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近年，手術適応外の中枢気道狭窄症例に対して，気道ステント留置の有用性は多く報告されるようになった．今回，高度呼吸困難を伴う悪性腫瘍気管浸潤による気管狭窄に対して，気管ステント留置術を行った症例を経験したので報告する．症例，90歳女性．201X年2月より尿路感染症の治療中であったが，経過中に呼吸困難が出現した．CT上気管右側上縦隔に気管狭窄を来す腫瘤を認めたため，当科に紹介となった．著明な呼吸困難のため，noninvasive positive pressure ventilation（NPPV）管理とした．気管支鏡にて，声帯より約2.5 cm末梢の気管に直接浸潤による高度狭窄を認めたため，expandable metallic stent（EMS）, proximal typeを留置した．留置後，気管狭窄部のpatencyは改善し，NPPVも離脱できた．酸素投与も中止となり，端坐位保持や自立した食事摂取も可能となった．気管ステント留置8日後，突然血圧低下．心エコーにて左室心基部の過剰収縮と冠動脈1枝病変では説明できない心尖部の無収縮を認め，たこつぼ型心筋症と診断された．保存的に経過観察していたが，心機能増悪し，EMS留置後11日目永眠となった．悪性腫瘍気管浸潤に対する気管狭窄に対して，EMS留置は有効な手段と考えられた．また，気道狭窄症状やストレスの強い症例では，たこつぼ型心筋症発症のリスク軽減のため，できるだけ早い段階で気道ステントなどの気道を確保できるような治療介入することが必要と考えられた． The utility of stent placements has been widely reported. We performed a thought-provoking stent placement for malignant tracheal stenosis recently. A 90-year-old woman who was admitted to our hospital because of a urinary tract infection was treated with a course of antibiotics, but she demonstrated a rapidly progressive course with dyspnea. Chest computed tomography showed severe tracheal stenosis due to an upper mediastinal mass. She was put on noninvasive positive pressure ventilation (NPPV) because of severe respiratory failure. Bronchoscopy showed severe tracheal stenosis due to direct invasion by the upper mediastinal mass. An expandable metallic stent (EMS) was placed in the trachea, after which a bronchoscopy showed a widely patent airway, and she got off NPPV. Then she did not need supplemental oxygen. She could seat herself, and have an enough meal, independently. However, takotsubo cardiomyopathy occurred and she died 11 days after the placement of the EMS. Since a malignant airway complication can be fatal, tracheal stent placement is a useful treatment in the management of malignancy with airway stenosis. In this case, it was thought that an early intervention of airway stenosis would have reduced the risk of takotsubo cardiomyopathy in a patient with severe symptoms of airway stenosis and stress.

The patient was a 44-year-old woman with a tracheal stent in whom general anesthesia was performed or insertion of a continuous ambulatory peritoneal dialysis catheter. She had experienced cardiac arrest 2 years before due to hyperkalemia caused by diabetic nephropathy. After success of cardiac resuscitation, she was tracheal-intubated and mechanical ventilation was performed for 11 days. However, she subsequently suffered serious dyspnea due to advanced granuloma of the trachea following remove of endotracheal tube. Tracheotomy was performed at 1 month after extubation and a tracheal stent was inserted. On this case, general anesthesia was induced with propofol and maintained with 2 L/min oxygen, 2 L/min nitrous oxide and 1.5% sevoflurane As airtight could be kept with a slitless laryngeal mask airway（LMA）, respiratory management proceeded smoothly during anesthesia. The reason of choice of slitless LMA instead of endotracheal tube is as follows. A slit disturbances an emergence tracheal intubation and bronchoscopy through the LMA. The space between the vocal chords and the upper end of stent（approximately 1 cm）was too small to intubate an endotracheal tube. As if endotracheal intubation were performed under these circumstances, the tip of the endotracheal tube remains in the stent. In addition, performing endotracheal intubation would have risked distal movement of the stent and difficulty with extubation due to compatibility affinity between the material properties of the stent and the endotracheal tube.