Acquired Subglottic Stenosis – A Novel Approach of Retrograde Stenting In A Heightened Stress Environment

INTRODUCTION: The incidence of acquired subglottic stenosis(SGS) has decreased since the last century. In late 1960s, when intubation and ventilation gained foothold, the incidence was as high as 24%. By the 1970s and 1980s, it decreased to 1–8%.(2) In modern era of protocolized ICU care with regular cuff pressure monitoring, SGS should be unheard off. Here we report an interesting case of acquired SGS in the backdrop of Acute Coronary Syndrome. CASE REPORT: This 46 yr old male a known DM, HTN, old CVA and IHD was referred from a nearby hospital following presumed ACS-cardiac arrest after attempted tracheal dilatation and stenting. Patient had developed long segment SGS following long term ventilation in another hospital after CVA. The patient was undergoing tracheal stenting when he had a cardiac arrest with fresh ECG changes and was reverted back. Procedure was abandoned, intubated with a smaller size endotracheal tube and referred here with inotrope/vasopressor & ventilatory support. He was managed with elective ventilation, inotropes, dual antiplatelets and supportive measures. In view of tight tracheal stenosis at subglottic level with a diameter of 4mm elective PCDT was done at a lower level and the patient was weaned off ventilator by 48 hours. CAG revealed tight lesion in LAD with no signs of Acute MI. Elective PTCA was advised. Patient and attenders wanted to get stenting done first and later PTCA. 2 weeks later, patient was admitted for elective tracheal stenting. On attempted fiberoptic bronchoscopy(FOB), severe swelling of aryepiglottic folds(false cords)was noticed and the scope couldn't be passed beyond that. Procedure abandoned and tracheostomy tube reinserted. Patient was reviewed 15days later, after a course of racemic adrenaline nebulization and steroids. This time edema had decreased but still FOB couldn't be passed beyond vocal cords. It was decided to go for serial dilatation with rigid bronchoscopes. Serial dilatation was done with Nos 3.7,4.5 & 6 sized rigid bronchoscope under anaesthesia. Attempts to deploy stent through FOB deemed unsuccesful, since patient was becoming hypoxic it was decided to do it as a 2-stage procedure and tracheostomy tube reinserted. Stent was deployed through the stoma below the stenosis with scope introduced through the tracheostomy site. The next day after 24 hours of ventilation and hemodynamic stability, FOB performed through oral route, the deployed stent was pulled back to its intended site of severe SGS. Check bronchoscopy showed stent placement across stenotic part of trachea 1cm below vocal cords & covering whole stoma. Ventilation status and haemodynamics were stable, tracheostomy tube decanulated. DISCUSSION: Tracheal stenting is an alternative when condition of the patient precludes surgical reconstruction due to high perioperative morbidity and mortality.(1,3) In our case tight LAD lesion and poor LV function necessitated a more conservative approach in the form of tracheal stenting. Anticipation of problems including keeping options of rigid bronchoscopy and timely intervention with a multiprofessional approach will avoid serious complications and lead to better outcomes.(4) CONCLUSION: We had to resort to a novel way of using initially serial dilatation with rigid bronchoscopy and deploying the stent distally only to be pulled back later in a 2 staged procedure in view of poor cardiovascular reserve, limited apnea time and high mortality risk and were successful.