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there are reports of embolic events in PAVFs measuring below the 3-mm
“standard.”
13–15
Over a 260 cm 0.035-in stiff Amplatzer wire, the diagnostic
catheter is exchanged for a White LuMax set, which comes in two sizes: 7-Fr
or 8-Fr guide catheter with a coaxial angled tip inner catheter. At this point,
the patient should receive a bolus of intravenous heparin (~40 IU/kg). The
pulmonary artery lower segments are generally easily accessed by “flopping”
the Bentson wire down into the basilar segment. A hydrophilic angle tip wire
such as a Glidewire (Terumo Medical Corporation, Somerset, New Jersey)
may facilitate selection of the feeding vessel but should be used with care as
dissection can occur. The middle and upper segments are more challenging to
cannulate and may require a more sharply angled catheter such as a Judkins
right coronary catheter (Cordis) or a left internal mammary catheter.
Detachable Amplatzer Vascular Plugs (AVPs) (St. Jude Medical, Inc.,
St. Paul, Minnesota) and pushable Nester 0.035-in coils (Cook Medical, Inc.,
Bloomington, Indiana) are our embolic devices of choice (Figs. 19.5 and
19.6, respectively). Coils and AVPs should be oversized by 20%. The coils
should be densely packed and placed as close the fistulous sac as possible,
ideally within 1 cm.16 There are some who believe that packing the
aneurysmal fistulous sac has a lower recanalization rate.17 This has yet to be
well established in the literature. Occasionally, microcatheters may be needed
to deliver 0.018-in coils in a precise location.18 Many different microcoils are
available—both pushable and detachable forms. The anchor technique is used
when there is concern about a coil passing through the PAVF and ending up
in the systemic circulation. This involves “anchoring” the first loop of the
coil into a small side branch of the pulmonary artery that is feeding the
PAVF.1 Alternatively, a large detachable coil may be used as a scaffold to
provide stability for placement of more economical pushable coils.
A noncontrast chest CT should be performed 6 months following
embolization to evaluate for any residual PAVF patency. The draining vein
and aneurysmal sac should disappear or be reduced by 70%. Any
reappearance of the draining vein or aneurysmal sac on future follow-up
studies performed every 3 to 5 years indicates recanalization. Reperfusion of
a previously embolized PAVF is reported about 7% of the time (Fig. 19.11).
Causes include not packing the coils densely enough, an accessory vessel that
was not embolized, reperfusion from a collateral pulmonary artery vessel, and
reperfusion of a collateral bronchial artery vessel. The significance of these
recanalized PAVFs is unknown. Some believe that the risk of embolus from
these previously treated lesions is less because the coil pack may act as a
“filter” and the flow through these lesions is slower. At our institution, we err
on the side of caution and reembolize the recanalized PAVFs.
Follow-up chest CT may also reveal the presence of “new” PAVFs,
which may or may not be symptomatic. These lesions were likely present on
previous studies or were microscopic and have enlarged over time. All
accessible lesions greater than 3 mm in diameter should be treated.
11,12
PAVFs are classified as simple or complex.19 Most (85%) AVFs are
classified as simple, meaning that the malformation arises from one or more
arteries within a single pulmonary segment. Up to 10% of lesions are
considered complex with arterial vessels arising from more than one
pulmonary segment, whereas 5% or fewer have involvement of multiple
lobes. These are considered diffuse and outcomes in these patients are worse.
Pulmonary flow redistribution has been used with some success. This
involves the lobar occlusion of pulmonary artery feeding the diffusely
involved lobe.
20,21
Lung transplantation, with or without cardiac
transplantation depending on presence of high-output heart failure, has been
reported for diffuse PAVFs.
22
POTENTIAL COMPLICATIONS
Patients should be evaluated with a preoperative electrocardiogram (ECG) to
look for left bundle branch block (LBBB). Passing the catheters through the
heart can induce a right bundle branch block. In a patient with a preexisting
LBBB, total heart block can ensue.
Air embolism occurs less than 5% of the time but should always be a
concern. Due to its anterior origin, the right coronary artery may be
unintentionally embolized with air bubbles or clot causing angina or ECG
changes, which can be treated with sublingual nitroglycerin and atropine for
bradycardia. Rarely, TIAs may occur. The reported complication rate
including angina and TIA is less than 2%. Pleurisy is a common
postprocedural complaint (12%). This is treated with anti-inflammatory
medication. Rarely, severe, delayed pleurisy occurs.
Coil migration into the systemic arteries has been reported along with
successful snare retrieval.
19,23
If this happens, immediately bolus the patient
with intravenous heparin for a target activated clotting time near 250 seconds.
Proceed with arterial access and retrieval of the embolized coil.
CONCLUSION
Embolization of a PAVF can be technically challenging. Careful attention to
preprocedure imaging, high-quality angiography, meticulous technique, and a
good knowledge of embolic agents are keys to success.
TIPS AND TRICKS
Angiography
• Use a 2-s injection of 10–25 mL of iodine contrast.
• Use the ipsilateral oblique (40–60 degrees) to spread the basilar
pulmonary artery segments.
• The flush catheter typically enters the left pulmonary artery. Curve
the back end of a Bentson wire to facilitate steering the MONT-1
catheter to the right side.
• Carefully review your pulmonary angiogram on the workstation.
Avoid “search satisfaction” by following each segmental artery out
the entire length. Many patients will have multiple PAVFs.
