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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
the cause of bleeding or are involved together with the bronchial arteries.
Nonbronchial systemic collateral arteries differ from anomalous bronchial
arteries because they are not congenital but developed through several
pulmonary diseases.
47
Systemic collateral arteries may include a wide spectrum of arteries
within or near the thorax, such as the thyrocervical trunk, intercostal, internal
mammary, thoracodorsal, and lateral thoracic arteries and other branches
from the subclavian artery. Intra-abdominal arteries, including the inferior
phrenic arteries, may also provide nonbronchial collateral supplies for the
lung lesions that cause hemoptysis
48–51
(see Fig. 18.1).
The nonbronchial systemic collateral arteries are common in the
presence of pleural thickening and adhesion, in chronic inflammatory lung
disease, or pulmonary malignancies, thereby facilitating transpleural systemic
pulmonary anastomosis.
47
Angiographic Signs
The diagnosis of bleeding by arteriography is simple but controversial. When
direct signs such as extravasation, aneurysms, or pseudoaneurysms are
observed, diagnosis is easy and the cause of hemoptysis is clear. However,
extravasation of contrast agent is observed in only 3.6% to 10.7% of cases
41
(Fig. 18.10).
Angiographic indirect findings in hemoptysis include hypertrophic and
tortuous bronchial arteries, areas of hypervascularity and neovascularity, and
shunting of blood into pulmonary artery or vein52 (Fig. 18.11).
In our series,23 bronchial angiography revealed abnormalities that would
account for hemoptysis in 287 patients (91.4%). Of those, 58 (20.2%)
presented direct signs of hemorrhage (extravasation and/or aneurysm). The
remainder only showed indirect signs that were more or less intense (Table
18.3).
INDICATIONS AND CONTRAINDICATIONS
Not every hemoptysis requires either embolization of bronchial, systemic, or
pulmonary arteries. Most small entity hemoptysis require only a correct
diagnosis and conservative medical treatment. Massive hemoptysis is the
most important indication for invasive treatment by surgery or embolization.
There is no agreement in the definition proposed for the term massive
hemoptysis, being the most commonly used for a blood expectoration greater
than 300 to 600 mL in 24 hours. Furthermore, the reliability of patient
measurement and reporting of volume of expectorated blood may be limited
in real life, therefore a more reasonable practical definition would be any
amount of hemoptysis that is life threatening
28,43
(Fig. 18.12).
The main indications for embolization treatment are outlined in Table
18.4.
The only real contraindications for bronchial or nonbronchial artery
embolization are the usual contraindications for angiography, including
intractable coagulopathy, renal dysfunction, and severe contrast allergy. The
presence of medullary artery with insurmountable embolization risk, such as
a bronchial artery that is too small to be selectivized or a medullary artery
that cannot be occluded with a proximal coil, would also contraindicate the
technique,. Likewise, inexperience or inability to safely catheterize
selectively or embolize the bleeding branches should contraindicate the
intervention due to the high risk of embolic agent migration to other
territories.
43
TECHNIQUE
Bronchial and nonbronchial artery embolization requires a thorough detailed
examination to discover angiographic pathologic vessels. Both diagnosis and
treatment should be performed in a vascular interventional operating room
equipped with the best possible imaging technology and the means of
constant monitoring and appropriate resuscitation to solve any unexpected
issue. The operator must be familiar with the anatomy of thoracic and
bronchial arteries as well as the technical considerations and materials of
embolization. It can use different arterial access, but perhaps the most used is
the right femoral artery. In all cases, an angiogram of thoracic aorta is
recommended to demonstrate bronchial artery anatomy and to identify other
systemic collateral vessels (Fig. 18.13).
The initial aortogram shows hypertrophied arteries and denotes possible
aberrant origins of ectopic arteries that reach the pulmonary parenchyma.
21,53
A methodical selective catheterization of the major bronchial arteries is
mandatory even if the aortogram did not show any pathologic bronchial
artery.21 Although 4-Fr to 5-Fr cobra-type curved catheters are the most
commonly used for catheterization, several different configurations (e.g.,
Simmons 1, Headhunter, Michaelson, Yashiro-type, Sos-Omni catheters, etc.)
should be available for optimal selection of bronchial arteries.
Most of the authors recommend the routine use of coaxial
microcatheters for superselective bronchial artery catheterization.
Superselective catheterization allows a safe position and allows the blood
flow necessary to achieve distal embolization
1
,54,55
(Fig. 18.14).
The use of microcatheters is of particular importance when embolizing
the right intercostobronchial trunk to avoid the occlusion of intercostal
branches shunting directly to the anterior spinal artery.
