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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3733_Библиотеки_им_академика_М_И_Перельмана.pdf
embolization).
57,60,73
Early rebleeding in general is due to incomplete embolization or
presence of overlooked collateral vessels. Up to 20% of patients will bleed
again in the first month. Late rebleeding (months or years), on the other hand,
is due to progression or reactivation of the underlying disease and lesion
revascularization by collateral vessels from other bronchial arteries and
systemic arteries of the neighborhood.
The main factors for recurrence are improper technique, partial
embolization, or embolization of side branches involved in the injury but
which are not the origin of the bleeding. Other causes include the use of
absorbable embolic agents, acute vascular pathologic processes, or chronic
diseases such as tuberculosis, aspergillosis, and cancer.
13,74,75
Also, if the
primary disease is not adequately treated, such as in tuberculosis and in
aspergillosis lung infections, it is expected to have a higher recurrence rate of
bleeding.
Chronic or resistant tuberculosis has high rate of recurrence, whereas
acute tuberculosis sensitive to antituberculosis therapy has a favorable
outcome with low rate of rebleeding after embolization.
57,75
Hemoptysis is the most common symptom in aspergilloma; it occurs in
69% to 83% of all patients, and it ranges from mild to life threatening, with a
mortality rate ranging from 2% to 50% and with an early and very high
recurrence rate.
57,76
Patients with lung cancer carry a 10% to 30% risk of developing
hemoptysis and are also at risk of recurrence following embolization.
14,77
It is important to know that hemoptysis is a symptom that can become
fatal in patients suffering from a severe pulmonary disease. Embolization is a
symptomatic treatment of hemoptysis. It is necessary to medically or
surgically resolve the underlying condition, when possible.52 It is therefore
important to identify and embolize all vessels that may be contributing to the
abnormal blood supply, including any nonbronchial systemic or pulmonary
arteries. The underlying pathology should be treated if possible to achieve
long-term hemoptysis control.
POTENTIAL COMPLICATIONS
The most frequent complications of hemoptysis embolization include chest
pain (24% to 91%) and dysphagia (1% to 18%). They are temporary
symptoms due to ischemic phenomena caused by embolization of intercostal
and esophageal branches respectively.
13,21,52
It is known that the bronchial arteries supply not only the bronchial
artery branches but also provide for the vasa vasorum of the aorta, pulmonary
artery wall, esophagus, pleura, and spinal cord.
52
To prevent accidental embolization, we have to work in optimal imaging
conditions (adequate equipment, high dose, zoom, and collimation) to
identify any leakage to an undesired structure and with the adequate materials
for microcatheterization. Every injection should be performed under
fluoroscopic control with a slow, careful, and precise infusion of the mixture
(iodine contrast and embolic agent, choosing an adequate proportion
depending on the contrast concentration and the employed agent).
Subintimal dissection of the aorta or the bronchial artery during
hemoptysis embolization is another frequent minor complication, with a
reported prevalence of 1% to 6.3%. There are usually no symptoms or
problems related to it. This complication can be avoided with the use of soft
tip diagnostic catheters, microcatheters coaxially, and gentle hand
injections
15,21
(Fig. 18.17).
Probably the most feared and serious complication is the embolization
of the anterior spinal artery, which can be caused by transverse myelitis. The
prevalence of spinal cord ischemia after hemoptysis embolization is reported
to be 1.4% to 6.5%. When the anterior medullary artery (Adamkiewicz
artery) is visualized at angiography, embolization should not be performed.
Therefore, good imaging and extensive previous diagnostic angiographies or
scans are essential.
54,78–80
As has been already said, sometimes, the medullary artery cannot be
visualized at the beginning of the embolization because it is very thin and
bronchial flow is dominant. Therefore, embolization should always be
performed meticulously, slowly, and under fluoroscopic guidance to stop on
time and avoid its accidental embolization.
36
Another serious but infrequent complication is the posterior cerebral
circulation stroke because of embolism to the occipital cortex, either via
bronchial artery–pulmonary vein shunt or via collateral vessels between
bronchial and vertebral arteries.
81,82
Other rare complications reported in the literature include aortic and
bronchial necrosis, bronchoesophageal fistula, ischemic colitis, and
pulmonary infarction.
83,84
TIPS AND TRICKS
Tips
• Chest CT angiography previous to embolization shortens the
procedure length because it helps to locate the bleeding.
• It is useful to include the entire thoracic aorta in the angiography to
get the whole picture of bronchial and intercostal arteries and any
other anomalous artery arising from the aorta.
• An adequate equipment and radiographic technique that achieve a
high image quality is essential to visualize medullary and esophageal
arteries.
• Anterior medullary artery can usually be found in the left hemithorax.
• Always use a microcatheter coaxial to the diagnostic catheter.
• Always use spherical particles greater than 300 μm to avoid leakage to
the systemic circulation through shunts.
• Ensure distal embolization.
• Systematically check every bronchial and thoracic systemic artery.
• In case of inflammatory or infectious disease such as tuberculosis, do
not forget to also check the pulmonary circulation due to the
possibility of shunting .
Tricks
• Do not introduce the diagnostic catheter (4-Fr to 5-Fr) into the
bronchial artery to avoid vasospasm.
• If it is not possible to stabilize the microcatheter, try to use a 5-Fr to
6-Fr guiding catheter in the aorta.
• Try to get as distally as possible with the microcatheter gently using a
soft tip 0.014-in microwire.
• Use spherical particles greater than 300 μm, ensure a homogenous
mix, and deliver them slowly. Take your time.
• Perform control checks gently and slowly to avoid particle lavage to
the systemic circulation.
• When a medullary, esophageal, or tracheal artery is visualized, it is
possible to close it proximally with a coil to avoid particle
embolization.
• Once distal embolization is ensured, some authors recommend
proximal coil occlusion. Other authors emphatically advise against it.
SUMMARY
Hemoptysis is a fairly common symptom of a group of respiratory diseases.
Fortunately, only a few are massive and/or life threatening. Massive and
recurrent hemoptysis are those that require invasive treatment. In the
management of hemoptysis, location of the bleeding point is essential.
Multidetector CT and bronchoscopy play an important role before
angiography. Embolization with nonabsorbable particles is the preferred
treatment of massive hemoptysis. Embolization is, in general, a symptomatic
treatment: never forget the treatment of the underlying disease, if possible.
Surgery is reserved for some difficult cases and embolization failures.
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