable airway patency resulting in an improved quality and length of life span in patients with lung cancer ( 2 ) .
hemoptysis particularly occurs in about 30% of all the lung cancer patients , and can be lethal to them .
the treatment options of hemoptysis are pharmacology , bronchoscopic intervention , vascular embolization and surgical resection ( 3 ) . in selected cases ,
however , these measures only offer transient control of bleeding and need prolonged mechanical ventilation ( 4 ) . in the present report
, we have described three cases of selective bronchial stent placement in patients with uncontrolled hemoptysis from lung cancer .
between september 2009 and july 2010 , 3 men ( mean age 65.3  17.0 years ) with uncontrolled hemoptysis from lung cancer underwent bronchial stent insertion . patients who had dyspnea and recurrent or prolonged hemoptysis despite continued conservative management were selected for the airway stenting .
all bronchial stent placements were performed in the angiography room under fluoroscopic and bronchoscopic guidance .
a 0.035 hydrophilic guidewire was advanced to the distal portion of stenotic and bleeding segment of bronchus under bronchoscopic guidance .
a 5 fr angiographic catheter was then inserted and consecutively a small amount of non - ionic contrast material was injected into the airway to obtain bronchogram .
then , a covered retrievable stent ( hercules airway stent , s&g biotech , seongnam , korea ) was deployed in the target area under fluoroscopic guidance .
finally , follow - up bronchoscopy was performed immediately after stenting to confirm the location and patency of the inserted stent .
a 78 year - old male was diagnosed with central non - small cell lung cancer 12 months earlier .
the primary lung cancer was located in the proximal right upper lobar bronchus associated with postobstuctive atelectasis of the right upper lobe . however , at the time of diagnosis , the patient refused all the curative means .
we performed ct imaging on outpatient clinics , which showed a completely obstructed right upper lobar bronchus by a tumor with postobstructive pneumonia of the right upper lobe .
the wall of the right main bronchus and bronchus intermedius was thickened and the lumen of the right main bronchus was almost narrowed by tumor infiltrations .
a bronchoscopic examination demonstrated that orifice of the right main bronchus was nearly completely obstructed by the endoluminal mass and there was diffuse bleeding from the right main bronchus .
the patient received urgent external beam radiotherapy to control bleeding from the friable endobronchial tumor and bleeding gradually decreased for several days .
however , eleven days after the radiation therapy , a sudden onset of dyspnea developed .
chest radiography showed that the right lung had totally collapsed and bronchoscopic examination revealed complete obstruction of the right main bronchus with diffuse bleeding .
bronchial artery embolization could not be considered as a treatment option for hemoptysis because bleeding conditions were not because of active arterial bleeding and there was no prominent contrast enhancement of the mass as seen on the ct scan .
we decided that bronchial stent insertion in the right main bronchus was necessary to both , re - open the airway and to control the bleeding of tumor through the tamponade effect .
after the bronchogram , which was performed to identify the airway on a fluoroscopic image , we decided to sacrifice superior segment of the right lower bronchus to preserve basal segments of the right lower lobe .
the 12 mm - 4.3 cm self - expanding silicone - covered nitinol stent ( hercules airway stent , s & g biotech , seongnam , korea ) was deployed in the right lower lobar bronchus to the right main bronchus . however , proximal portion of the right main bronchus was not completely covered due to its insufficient length . for this reason ,
another 12 mm - 5.3 cm self - expanding silicone - covered nitinol stent was reinserted , overlapping the first stent . at the end of the procedure ,
an immediate improvement in the aeration of the right basal lung was observed on fluoroscopy and hemoptysis was subsided ( fig .
nevertheless , the patient died two days later due to lack of expectoration that resulted in whole lung aspiration pneumonitis or pneumonia .
a 72 year - old man , with a history of tuberculosis ten years ago and an exposure to asbestosis , was diagnosed with squamous cell carcinoma on the left lower lobe about 20 months earlier .
the patient underwent left lower lobectomy after a month of the diagnosis and had been treated with postoperative chemotherapy , but it failed to prevent recurrence and progression of the disease .
the ct scan , which was performed on his visit , demonstrated an extremely stenotic left main bronchus by metastatic lymphadenopathy in mediastinum and both the hila ( fig .
