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154 Pulmonary and Bronchial Arteries
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plications ranges from 1 to 5%. Complications include
contrast reaction, transient renal dysfunction, access site
hematoma, arrhythmia, and respiratory distress. Cardiac
perforation is rare when pigtail catheters are used. The
incidence of major complications has been reported to
be less than 1%.
7,8
The most common indication for pulmonary arteriography is for a patient with an indeterminate V/Q study.
Pulmonary arteriography is often performed in patients
with a low-probability V/Q study with a strong clinical
suspicion of pulmonar y embolism. A pulmonary arteriogram may be performed in patients with a high-probability V/Q study to confirm the diagnosis before starting
anticoagulation, thrombolytic therapy, insertion of an inferior vena cava filter, or if the clinical suspicion for pulmonary embolism does not correlate with the result of
the V/Q study.
Pulmonary embolization occurs to the lower lobes in
more than 50% of patients and is bilateral in 25% of
patients.
9
Pulmonary emboli may lyse spontaneously, organize and incorporate into the arterial wall as a plaque,
or recanalize. Partial lysis of pulmonary emboli can occur
within 24 hours, and complete lysis can occur within 1 to
3 weeks.
10
The primary angiographic signs of pulmonary embolism include an intravascular filling defect (Fig. 15-1) and
an abrupt vessel cutoff (Fig. 15-2). Overlying vessels must
not be confused to be filling defects. Occasionally, a small
branch is occluded flush with the origin of the vessel,
which makes detection difficult. Secondary angiographic
findings of pulmonar y embolism include parenchymal
staining, decreased perfusion, crowded vessels, delayed
venous return from the affected area, pruning of vessels,
slow flow, and shunting away from the involved lung.
Pulmonary arter y catheterization most commonly is
performed by the transfemoral route, but it can be performed from an upper-extremity vein or internal jugular
vein approach. When using the common femoral vein
approach, an iliac and inferior venacavogram is performed to exclude the presence of thrombus before the
catheter is advanced into the right atrium.
Catheters used for pulmonary arteriography typically
have a pigtail tip to resist catheter recoil and multiple side
holes to allow for rapid contrast injection. End-hole
catheters have been known to cause myocardial injury
and pericardial extravasation through recoil and jet effect. The Grollman-type pigtail catheter has good torque
control and is angled at the distal shaft that facilitates
catheter passage through the tricuspid valve and right
ventricular outflow tract (Fig. 15-3). After the right ventricle is entered, the catheter is rotated to direct the tip
toward the pulmonic valve. The catheter then is advanced into the pulmonary artery. An alternative method
uses a standard pigtail catheter and a tip-deflecting
guidewire to angle the distal shaft of the catheter.
FIGURE 15-1. Pulmonary embolism. Intraluminal filling defect
is present within a left lower lobe pulmonary artery branch
(
arrow
).
FIGURE 15-2. Pulmonary embolism. An abrupt vessel cutoff
is present at the right upper lobe pulmonary artery branch
arrow
).
(
FIGURE 15-3. Grollman pigtail catheter.
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The patient’s electrocardiogram must be monitored
continuously for the occurrence of induced ventricular
ectopic beats during catheter manipulations within the
cardiac chambers. Catheter-induced ventricular tachycardia usually can be reversed by immediately withdrawing the catheter. Rarely, intravenous administration of
lidocaine or electroversion may be required. If left bundle-branch conduction block is present, there is a risk of
inducing total heart block during catheterization, and a
temporary cardiac pacemaker should be placed before
J. E. Silberzweig
155
the catheter is introduced into the pulmonary artery.
Pulmonary artery pressure can be measured using the
diagnostic catheter. Some interventionalists recommend
decreasing the contrast injection rate and volume in patients with a pulmonar y artery systolic pressure greater
than 40 mm Hg; however, no relationship between administered contrast dose and complications in patients
with pulmonary hypertension has been demonstrated.
