How are stents removed based on their type and anatomical location?

Stent Removal Methods by Type and Location

Stent removal technique depends critically on whether the stent is fully covered versus partially covered, with fully covered stents removed by simple endoscopic traction while partially covered or embedded stents require the "stent-in-stent" technique to safely extract them.

Esophageal and Gastrointestinal Stents

Fully Covered Self-Expanding Metal Stents (FCSEMS)

• Direct endoscopic removal is the standard approach for FCSEMS, which are preferred over uncovered stents specifically because they can be removed 1
• These stents are recommended for esophageal and gastric cardia malignant obstructions precisely because removal is straightforward 1
• Removal is performed endoscopically using grasping forceps under direct visualization 1

Partially Covered or Embedded Stents

• The "stent-in-stent" technique is the definitive method when tissue ingrowth prevents standard removal 2, 3, 4
• This involves placing a second fully covered stent inside the embedded stent for 3-9 days (median 9 days, though ≤6 days is optimal) 3, 4
• The overlapping second stent induces pressure ischemia of granulation tissue, allowing mobilization of both stents together 3, 4
• Success rate is 100% with this technique, with no serious adverse events when performed correctly 3
• Critical timing: The second stent should remain in place for a limited duration (≤6 days consistently successful) to avoid complications 3

Post-Bariatric Surgery Stents

• For partially covered stents after sleeve gastrectomy, the stent-in-stent technique is employed when initial removal fails 2
• A fully covered overlapping stent is inserted and both are removed together 2 weeks later 2

Airway Stents

Metallic Airway Stent Removal

• Removal requires rigid bronchoscopy under general anesthesia - this is non-negotiable for safety 5
• The basic technique involves steady traction with alligator forceps while using the rigid bronchoscope barrel or Jackson dilator to separate the stent from the airway wall 5
• Pre-treatment of the airway wall with thermal energy may be necessary before attempting removal 5
• Critical warning: Complications occur commonly (retained pieces in 23%, mucosal tears with bleeding in 13%, re-obstruction requiring temporary silicone stent in 47%) and must be anticipated 5
• This procedure should only be performed at centers equipped to manage life-threatening complications including airway obstruction and death 5

Cardiovascular Stents

Renal and Vascular Stents

• Cardiovascular stents are generally permanent implants and not designed for removal 1
• The guidelines focus on placement technique and assessment of anatomic success rather than removal 1
• If intervention is needed for restenosis, repeat angioplasty or additional stenting is performed rather than stent removal 1

Ductal Stents (Pediatric Cardiac)

• Patent ductus arteriosus stents in newborns are temporary palliation devices that remain until definitive surgery 1
• These are not removed but rather addressed during subsequent surgical repair 1
• Early restenosis is common (freedom from reintervention 89% at 6 months, 55% at 12 months), requiring repeat intervention rather than removal 1

Urological Stents

Migrated Ureteral Stents

• Ureteroscopic removal under local anesthesia is effective for mildly migrated stents (below the pelvic brim) 6
• Success rate is 91.9% with this approach in the outpatient setting 6
• Semirigid ureteroscopy is performed without general anesthesia, with mean pain scores of 1.73/5 6
• Patients are discharged within 1 hour with no hospital admissions required 6

Key Technical Considerations

Stent Anchoring and Migration Prevention

• Stent fixation methods (endoscopic suturing, over-the-scope clips) reduce migration but complicate removal 1
• When anchoring is used, plan for removal technique in advance 1

Common Pitfalls to Avoid

• Never attempt to remove partially covered stents without the stent-in-stent technique - direct removal risks severe bleeding and esophageal tears 3, 4
• Do not leave the second stent in place too long (>6 days increases risk) when using stent-in-stent technique 3
• Metallic airway stent removal should never be attempted without rigid bronchoscopy capability and general anesthesia 5
• For ureteroscopic removal, only attempt with mild migration (below pelvic brim); more severe migration requires alternative approaches 6