fresh bloody sputum developed on the fourth day of admission and frequency of hemoptysis gradually increased up to three times per hour .
respiration rates were raised up to a 40/min and the hemoglobin level dropped from 10.1 g / dl to 7.1 g / dl .
we decided to insert the covered bronchial stent into the left main bronchus . on the fifth day after admission ,
12 mm - 5.3 cm self - expanding silicone - covered nitinol stent ( hercules airway stent : s & g biotech , seongnam , korea ) was deployed in the left main bronchus under bronchoscopic and fluoroscopic guidance .
bleeding through the endotracheal tube gradually decreased and stopped within two days after the procedure .
he required continuous renal replacement therapy ( crrt ) due to acute renal failure by hypotension .
sixteen days after the bronchial stent placement , he expired because of multi - organ failure .
a 46 year - old male was diagnosed with non - small cell lung cancer 30 months earlier .
the primary cancer was located in the orifice of the left upper lobe bronchus without metastasis .
he was treated with left pneumonectomy after neoadjuvant chemotherapy along with postoperative radiation therapy and systemic chemotherapy .
eleven months after the surgery , chest ct scans showed recurring mass at the stump of the left main bronchus , which was also confirmed by bronchoscopic biopsy .
the patient underwent second and third line systemic chemotherapy , but it was unable to stop the disease from progressing .
approximately four months prior to this visit , he was admitted due to presence of blood - tinged sputum . at that time , a bronchoscopic examination showed that the bleeding was from recurred mass in the left main bronchus .
he visited again within several weeks due to dysphagia and recurrent blood - tinged sputum .
we performed ct imaging , which depicted progression of a recurred mass at the stump of the left main bronchus .
ct scan also showed narrowing of distal trachea and right proximal main bronchus ( fig .
, it showed invasion of adjacent esophagus by the recurred mass with conglomerated lymphadenopathy . on the eighth day of admission
, he coughed up approximately 500 ml of fresh blood and the patient was transferred to the intensive care unit .
first , a 18 mm - 4 cm self - expanding silicone - covered nitinol stent ( hercules airway stent : s & g biotech , seongnam , korea ) was deployed in the distal trachea and another 12 mm - 3 cm self - expanding silicone - covered nitinol stent was deployed in the distal trachea to the right main bronchus , overlapping the former one ( fig .
, there was a gradual decrease in the hemoptysis except for an episode of scanty bleeding that halted after conservative treatment . however , the patient needed daily bronchoscopic toileting because of lack of self - expectoration and retained mucus secretion .
between september 2009 and july 2010 , 3 men ( mean age 65.3  17.0 years ) with uncontrolled hemoptysis from lung cancer underwent bronchial stent insertion . patients who had dyspnea and recurrent or prolonged hemoptysis despite continued conservative management were selected for the airway stenting .
all bronchial stent placements were performed in the angiography room under fluoroscopic and bronchoscopic guidance .
a 0.035 hydrophilic guidewire was advanced to the distal portion of stenotic and bleeding segment of bronchus under bronchoscopic guidance .
a 5 fr angiographic catheter was then inserted and consecutively a small amount of non - ionic contrast material was injected into the airway to obtain bronchogram .
then , a covered retrievable stent ( hercules airway stent , s&g biotech , seongnam , korea ) was deployed in the target area under fluoroscopic guidance .
finally , follow - up bronchoscopy was performed immediately after stenting to confirm the location and patency of the inserted stent .
a 78 year - old male was diagnosed with central non - small cell lung cancer 12 months earlier .
the primary lung cancer was located in the proximal right upper lobar bronchus associated with postobstuctive atelectasis of the right upper lobe . however , at the time of diagnosis , the patient refused all the curative means .
we performed ct imaging on outpatient clinics , which showed a completely obstructed right upper lobar bronchus by a tumor with postobstructive pneumonia of the right upper lobe .
the wall of the right main bronchus and bronchus intermedius was thickened and the lumen of the right main bronchus was almost narrowed by tumor infiltrations .
a bronchoscopic examination demonstrated that orifice of the right main bronchus was nearly completely obstructed by the endoluminal mass and there was diffuse bleeding from the right main bronchus .
the patient received urgent external beam radiotherapy to control bleeding from the friable endobronchial tumor and bleeding gradually decreased for several days .
however , eleven days after the radiation therapy , a sudden onset of dyspnea developed .
