The use of balloon-expandable metallic stents in the treatment of pediatric tracheomalacia and bronchomalacia.

OBJECTIVE: To evaluate the use of balloon-expandable metallic stents in the treatment of children with tracheomalacia and bronchomalacia in whom conventional therapy has failed. DESIGN: Retrospective case series. SETTING: Tertiary pediatric otolaryngology and cardiothoracic surgery referral center. PATIENTS: Six patients were identified as having undergone bronchoscopic placement of metallic balloon-expandable stents between 1994 and 1997. The age at stent placement, prior surgical interventions, and indications for and sites of stent placement were noted. Also, the complications related to stent placement and the current airway status of the patients were reviewed. INTERVENTIONS: Twelve balloon-expandable metallic angioplasty stents (Palmaz; Johnson & Johnson Interventional Systems Co, Warren, NJ) were placed bronchoscopically in 6 patients. Six stents were placed in the lower trachea, and 6 were placed in the main bronchi. The stents were balloon expanded under fluoroscopic guidance. MAIN OUTCOME MEASURE: Discontinuation of mechanical ventilation. RESULTS: The age at stent placement ranged from 1.5 to 38 months (mean age at placement, 10 months). The indications for stent placement were (1) tracheomalacia or bronchomalacia, (2) pericardial patch or slide tracheoplasty failure, and (3) bronchomalacia caused by tetralogy of Fallot and large pulmonary arteries. The primary complication of stent placement was postoperative granulation tissue formation. One patient required the removal of 2 tracheal stents because of granulation tissue formation. There were 2 deaths in the series, 1 possibly related to stent placement. Four of the 6 patients were weaned from mechanical ventilation, and 3 experienced prolonged relief of airway obstruction. CONCLUSIONS: Metallic balloon-expandable stents are effective in relieving lower tracheomalacia and bronchomalacia in select patients. Only patients in whom conventional therapy has failed should be considered for stent placement.

A lipoprotein characterizing obstructive jaundice. II. Isolation and partial characterization of the protein moieties of low density lipoproteins.

The plasma low density lipoproteins (LDL) in biliary obstruction are characterized almost exclusively by the presence of the immunochemically distinct lipoprotein families, lipoprotein B (LP-B) and lipoprotein X (LP-X). It is suggested that LP-X, with its uniquely high content of unesterified cholesterol and phospholipid, is primarily responsible for the unusual lipid composition of LDL and the abnormal plasma lipid composition in obstructive jaundice. To show their protein moieties, we isolated LP-X and LP-B from the LDL in plasma obtained from patients with obstructive jaundice. A separation procedure was employed which combines ultracentrifugation, heparin precipitation, and ethanol fractionation. Whereas LP-B was characterized by the presence of apolipoprotein B (ApoB), intact LP-X contained a protein moiety of unique composition consisting of a mixture of albumin (approximately 40%) and the specific apolipoprotein, ApoX (60%). These two protein moieties were separated by preparative ultracentrifugation at d 1.21 g/ml of a solution of partially delipidized LP-X. LP-X thus comprises an albumin-lipoprotein complex in which the masked antigenic site of albumin can be revealed by partial or total delipidization. Apolipoprotein X, the characteristic nonalbumin protein moiety of intact or partially delipidized LP-X, was immunochemically different from ApoA, ApoB, albumin, gamma-globulins, and other serum proteins. The results of analytical ultracentrifugation and the immunochemical and electrophoretic properties of ApoX indicated it to be a complex protein consisting possibly of several nonidentical polypeptides. ApoX was characterized by its amino acid composition, and by serine and threonine as the major N-terminal and alanine as the major C-terminal amino acids. It has been suggested that ApoX is similar to, if not identical with, apolipoprotein C.

A lipoprotein characterizing obstructive jaundice. I. Method for quantitative separation and identification of lipoproteins in jaundiced subjects.

Three immunochemically and electrophoretically distinct lipoproteins, LP-A, LP-B, and LP-X,(1) were isolated from the low density lipoprotein fraction (1.006-1.063 g/ml) in plasma from patients with biliary obstruction by a separation procedure which combines ultracentrifugation, heparin precipitation, and ethanol fractionation. This method, here described, permits the quantitative determination of individual plasma lipoprotein families on the basis of their protein moieties, rather than on the basis of their lipid moieties or density. The chemical composition of the unique lipoprotein, LP-X, was similar to that of an abnormal lipoprotein, OLP, isolated by Russ et al. (29) and by Switzer (30). In obstructive jaundice plasma, the combined LP-X and LP-B accounted for 98% and the LP-A for only 2% of the total protein content of the LDL fraction. This study indicates that the plasma lipoprotein pattern in obstructive jaundice is characterized by (a) a decreased concentration of HDL, (b) an increased concentration of LDL, and (c) the presence in the LDL fraction of varying amounts of a specific lipoprotein, LP-X, immunochemically and chemically distinct from LP-A and LP-B. LP-X, with its characteristically high content of unesterified cholesterol and phospholipids, is primarily responsible for the unusual protein and lipid content of the LDL fraction. Screening tests in 61 patients with various forms of jaundice indicated that a characteristic immunoelectrophoretic precipitin are between plasma samples and purified antibodies to LP-X was observed only in patients with obstructive jaundice. This simple immunochemical test may represent a valuable new tool in the differential diagnosis of obstructive and nonobstructive jaundice.