11
A technically adequate pulmonar y arteriogram to exclude the presence of pulmonary embolus requires selective catheterization of the right and left pulmonary arteries, with imaging in at least the frontal and one oblique
projection. The ipsilateral posterior oblique view tends to
produce the least amount of vascular overlap, especially
of the lower lobes (Fig. 15-4). If any injection demonstrates embolus, the examination usually can be stopped.
Massive pulmonary emboli or emboli that do not respond to anticoagulation may require aggressive therapy.
Catheter-directed thrombolytic therapy, thromboaspiration, mechanical clot fragmentation, and stent placement have been used to treat massive pulmonary embo-
12–15
lism.
The role of local transcatheter therapy for acute
pulmonary embolism has yet to be defined. Surgical pulmonary embolectomy is performed as a last resort in
A B
FIGURE 15-4. Pulmonary embolism. Selective left pulmonary arteriogram in the right posterior oblique projection A: shows
overlap of the lower lobe branches. The left posterior oblique view B: clearly demonstrates a large left lower lobe embolus.
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patients with cardiopulmonary collapse who do not respond to transcatheter techniques.
Chronic pulmonary embolism
Repeated episodes of pulmonary embolism with failureof
the pulmonary emboli to lyse or recanalize may result in
pulmonary hypertension and right ventricular dysfunction. Computed tomography (CT) and magnetic resonance imaging are useful in differentiating this disorder
from other causes of chronic pulmonary artery hypertension. Angiography is the definitive diagnostic procedure
performed for diagnostic confirmation and preoperative
planning for open thromboendarterectomy. Chronic
thromboembolic disease produces webs, luminal irregularities, segments of abrupt vessel narrowing, and obstruction (Fig. 15-5).
16
The main pulmonary arteries are usu-
ally dilated. The disease is usually bilateral.
Pulmonary arteriovenous malformations
Pulmonary arteriovenous malformations (PAVMs) are
abnormal connections that develop between pulmonar y
artery and pulmonary vein branches originating from
abnormal development of pulmonary capillaries. The
PAVM results in a right-to-left shunt. PAVMs are divided
into simple and complex malformations. Simple malforma-
tions have a single segmental artery and draining vein.
Complex malformations have two or more arteries that sup-
ply the PAVM with one or two draining veins (Fig. 15-6).
About 80 to 90% of all PAVMs are simple, and 10 to 20%
are complex. PAVMs are found most commonly in the
lower lobes and are multiple in 33 to 50% of patients and
bilateral in 8 to 20%.
17,18
PAVMs may occur sporadically, but most are seen in
patients with Osler–Weber–Rendu syndrome, also known
as hereditary hemorrhagic telangiectasia (HHT), an autosomal dominant disease characterized by telangiectasias or
AVMs of the respiratory tract, gastrointestinal tract, and
brain. Ninety percent of patients with HHT have epis-
17–19
taxis.
About half of patients with PAVMs have HHT.
The likelihood of having HHT is greater if the patient has
multiple PAVMs rather than a single lesion. Family members should be evaluated because up to one third of them
also have PAVMs.
Patients with PAVMs commonly have initial symptoms
related to pulmonary-to-systemic shunting, such as low
arterial blood oxygen leading to dyspnea and fatigue, or
they may have systemic arterial embolization resulting in
stroke or brain abscess. Rupture of a PAVM may result in
hemoptysis or hemothorax.
The goal of PAVM treatment is occlusion of the shunt
to prevent complications resulting from paradoxical embolization and to enhance arterial oxygen saturation. Embolotherapy is recommended when the feeding artery of
18
a PAVM exceeds 3 mm in diameter.
Embolotherapy
with coils or detachable balloons has become the treat-
19
ment of choice.
The use of liquid or small-particle embolic agents for therapeutic embolization is ineffective
and may result in inadvertent systemic embolization.
Therapeutic embolization is performed at the pulmo-
FIGURE 15-5. Chronic pulmonary thromboembolism. Webs
arrow
) and mural irregularities (
(
curved arrow
) are present.
