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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3726_Библиотеки_им_академика_М_И_Перельмана.pdf
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3.6 Thoracic Arterial Bleeding
91
Fig. 3.90 Aortography was unable to show a bleeding source (a–d). Selective angiography of the left gastric artery
showing spasm and no bleeding (e). Control image after embolization with micro coils (arrow) (f)
92
ef
Fig. 3.90 (continued)
3 Thoracic Vascular Emergencies
(Fig.3.95a, b). Amplatz plugs with diameters of
10 mm and 8 mm and detachable micro coils
with diameters of 10 mm and 8 mm were
3.6.1.2 Bleeding fromaPulmonary
Artery Aneurysm/
Pseudoaneurysm
deployed into both PAVMs with good result
(Fig.3.95c, d). Finally, one more PAVM was dis-
covered and occluded with detachable micro
coils measuring 6mm in diameter and an Amplatz
plug measuring 6mm in diameter. Control angiography showed a satisfactory result, and no
additional PAVMs were seen during the scan
(Fig.3.95e, f).
Key Points
• Ruptured PAVMs are a very rare
presentation
• In a majority of cases, the patient had
Osler-Weber-Rendu disease (HHT)
• Embolization is the rst-line treatment
Outcome
The patient recovered very well, and ECMO
treatment was stopped after successful embolization. The patient did not experience any complications, and oxygen saturation increased to 98%
with normal respiration. Following genetic testing, it was found that the family has Osler-WeberRendu disease. Additionally, contrast-enhanced
CT of the cerebrum was eventually performed
but found no brain malformations. CT showed
well-deployed micro coils and Amplatz plugs no
new PAVMs (Fig.3.96).
Aetiology andClinical Presentation
A 62-year-old healthy patient was admitted due
to acute onset of haemoptysis and chest pain. The
patient had never been ill and never had any kind
of surgery or interventions. There were no signs
of a lung infection, and the patient did not have
chronic obstructive pulmonary disease. There
was no history of smoking. Haemoptysis was
massive, >500mL in the last 24h. The patient
was haemodynamically stable, but the risk for
aspiration was high.
bc
3.6 Thoracic Arterial Bleeding
a
93
Fig. 3.91 Contrast-enhanced CT showing contrast agent
inside the oesophagus (a) (blue arrows). Orange arrows
indicate haematoma in the oesophagus and ventricle (c).
Yellow arrow on sagittal reconstruction (b) shows aortooesophageal stula. White arrow indicates micro coils in
the left gastric artery
94
3 Thoracic Vascular Emergencies
a
c
b
d
Fig. 3.92 Repeat aortography shows massive bleeding and aorto-oesophageal stula- (blue arrows) (a, b). The bleeding
was arrested after stent graft deployment as shown on early- and late-phase control angiography (black arrows) (c, d)
3.6 Thoracic Arterial Bleeding
95
a
b
c
Fig. 3.93 Control contrast-enhanced CT showing a well-deployed stent graft –(blue arrows) and no bleeding. White
arrow indicates micro coils in the left gastric artery
96
3 Thoracic Vascular Emergencies
a
Fig. 3.94 Non–contrast-enhanced CT showing a ruptured left arterio-pulmonary-venous malformation (blue arrows)
(a, b). Right lower lobe atelectasis is indicated by the white arrow (a)
Pre-interventional Diagnosis
Emergency angiography through the right renal
b
3.7 Intercostal/Bronchial Artery Bleeding
vein was performed (Fig.3.97a, b). Angiography
showed an aneurysmatic PAVM with a feeding
artery 6 mm in diameter. The aneurysmatic
3.7.1 Bleeding fromtheIntercostalBronchial Artery
PAVM showed no sharp edges.
Endovascular Treatment
An Amplatz plug measuring 10mm in diameter
was advanced through a 7 Fr sheath into the
PAVM and deployed with complete exclusion of
and no ow through the aneurysmatic PAVM
after deployment (Fig.3.97c, d).
Outcome
The patient recovered very well and presented
with no new bleeding problems. The patient was
discharged from the hospital 2days after embolization. Control CT one (Fig. 3.98) and 5 years
(Fig. 3.99) after embolization showed satisfactory results with almost complete resolution of
the aneurysmatic PAVM. The patient’s family
had been diagnosed with HHT/Osler-WeberRendu disease.
Key Points
• The bronchial artery is the most frequent bleeding source in cases of
haemoptysis.
• Sometimes bleeding from the pulmonary artery can occur; therefore, it is
important to exam the artery.
• Embolization is very useful and is the
rst-line treatment choice.
3.7.1.1 Aetiology andClinical
Presentation
A 69-year-old patient with non-small-cell lung
cancer (NSCLC) treated with stereotactic radiotherapy was admitted to our institution. The
cd
3.7 Intercostal/Bronchial Artery Bleeding
97
a
b
Fig. 3.95 Angiography through a 7 Fr guiding catheter
showed at least two complex PAVMs with feeding arteries
measuring 8mm (blue arrows) (a, b). (c) black arrow indi-
cates micro coils in one PAVM.Blue arrow indicates an
Amplatz plug in another PAVM. (d) orange arrow indicates a smaller PAVM occluded with 6mm micro coils and
an Amplatz plug. (e and f) control angiography showing a
satisfactory result. There were no PAVMs in the right lung
98
ef
Fig. 3.95 (continued)
3 Thoracic Vascular Emergencies
patient developed haemoptysis a few days after
the last treatment. Bronchoscopy was unable to
identify the source of bleeding, and thus it could
not be treated endoscopically. The patient was
haemodynamically stable, but the haemoptysis
was ongoing.
3.7.1.3 Endovascular Treatment
A 5 Fr diagnostic catheter was used for selective catheterization of the right hypertrophic
intercostal- bronchial trunk via percutaneous
insertion through the right femoral artery.
Furthermore, the microcatheter was advanced
distally into the bleeding arteries (Fig.3.101).
3.7.1.2 Pre-interventional Diagnosis
Contrast-enhanced CT of the chest was performed
(Fig. 3.100b, c). The previous CT (Fig. 3.100a)
only showed NSCLC in the right upper lung,
Embolization of the bleeding arteries was performed rst with 300–500 μm microspheres
and then 3 mm diameter micro-coils. There
were no complications during the intervention.
whereas the latest CT showed bleeding into the
central lung parenchyma and in the right upper
lobe. CT showed an intercostal- bronchial artery
on the right side and consolidation and ground
glass opacications in the artery irrigation zone,
which was described as bleeding. A nasogastric
sonde was advanced into the stomach, and the
patient was intubated to prevent aspiration.
3.7.1.4 Outcome
The patient was extubated the day after
the haemoptysis ceased. No complications
occurred during the stay in the hospital. No
new episode of haemoptysis was recorded.
Control contrast- enhanced CT 3 months after
embolization showed satisfactory results and
3.7 Intercostal/Bronchial Artery Bleeding
99
Fig. 3.96 Contrast-enhanced CT showing a satisfactory result and no new PAVMs
100
3 Thoracic Vascular Emergencies
a
c
b
d
Fig. 3.97 Angiography revealed a single PAVM in the
left lung with a 6mm feeding artery. White arrows indicate the aneurysmatic PAVM (a, b). (c) advancement of a
10 mm Amplatz through a 7 Fr guiding catheter (blue
arrow). (d) control angiography after Amplatz plug
deployment showing immediate occlusion of the PAVM
(blue arrow)