56
To identify the bleeding bronchial artery, it is necessary to selectively
catheterize each of the bronchial artery independently and slowly inject small
quantities of contrast manually. If all explored bronchial arteries are normal,
then the systemic arteries that surround the thorax (internal mammary, lateral
thoracic, intercostals, etc.) have to be methodically explored bilaterally; if
they are also normal, then we should study the pulmonary arteries. When
pleural thickening, peripheral tumors, or peripheral lung scars are detected, it
is mandatory to study the systemic vascularization anyway.
21
It has been established that embolization should always be the most
distal possible to prevent recurrences by collateral vessels. The rationale for
this approach is that the distal embolization of the bronchopulmonary
pathologic anastomosis slows the flow in the smaller vessels, making it easier
to occlude them. In fact, several authors contraindicate the use of coils in
hemoptysis embolization because they produce a more proximal occlusion
and, in case of recurrence, they can complicate the access to the diseased
arteries.
52
In our experience, the proximal occlusion, after distal embolization,
reinforces decreasing the bronchial artery flow and ensures its occlusion (Fig.
18.15). In case of recurrence by collaterals, that new collaterals are the ones
to be closed. With this technique in 15-year follow-up, we observed a lower
rate of recurrence (10.4%) than most authors (10% to 55%).
23,57
Several embolic materials are available for bronchial artery
embolization. The use of embolization agents smaller than 300 μm should be
avoided. Pump58 and Bernard et al.59 have demonstrated that
bronchopulmonary anastomoses could allow the flow of particles smaller
than this size, so they can produce pulmonary infarction (bronchial artery
shunt to pulmonary artery) or systemic embolization (bronchial artery shunt
to pulmonary vein).
The main embolic agents used for hemoptysis treatment are absorbable
gelatin sponge, polyvinyl alcohol, trisacryl microspheres, N-butyl
cyanoacrylate, ethylene vinyl alcohol, and metal coils60 (Table 18.5).
Absorbable gelatin sponge (Gelfoam; Baxter, Deerfield, Illinois) is the
most economical agent; it is readily available and easy to use. Delivering the
material through microcatheters can be difficult. Moreover, it has the
disadvantage of producing temporary arterial occlusion with a high rate of
recurrence by recanalization when gelatin is reabsorbed in 15 to 30 days.
8,9,54
Polyvinyl alcohol (PVA) is a nonabsorbable particulate agent available
in various particulate sizes. The most common particle size for bronchial
artery embolization ranges from 250 to 500 μm.
55,61–63
Currently used trisacrylic PVA microspheres show a spherical
morphology of fairly uniform size, compliant and nonclumping, and easily
delivered through microcatheters. There are several companies that sell
different types of microspheres with small variations and different
characteristics.
64
Ethylene vinyl alcohol, known as Onyx (Covidien, Irvine, California), is
a copolymer dissolved in dimethyl sulfoxide and suspended in micronized
tantalum powder to provide contrast for visualization under fluoroscopy. The
embolic agent Onyx is safer and easier to use than other liquid glues (as
Histoacryl; B. Braun Medical, Inc., Bethlehem, Pennsylvania) but has the
drawback of its high price.
65
Histoacryl consists of monomeric N-butyl cyanoacrylate, which
polymerizes quickly in contact with tissue fluid. Histoacryl is available in
two colors: translucent, especially for facial application, and blue, which
enables an easy control over the quantity applied. It solidifies in a few
seconds upon contact with blood. Its management requires a lot of expertise
because the tip of the microcatheter may quickly become trapped in the glue
and can be difficult to retrieve.
66,67
The use of metal coils for bronchial artery embolization in the treatment
of hemoptysis is controversial. As it has been already said, many authors
advise against its use based on the difficulty of treating a recurrence.
52,60
Other authors defend embolization using microcoils with acceptable rates of
recurrence.
68,69
We use the combination of distal embolization with microspheres and
detachable microcoils at the proximal end (Fig. 18.16). Long-term follow-up
supports the benefits of this technique.
2,70
OUTCOMES
Bronchial and nonbronchial systemic artery embolization is the treatment of
choice for massive and recurrent hemoptysis. Immediate control of bronchial
bleeding is achieved in 73% to 99% of cases
23,57,64,71,72
(Table 18.6).
Technical success achieved with new technologies is very high (>90%
of cases), whereas clinical success varies depending on the length of the
follow-up. It seems that these new technologies have not improved the
clinical long-term outcome, but there are no randomized studies with
sufficient clinical evidence to categorically state that. At least, calibrated
microparticles and microcatheters seem to have improved the efficacy in
arterial occlusion and, especially, the safety.
Immediate control of a massive bleeding rate ranges from 80% to 100%
using different embolic agents. The Achilles heel of this procedure is a
recurrence up to 50% or even 75%, as stated by some authors. It is difficult to
establish the true rate of recurrence if there is no consensus of defining
recurrence. If we consider small bloody sputum episodes without clinical
significance, our recurrence will be high. Some authors only record episodes
of hemoptysis requiring medical management (surgery or