J. E. Silberzweig
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157
A B
C
FIGURE 15-6. Pulmonary arteriovenous malformation
(PAVM). A: This patient presented with a brain abscess
resulting from B: a large complex right upper lobe AVM.
There are two feeding arterial branches (
and a large draining vein (
by placement of embolization coils.
arrow
). C: The AVM was occluded
curved arrows
)
158 Pulmonary and Bronchial Arteries
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nary artery branch immediately proximal to the malformation. Embolotherapy is preferred over surgical resection in patients with multiple PAVMs because embolization spares normal lung and allows for future
embolization of enlarging PAVMs.
■ Bronchial Arteriography
Management of hemoptysis is frequently a challenging
clinical problem. Most patients with mild intermittent
bleeding respond to supportive therapy and to medications that treat the underlying cause; however, the mortality rate in patients with acute massive hemoptysis is
high in those who are inadequately treated, with death
resulting from asphyxiation rather than from exsanguination. The definition of massive hemoptysis varies in the
medical literature from less than 100 mL to greater than
600 mL in 24 hours.
20
Criteria for bronchial artery embolization are variable, and the amount of hemoptysis
may be difficult to measure; however, a patient with any
amount of hemoptysis that is life threatening may benefit
from bronchial artery embolotherapy.
The most common causes of massive or repeated
hemoptysis include tuberculosis, bronchiectasis, pneumoconiosis, aspergilloma, cancer, amyloidosis, sarcoidosis, and cystic fibrosis. These destructive lung processes
cause massive hemoptysis by erosion of blood vessels in its
vicinity. Hemorrhage usually arises from the bronchial
arteries. The pulmonary artery is rarely a source of
hemoptysis. Conditions that may result in hemorrhage
arising from the pulmonary artery include a Rasmussen
aneurysm (erosion of a tuberculosis cavity into a pulmonary artery branch), traumatic pseudoaneur ysm (e.g., overinflation of a Swan–Ganz catheter balloon, penetrating
thoracic trauma) (Fig. 15-7), and PAVMs.
Surgery can be a definitive treatment for massive
hemoptysis but is a viable option only for patients who
present with localized unilateral disease. Surgery is contraindicated for patients with diffuse, bilateral, or advanced pulmonar y disease. Other contraindications to
surgery include inability to localize the site of bleeding,
bleeding from both lungs, and nonresectable malignancy. Bronchial arter y embolization is an effective primary method to control massive or recurrent hemoptysis,
especially in patients who are not suitable candidates for
surgical resection. Bronchial arteriography and embolization can be performed in combination with surgery or
medical therapy of the underlying condition. Angiographic localization and embolization of the bleeding vessels can be used to stabilize a patient prior to surgery.
Localization of the bleeding site is often useful before
arteriography because abnormal but nonbleeding vessels
may be encountered in patients with diffuse or bilateral
disease. Bronchoscopy can be used to identify the side
and sometimes site of bleeding; however, it may be technically challenging in patients with acute massive hemoptysis. Chest radiography and CT might indicate the
source of hemorrhage, but these tests are often unreliable. If the site of hemorrhage cannot be accurately localized or if diffuse disease is present, all identifiable bronchial artery branches are embolized.
The bronchial arteries are variable in number and
distribution, but most arise from the descending thoracic
aorta at the level of the T5–T6 vertebral bodies and the
carina. The most common bronchial arter y origin variations include single arteries bilaterally (30%), two bronchial arteries on one side and a single bronchial artery on
the contralateral side (45%), and four bronchial arteries
with two on each side (20%) or three left and one right
21
(4%).
The most common arteriographic findings in
patients with bronchial artery bleeding include enlargement of the bronchial artery (diameter ⬎3 mm), hypervascularity, aneurysmal dilatation, prominent parenchy-
A
FIGURE 15-7. Traumatic pulmonary artery pseudoaneurysm. A: A pseudoaneurysm of the lingular branch of the left pulmonary
artery resulting from a gunshot wound. B: Treatment was with coil embolization.
