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Pulmonary Tumor Embolism Diagnosed by Endobronchial Ultrasound

of the 9 patients symptomatically improved. Of these, meaningful improvement in dyspnea before symptomatic recurrence lasted between 2 weeks and 4 months. Two patients were liberated from the ventilator following stent placement. Of these, 1 had stents placed in the left upper and lower lobe due to metastatic renal cell carcinoma and he survived for 8 months. The second patient concurrently underwent tracheobronchial Y stenting and stenting of the bronchus intermedius for refractory small cell carcinoma and expired 2 weeks after stent placement. She was extubated and able to communicate with her family, her goal for the procedure. Of the others, 1 underwent repeated bronchoscopy due to mucus plugging with removal of the stent at 4 months, another had the stent removed after 49 days due to only temporary symptomatic improvement, and 1 had a refractory cough despite improvement in dyspnea and insisted on stent removal. Razi et al1 described an improvement in dyspnea, performance status, and mortality following stent placement. Improvements in spirometry, the 6-minute walk test, and expediting extubation have also been described for central airway stents.1–3 A PubMed search for distal airway stenting revealed only 1 study to date. Walser et al4 reported a series of 30 patients, 13 of whom required proximal and distal airway stenting and 5 who required exclusively distal airway stenting. One third of their patients died within 30 days of the procedure, many of whom had incomplete relief of airway obstruction and more advanced disease. They detected radiographic improvement in only 33% of patients and noted that up to 10% of patients improved only after 1 to 2 weeks of having the stent in place and not immediately after placement. They concluded that the clinical improvement (including subjective dyspnea and functional improvement) and survival when distal airways were stented was equivalent to their results in the central airways. When confronted with the prospect of placing a distal airway stents, we believe several key features should be addressed, including feasibility, anticipated benefit, alternative therapies, and potential complications. Although often feasible, the most significant clinical benefit in our patients was in the context of multiple airway stents and in the setting of respiratory failure requiring mechanical ventilation. Alternative therapies should be considered. Petera and colleagues demonstrated clinical improvement in up to 77% of patients who received concurrent intraluminal brachytherapy and external beam radiation. The use of intraluminal brachytherapy after prior external beam therapy led to an improvement in 56% of patients.5 Complications in our small group of patients included granulation tissue formation, tumor ingrowth, and mucus plugging, similar to those with larger airway stents. In summary, distal airway stents may have benefit, but conclusions regarding stent utility in distal airways should be reserved until research can dictate future practice.