**Background:** Malignant central airway obstruction (MCAO) is a life-threatening complication common in advanced-stage lung cancers and pulmonary metastatic carcinomas. When MCAO involves the tracheal carina or is accompanied by fistula formation, treatment becomes particularly challenging. Airway stent placement is a palliative approach to relieve respiratory distress, prolong survival, and improve lung function, but debate continues regarding optimal stent type. This case report describes a novel hybrid approach using both a Y-shaped covered metallic stent and a Y-shaped silicone stent to manage MCAO with carina-esophageal fistula.
**Methods:** A 61-year-old male with a history of esophageal squamous cell carcinoma (diagnosed 1 year prior) presented with cough, purulent sputum, and asthma that had worsened over more than 1 month following esophagectomy. He had received neoadjuvant chemotherapy/immunotherapy (2 cycles), postoperative chemotherapy/immunotherapy (4 cycles), and radiotherapy. On admission (September 19, 2022), he was in severe respiratory distress with tachypnea (respiratory rate 26/min), tachycardia (heart rate 155 bpm), cyanosis, and bilateral wet rales. Arterial blood gas on noninvasive ventilation (FiO₂ 50%) showed pH 7.47, PCO₂ 54.9 mm Hg, PO₂ 78.2 mm Hg. Laboratory findings included leukocytosis (white blood cell count 14.72×10⁹/L, 92.5% neutrophils), anemia (hemoglobin 78 g/L), elevated procalcitonin (0.98 ng/L), and elevated D-dimer (527 ng/mL). Bronchoscopy revealed copious purulent secretions and a fistula between the tracheal carina and esophagus. Bronchoalveolar lavage NGS identified Acinetobacter baumannii and Candida tropicalis. Chest CT showed post-esophagectomy changes, carina-esophageal fistula, bilateral pneumonia, and mediastinal lymphadenopathy. The patient was diagnosed with stage IV esophageal squamous cell carcinoma, carina-esophageal fistula, severe pneumonia, and hypoproteinemia. He was treated with intravenous imipenem cilastatin and tegacycline, plus enteral nutrition via jejunal tube. On September 20, under general anesthesia via rigid bronchoscopy, a large fistula was visualized behind the carina extending to the right main bronchus approximately 0.5 cm from the right intermediate bronchus, with the left main bronchus infiltrated and narrowed. A Y-shaped silicone stent (main branch 15×18 mm, side branches 12×20 mm and 12×8 mm) was placed in the right main bronchus, and a Y-shaped covered metallic stent (trachea section 16×40 mm, right branch 14×15 mm, left branch 12×30 mm) was placed in the lower trachea. High-frequency ventilation was used intraoperatively to reduce air leakage and CO₂ retention.
**Key Results:** The patient's asthma symptoms improved within 2 days post-procedure. Oxygen saturation was approximately 94% on 3 L/min nasal oxygen. Sputum volume decreased and oxygenation index improved. At 9 days post-operation, laboratory improvements included: white blood cell count decreased from 14,720 to 10,700 per mm³; C-reactive protein decreased from 40.51 to 29.95 mg/dL; blood urea nitrogen decreased from 10.1 to 3.21 mmol/L; albumin increased from 34.14 to 35.05 g/L; arterial blood gas on 3 L/min nasal oxygen showed pH 7.45, PCO₂ 48.2 mm Hg, PO₂ 73.4 mm Hg; and PO₂/FIO₂ ratio improved from 156.4 to 222.4 mm Hg. Electrocardiogram converted from atrial flutter to sinus rhythm with short PR interval. Anti-infection therapy was changed to piperacillin tazobactam plus levofloxacin based on culture results showing Pseudomonas aeruginosa. The patient was followed for more than 2 months with improved quality of life.
**Clinical Implications:** This case demonstrates that a hybrid stent approach—combining a Y-shaped silicone stent and a Y-shaped covered metallic stent—can effectively address complex malignant airway disease involving the carina and esophageal fistula. The silicone stent was placed in the right main bronchus to preserve right upper lobe function and minimize granulation tissue formation, while the covered metallic stent in the lower trachea provided strong support and effective fistula occlusion. This tailored approach may be considered as a palliative option for patients with complex MCAO where single-stent solutions are inadequate. The authors note that malignant esophagotracheal fistula carries a poor prognosis (median survival approximately 56–60 days for esophageal cancer patients), and treatment goals are primarily palliative—improving quality of life and reducing aspiration and sepsis risk.