chest radiography showed that the right lung had totally collapsed and bronchoscopic examination revealed complete obstruction of the right main bronchus with diffuse bleeding .
bronchial artery embolization could not be considered as a treatment option for hemoptysis because bleeding conditions were not because of active arterial bleeding and there was no prominent contrast enhancement of the mass as seen on the ct scan .
we decided that bronchial stent insertion in the right main bronchus was necessary to both , re - open the airway and to control the bleeding of tumor through the tamponade effect .
after the bronchogram , which was performed to identify the airway on a fluoroscopic image , we decided to sacrifice superior segment of the right lower bronchus to preserve basal segments of the right lower lobe .
the 12 mm - 4.3 cm self - expanding silicone - covered nitinol stent ( hercules airway stent , s & g biotech , seongnam , korea ) was deployed in the right lower lobar bronchus to the right main bronchus . however , proximal portion of the right main bronchus was not completely covered due to its insufficient length .
for this reason , another 12 mm - 5.3 cm self - expanding silicone - covered nitinol stent was reinserted , overlapping the first stent . at the end of the procedure ,
an immediate improvement in the aeration of the right basal lung was observed on fluoroscopy and hemoptysis was subsided ( fig .
nevertheless , the patient died two days later due to lack of expectoration that resulted in whole lung aspiration pneumonitis or pneumonia .
a 72 year - old man , with a history of tuberculosis ten years ago and an exposure to asbestosis , was diagnosed with squamous cell carcinoma on the left lower lobe about 20 months earlier .
the patient underwent left lower lobectomy after a month of the diagnosis and had been treated with postoperative chemotherapy , but it failed to prevent recurrence and progression of the disease .
the ct scan , which was performed on his visit , demonstrated an extremely stenotic left main bronchus by metastatic lymphadenopathy in mediastinum and both the hila ( fig .
fresh bloody sputum developed on the fourth day of admission and frequency of hemoptysis gradually increased up to three times per hour . shortly afterwards , shortness of breath developed .
respiration rates were raised up to a 40/min and the hemoglobin level dropped from 10.1 g / dl to 7.1 g / dl .
we decided to insert the covered bronchial stent into the left main bronchus . on the fifth day after admission ,
12 mm - 5.3 cm self - expanding silicone - covered nitinol stent ( hercules airway stent : s & g biotech , seongnam , korea ) was deployed in the left main bronchus under bronchoscopic and fluoroscopic guidance .
bleeding through the endotracheal tube gradually decreased and stopped within two days after the procedure .
he required continuous renal replacement therapy ( crrt ) due to acute renal failure by hypotension .
sixteen days after the bronchial stent placement , he expired because of multi - organ failure .
a 46 year - old male was diagnosed with non - small cell lung cancer 30 months earlier .
the primary cancer was located in the orifice of the left upper lobe bronchus without metastasis .
he was treated with left pneumonectomy after neoadjuvant chemotherapy along with postoperative radiation therapy and systemic chemotherapy .
eleven months after the surgery , chest ct scans showed recurring mass at the stump of the left main bronchus , which was also confirmed by bronchoscopic biopsy .
the patient underwent second and third line systemic chemotherapy , but it was unable to stop the disease from progressing .
approximately four months prior to this visit , he was admitted due to presence of blood - tinged sputum . at that time , a bronchoscopic examination showed that the bleeding was from recurred mass in the left main bronchus .
he visited again within several weeks due to dysphagia and recurrent blood - tinged sputum .
we performed ct imaging , which depicted progression of a recurred mass at the stump of the left main bronchus .
ct scan also showed narrowing of distal trachea and right proximal main bronchus ( fig .
in addition , it showed invasion of adjacent esophagus by the recurred mass with conglomerated lymphadenopathy . on the eighth day of admission
, he coughed up approximately 500 ml of fresh blood and the patient was transferred to the intensive care unit .
first , a 18 mm - 4 cm self - expanding silicone - covered nitinol stent ( hercules airway stent : s & g biotech , seongnam , korea ) was deployed in the distal trachea and another 12 mm - 3 cm self - expanding silicone - covered nitinol stent was deployed in the distal trachea to the right main bronchus , overlapping the former one ( fig .