B
mal stain, and bronchial-to-pulmonary artery shunting
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(Figs. 15-8 and 15-9). In patients with neoplasms, the
vascular supply is usually from bronchial arteries or parasitized intercostal arteries, and multiple feeding arteries
are often present. Embolization is performed, even
though no contrast extravasation is identified, because
contrast extravasation into a bronchus is a rare arteriographic finding. If a potential bleeding source cannot be
identified, a descending thoracic aortogram with the pigtail catheter placed near the left subclavian artery may be
helpful.
Nonbronchial systemic collateral arteries are a signifi-
cant bleeding source in many cases.
22
Common nonbronchial systemic collaterals include the internal mammary
artery, thyrocervical trunk, branches of the subclavian or
axillary artery, intercostal arteries, and inferior phrenic
artery.
Occasionally, a spinal arter y branch may arise from a
bronchial artery. Careful consideration must be given to
the arterial supply to the spinal cord when performing
bronchial arteriography and embolization. The anterior
spinal artery supplies the anterior portion of the cord
and can be identified by its characteristic cephalic course
with a hairpin bend in the midline within the ventral
median sulcus. Many interventional radiologists consider
the presence of spinal artery branches originating from
the bronchial artery a contraindication to embolization
(Fig. 15-10).
FIGURE 15-8. Bronchial arteriogram. Left bronchial arteriogram in a patient with massive hemoptysis from sarcoidosis.
Findings include bronchial artery enlargement and hypervascularity.
23
Some researchers, however, have described
J. E. Silberzweig 159
FIGURE 15-9. Bronchial artery to pulmonary artery shunting.
Right bronchial arteriogram in a patient with massive hemoptysis from tuberculosis. Findings include bronchial artery (
) to pulmonary artery (
row
vascularity.
curved arrow
) shunting and hyper-
ar-
successful bronchial artery embolization with no resultant neurologic complications in the presence of spinal
artery branches. These procedures were performed with
nonionic contrast and large embolization particles to pre-
24,25
vent unintentional embolization of spinal feeders.
Because of the remote possibility of spinal cord injury from
bronchial artery embolization, a neurologic examination
should be performed before bronchial arteriography is
done.
The most commonly used agents are polyvinyl alcohol
(PVA) particles and Gelfoam pledgets. PVA particle sizes
between 250 and 700 l are used. Smaller particles could
pass through small spinal artery branches or bronchial–pulmonary artery shunts. It is essential that the
catheter be well seated and that there is no obvious risk of
spinal artery embolization. If the spinal arteries are seen
and the catheter can be advanced distal to their origin,
embolic material can be placed from that location.
Visceral selective catheters, such as the Cobra, Simmons, or Mikaelsson, typically are used for bronchial
artery catheterization. A coaxial microcatheter is often
used for catheterization of bronchial artery branches.
Use of a conventional 5Fr catheter placed within the
origin of the bronchial artery may not allow passage of
embolic materials into peripheral branches because the
catheter may be occlusive and prevent flow beyond the
catheter tip. Use of a microcatheter permits superselective bronchial artery catheterization and embolization
26
160 Pulmonary and Bronchial Arteries
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FIGURE 15-10. Spinal artery branch. The right bronchial artery and superior intercostal artery arise from a common bronchial intercostal trunk. An anterior spinal artery branch (
arises from the superior intercostal artery (
curved arrow
arrow
). Embolization of the right bronchial artery was performed after
placing a microcatheter distal to the origin of the intercostal
artery and spinal artery branch.
without occluding flow into the bronchial artery and
occluding branches such as the spinal artery.
Bronchial artery embolization can be expected to provide initial control of hemorrhage in 75 to 90% of patients. Technical failure results from an inability to identify and catheterize the bronchial arteries. Failure to
catheterize a bronchial artery occurs in up to 10% of
23,27
patients.
The most common causes of recurrent
bleeding include incomplete initial embolization or failure to identify all bleeding vessels, recruitment of collateral vessels, recanalization of embolized vessels, and pro-
23,27
gression of disease.