• Invert the contrast image (so it appears white) to better see the PAVFs
when reviewing your angiography (Fig. 19.11).
• Do not oversedate the patient as snoring/deep inspiration causes
significant motion and may dislodge your carefully placed catheter.
Accessing the Lesion
• Commonly used wires: 0.035-in Rosen (Cook Medical, Inc.,
Bloomington, Indiana) or 0.035-in stiff Amplatzer for exchanging the
MONT-1 for the White LuMax set, Bentson for flopping into basilar
segments, semicurved 0.035-in hydrophilic Glidewire (Terumo
Medical Corporation, Somerset, New Jersey) for selecting more
difficult branches in the upper and middle lobes.
• Use a Judkins right coronary catheter or a left internal mammary
catheter to select upper and middle lobe branches.
• If you need to place an AVP II more distally than your Lumax guide
will go, you can place a 6-Fr 100-cm Envoy guide catheter (Codman
& Shurtleff, Inc., Raynham, Massachusetts), which will allow you to
place up to a 12-mm AVP II plug.
• Prowler Plus (Codman & Shurtleff, Inc., Raynham, Massachusetts) is
our microcatheter of choice because it has a 0.021-in inner diameter,
which allows for placement of pushable 0.018-in Nesters as well as
many detachable coils. The Ruby Coils (Penumbra, Inc., Alameda,
California) require a larger diameter microcatheter.
Embolization
• Densely pack the coils as close to the fistula as possible (<1 cm).
• We most commonly use AVP II, AVP 4, and Nester coils.
• We do not use the first-generation AVP device due to recanalization
concerns.
• A single detachable coil or AVP can be used as a scaffold for the
placement of pushable coils to obtain tight packing with reduced cost.
• Anchor technique: place the first portion of a pushable coil into a
distal side branch to prevent distal migration of the coil.
• Wait 5 min after placement of device to assess thrombosis.
• Oversize coils and AVPs by at least 20%. Some interventionalists
consider using longer coils (with 20%–30% oversize) and oversize
the AVP between 30% and 50% in larger and high-flow PAVF.
• Do not use particles or liquids due to the high-flow right-to-left shunt.
REFERENCES
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after embolotherapy of pulmonary arteriovenous malformations. J Vasc
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2. Ference BA, Shannon TM, White RI, et al. Life-threatening pulmonary
hemorrhage with pulmonary arteriovenous malformations and hereditary
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3. Shovlin C, Sodhi V, McCarthy A, et al. Estimates of maternal risks of
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7. Wooderchak-Donahue WL, McDonald J, O’Fallon B, et al. BMP9
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genetic features of pulmonary hypertension in patients with hereditary
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20
Chest Tumors
Shinichi Hori
BACKGROUND
Lung and Mediastinal Malignancy Treatment
Treatment of patients with advanced lung cancer or metastatic lung tumor,
usually with serious symptoms such as respiratory distress, pain, or vascular
stenosis of the superior vena cava or pulmonary artery, is often attempted.
Options commonly taken are palliative radiotherapy or systemic
chemotherapy. However, results suggest that these therapies give little
benefit. In the case of palliative radiotherapy, the results are indeterminate
and any improvement takes a long time to appear. Systemic chemotherapy is
often applied despite a history of poor results and serious systemic side
effects. Even if these therapies are at first effective, the new lesions created
soon cause problems. It is evident that more effective treatment is needed,
with fewer ensuing complications.
A new and promising treatment is selective chemoembolization of lung
and mediastinal malignancy. Selective catheterization technique of the
bronchial artery has shown by Neyazaki et al.1 in 1969: that blood supply to
the primary lung cancer as well as to metastatic pulmonary malignancies has
been provided mainly by the bronchial artery. This discovery has been
followed up with the following study results. Preoperative induction
chemotherapy using bronchial arterial infusion was reported to be effective.
2
Bronchial artery infusion therapy combined with radiotherapy improved the
prognosis of locally advanced lung cancer.
3
Bronchial artery infusion for
lung cancer was reported to be effective in a study with a small number of
patients.
4
In pathologic situations, the systemic arteries can penetrate into the lung
and mediastinum and irrigate neoplastic lesions. Hemoptysis caused by
bleeding from the bronchial artery, which shares systemic pressure, is well
controlled by the bronchial artery embolization.5 In another study, the
bronchial artery embolization for hemoptysis caused by lung cancer was
effective to control bleeding with limited complications.
6,7
The treatment of specific lesions in the thoracic cage, the mediastinum,
and the lung field is now possible due to recent advances in diagnostic
apparatus such as the three-dimensional (3-D) computed tomography (CT)
scanner to digital angiography and to therapeutic techniques using
microcatheters.
In this new approach, selective arterial infusion of antineoplastic agents
concentrates the drugs in the target lesion and reduces systemic exposure.
4
Embolization after the infusion helps retention of the drug by inhibiting
flushing out by the arterial flow. Selective embolization using new spherical
embolic materials does not cause the usual tissue damage because of reduced
local irritability. Well-calibrated spherical material will allow controlling the
occlusion level, which further avoids usual tissue damage. Arterial blockage
may induce necrosis of tumor tissue in some cases. This selective
chemoembolization of lung and mediastinal malignancy is a promising
treatment procedure for patients who are suffering from various symptoms,
such as severe cough or respiratory distress, caused by advanced cancer.
Local Breast Cancer Recurrence and Chest Wall
Metastases