, there was a gradual decrease in the hemoptysis except for an episode of scanty bleeding that halted after conservative treatment .
however , the patient needed daily bronchoscopic toileting because of lack of self - expectoration and retained mucus secretion .
hemoptysis is a potentially life - threatening manifestation of underlying lung disease that requires prompt diagnosis and management .
the etiology of hemoptysis varies ; bronghogenic carcinoma is one of the most common causes of hemoptysis with 19 - 32% of occurrence rate ( 5 ) . the bleeding results from necrosis of a tumor , the rupture of small blood vessels in the area , or a tumor invading one of the pulmonary blood vessels .
it is normally associated with mild to moderate amounts . however , massive bleeding can occur if the tumor erodes into one of the large pulmonary vessels and can signify a serious situation , where rapid treatment is crucial .
management of hemoptysis aims to stop hemorrhage , replace blood loss , and treat underlying etiologies .
in addition , they should be selectively intubated with a double - lumen endotracheal tube to prevent aspiration to the unaffected contralateral lung and preserve gas exchange .
endobronchial tamponade using a balloon tamponade catheter is an alternate site - specific therapy through the bronchoscopy ( 6 ) .
however , endobronchial tamponade only offers temporary relief and prolonged mechanical ventilation is necessary ( 4 ) .
surgery removes the source of bleeding and is the most definitive form of therapy for patients with hemoptysis .
however , a large proportion of patients are not the suitable candidates for surgery due to their advanced condition of pulmonary diseases with poor pulmonary reserves and preexisting co - morbidities .
in addition , mortality rates of up to 40% have been reported following emergency surgical interventions ( 7 ) .
bronchial artery embolization is considered a successful procedure to control hemoptysis in various pulmonary diseases and is the most effective non - surgical treatment available for massive hemoptysis ( 7 ) .
however , prognosis remains poor in the patients with tumor - related hemoptysis ( 8) .
airway stents are traditionally used in the palliation of lung cancer to maintain patency of reopened airways , to secure patency of a collapsed or extrinsically compressed central airway , and to seal fistulas ( 1 , 9 ) .
there have been two case reports that described airway stent placement to treat pulmonary hemorrhage from lung cancer ( 3 ) .
airway stent placement has been regarded as a successful treatment option with not only tamponade and isolation of bleeding source but also for the maintenance of airway . in the three patients mentioned in our series , the main indication for bronchial stent placement was airway obstruction with hemoptysis in advanced stages of lung cancer .
immediate re - opening of airway with improvement of aeration on fluoroscopic images was also observed in all the cases .
one patient died due to disease progression while surviving for three months after the procedure .
the remaining two patients died within 16 days after the procedure due to non - procedural related complications like , multi - organ failure or aspiration pneumonitis .
the retention of mucous secretion occurred in one stent placement and required daily bronchoscopic toileting .
so , patient 's life expectancy and general condition should be considered before selecting the patients for treatment .
the retention of mucous secretions is a common complication resulting from airway stent placement . covered airway stents or plastic stents prevent normal clearance of secretions and may lead to obstruction and infection .
the risk with a covered stent is much higher than with a bare one ( 10 ) .
covered airway stents have decreased risks of tumor in - growth and granulation tissue formation .
however , granulation tissue developed at the end because of irritation by the stent or the migration of a stent may block the bronchus ( 1 , 10 ) . other complications such as , breakage of the stent and fistula between bronchus and major vessels can also occur . in conclusion , using airway stenting for endobronchial tamponade may be considered as a treatment option for hemoptysis arising from lung cancer that can not be successfully dealt with other treatments .
however , identifying the patient 's underlying condition and morbidity is essential for patient 's selection .
airway stent placement also resulted in preservation of airway patency in patients with obstructive airway lesions .
 malignant airway obstruction and hemoptysis are common in lung cancer patients . 
 recently , airway stent is commonly used to preserve airway in malignant airway obstruction . 
 hemoptysis can be managed through various methods including conservative treatment , endobronchial tamponade , bronchoscopic intervention , embolization and surgery . in our case studies 
 , we sought to investigate the effectiveness of airway stents for re - opening the airway as well as tamponade effects in four patients with malignant airway obstruction and bleeding caused by tumors or lymph node invasions . 
INTRODUCTION
CASE REPORTS
Procedure Technique
Case 1
Case 2
Case 3
DISCUSSION