Late rebleeding (i.e., after 6
months) may occur in up to 20% of patients initially
controlled by bronchial artery embolization. This problem is not unexpected, however, because embolization is
a palliative procedure and does not directly treat the
underlying disease.
Complications from embolotherapy occur in about 2
to 5% of cases and include nontarget embolization, bronchial or esophageal necrosis, and subintimal aortic injec-
26,27
tions.
The most severe complication of bronchial ar-
tery embolization is ischemic injury to the spinal cord
from contrast- or embolization-related injury, because
radicular spinal arteries may arise from bronchial arteries
or from intercostobronchial trunks. The reported frequency of this complication is less than 1%.
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H.Spindola-Franc o, S. Segal, B. G. Fish, and M. A. GreenbergDiseasesof the Thorac ic Aorta
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16
■■■
Diseases of the Thoracic Aorta
HUGO SPINDOLA-FRANCO, SCOTT SEGAL, BERNARD G. FISH,
and MARK A. GREENBERG
Medical and surgical treatment as well as recently developed interventional catheter procedures for the treatment of aortic diseases requires precise delineation of the
pathological disorders. Concurrent with the development
of these new techniques, the emergence of new imaging
modalities such as magnetic resonance imaging (MRI),
spiral computed tomography (CT), and transesophageal
echocardiography (TEE) have revolutionized our ability
to diagnose these complex conditions. Once considered
the gold standard, angiography remains important only
when other techniques are inconclusive.
Acquired diseases of the aorta such as ectasia, aneurysm, dissection, and its variants occur as a result of degenerative processes in older persons. These processes
are accelerated in persons who have underlying connective tissue disorders such as Marfan syndrome and in
those with hypertension and atherosclerosis. Of these
entities, acute aortic dissection or rupture may represent
a surgical emergency. Aortic trauma also results in an
acute emergency requiring the most expeditious diagnosis and surgical management. Aortic arteritis syndromes
are caused by inflammatory diseases such as giant cell
arteritis and Takayasu arteritis, which may lead to aortic
insufficiency or obstructive lesions. Aortitis also occurs
during late stages of syphilis. Complications of catheter
and surgical procedures also may require surgical intervention. Recognition of these complications has become
more important as more procedures are performed. Secondary involvement of the aorta by neoplasms, abscesses,
and hematomas are a challenge to the clinician. Modern
imaging techniques have become essential in the diagnosis and management of these entities.
Congenital diseases of the aorta constitute a smaller
segment of the population with aortic disease.
common entities are preoperative and postoperative
coarctation of the aorta and patent ductus arteriosus.
Other uncommon disorders occasionally are encountered, including vascular rings, cervical aortic arch, interruption of the aortic arch, and anomalous origin of a
pulmonary artery.Pulmonary artery slingand ductusarteriosus sling are rarely encountered. Bronchial arteries are
dilated in cyanotic congenital heart disease with pulmonary atresia and may be hemodynamically significant as a
source of pulmonary blood flow.Coil embolizationmay be
necessary before surgical correction of these entities. Pulmonary sequestrations are supplied by vessels arising from
the aorta and may be treated by coil embolization.
■ Aortic Dissection
Aortic dissection consists of an intimal tear in the wall of
the aorta that causes separation of the intramural layers,
usually between the middle and outer thirds of the media,
creating a false lumen(Fig. 16-1). Blood in the false lumen
may reenter the true lumen via a second intimal tear, or it
may rupture through the adventitia into the periaortic
tissues. Most commonly, dissections are believed to be
caused by cystic medial necrosis. Proximal dissections tend
to occur in younger persons who often are found to have
Marfan syndrome (Figs. 16-2 and 16-3). Less commonly,
inherited connective tissue disorders such as osteogenesis
imperfecta, Turner syndrome, and Ehlers-Danlos syndrome may be associated with proximal dissections. Distal
dissections occur more commonly in older patients with
hypertension. Other less common causes include
1,2
The most
163
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