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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3869_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 35
Bronchial Artery Embolization
Simon McPherson
Clinical Features
• Major hemoptysis with respiratory compromise is an emergency. Bronchoscopic
airway management ± unilateral lung ventilation can be lifesaving.
• Hemoptysis kills by drowning the patient in their own blood. Death is by
asphyxiation from major airway obstruction, not by exsanguination.
• Systemic arterial supply accounts for >95% of major hemoptyses.
• Neo-angiogenesis is caused by the underlying condition. Bleeding is from
systemically pressurized abnormal pulmonary parenchyma.
• Bronchial artery embolization (BAE) stops bleeding by reducing this pressure.
The commonest causes are as follows:
• Chronic lung disease
◦ Cystic fibrosis
◦ Bronchiectasis from other causes
• Infection
◦ Tuberculosis
◦ Aspergillosis
◦ Abscess
◦ Chronic pneumonia
• Malignancy
◦ Bronchogenic cancer
◦ Metastases—rarely
• Congenital heart disease
• Leaking thoracic aortic anuerysm/penetrating ulcer
Pulmonary arterial and venous bleeding (Chapter 36) are rare. Consider in patients
with a history/risk of the following:
• Trauma, including iatrogenic (e.g., recent Swan–Ganz catheter)
• Tuberculosis (Rasmussen’s aneurysm)
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_35,
C
Springer-Verlag London Limited 2010
349
350 S. McPherson
• Right-sided endocarditis or infected DVT (especially IV drug abusers)
• Hereditary hemorrhagic telangectasia
Diagnostic Evaluation
• Assessment of the degree of respiratory compromise and skilled airway management are essential.
• Medical management may need to be supplemented by bronchoscopic pulmonary
clearance.
• Use history, imaging, and bronchoscopy to try to lateralize the site of bleeding
and to demonstrate the underlying cause. Overspill often results in blood in both
lungs.
Laboratory
• Arterial blood gas and oxygen saturation.
• Full blood count. Anemia is rare; anemia and thrombocytopenia should be
corrected.
• Any clotting abnormalities must be corrected.
• Assess for renal impairment and ensure adequate hydration.
Imaging
CXR
• Unilateral changes are uncommon but can lateralize the bleeding site and allow
targeted embolization.
• Compare with previous films if available. New changes indicate the side to be
assessed first.
CT
• Non-contrast-enhanced CT may show the likely side of bleeding.
• Contrast enhancement is unnecessary (except where a pulmonary artery cause
is suspected). Identification of the bronchial artery origins on CT does not
significantly aid BAE.
• If a pulmonary arterial cause is suspected, then contrast enhancement may show
a pseudoaneurysm. This is often more evident on multiplanar reformats.
35 Bronchial Artery Embolization 351
Indications
Life-Threatening Hemoptysis
• The conventional definition uses the volume of blood expectorated.
• This is variable (200–500 ml/24 h) and difficult to accurately quantify.
• A more useful definition is any hemoptysis that causes significant airway
compromise.
BAE Should Also Be Considered in
• Sudden onset of hemoptysis with increasing volumes. Such smaller “herald”
bleeds often precede a catastrophic hemorrhage.
• Patients with chronic lung disease, such as cystic fibrosis, when minor recurrent
hemoptysis precludes effective airway clearance maneuvers or adversely affects
the quality of life.
Adjunctive and Alternative Therapies
• Supportive measures (oxygen, bronchodilators, hydration, etc).
• With major hemoptysis, nurse the patient with the affected lung dependent to
decrease overspill into the non-bleeding lung.
• Bronchoscopic airway management and, if necessary, single-lung ventilation.
• Treat any infection; infection often precipitates hemoptysis.
• Tranexamic acid can occasionally be helpful in minor recurrent hemoptysis.
• Open surgical options should be discussed. They are usually the second-line
intervention except for those with potentially surgically curable malignancy.
• CT-guided antifungal instillation into aspergillomas has been advocated as a
supplementary treatment to BAE.
Contraindications
• No absolute contraindication exists. In those with severe iodinated contrast
reactions, consider using gadolinium. CO
• All other contraindications are relative and the risk of not treating massive
hemoptysis generally outweighs any risks.
must not be used above the diaphragm.
2
Specific Complications
• Neurological deficits are the most important
◦ Spinal (paraplegia – partial or complete). Due to embolization of anterior
spinal artery collaterals.
352 S. McPherson
◦ Cerebrovascular – very rare. Due to non-target embolization during subclavian
branch or aortic arch BAE.
• Odontophagia/difficulty swallowing—transient (3%). Esophageal necrosis has
been reported.
• Chest-wall pain – transient.
• Angina/myocardial infarction (coronary artery connections).
• Airway necrosis has been reported.
All Complications Are Minimized by
• Meticulous angiographic technique
• Avoiding liquid agents (glue), and by using particles larger than 300 μm
• Selective use of coils for vessels that cannot be occluded with particles
Anatomy
Normal Bronchial Artery Anatomy
Bronchial arteries supply trachea, bronchi, esophagus, posterior mediastinum, and
act as vasa vasorum for pulmonary arteries.
• Most bronchial arteries arise at the level of the left main bronchus (90% T5–6).
• Multiple arteries (including broncho-intercostal trunks) and conjoined origins are
common.
• Broncho-intercostal trunk more common on the right.
• Multiple arteries are more common on the left.
• Bronchial artery origins arise from the anterior aorta.
• Broncho-intercostal arteries arise from the posterior aorta.
• Normal bronchial arteries are limited to medial 1/3 or 1/2 of lung field.
Key Points in Bronchial Arteriography
• Bronchial arteries follow a meandering course toward pulmonary hilum along the
line of the bronchi.
• Intercostals follow undersurface of ribs and pass laterally.
• Bronchial–intercostal trunks have a slightly angulated cranial course; the
bronchial branch descends sharply caudally toward pulmonary hilum (Fig. 35.1).
• Spinal branches
◦ Anterior medullary arteries: initially course sharply cranially. A tight hair-
pin (180
(Fig. 35.2).
◦
) bend is followed by the straight midline anterior spinal artery
35 Bronchial Artery Embolization 353
Fig. 35.1 Combined
bronchial–intercostal trunk
(white arrow) arterial phase
showing bronchial arteries
(black arrowheads)and
intercostal arteries (white
arrowheads). Note early
filling of pulmonary vein
(black arrowhead)
Fig. 35.2 Angiography in a patient with recurrent hemoptysis following embolization. Previously
deployed coils in bronchial arteries (white arrowheads and small white arrows) and internal mammary artery (black arrowheads). Note filling of the anterior spinal artery (large white arrows)
354 S. McPherson
◦ Dorsal and ventral radicular arteries – smaller vessels from segmental
spinal arteries – course medially with a vertical, off-midline, not perfectly
straight course. Unintentional radicular artery embolization rarely has clinical
sequelae.
Aberrant/Variant Anatomy
• Bronchial arteries arising outside of T5/6 are considered anomalous.
• Arteries that can supply the bronchial circulation include the following:
• Intercostals
• Internal mammary (Fig. 35.3a)
• Inferior thyroid
• Costo-cervical
• Superior intercostal
• Inferior phrenic
• Subclavian (Fig. 35.4)
• Brachiocephalic
a
Fig. 35.3 (a) Bronchial arteries (white arrows) filling from internal mammary artery (white arrow-
head)(b) following embolization with coils and polyvinyl alcohol particles. Note coils (white
arrowhead) have been deployed beyond the lower bronchial supply to protect distal internal
mammary circulation
b
35 Bronchial Artery Embolization 355
Fig. 35.4 Large bronchial supply (white arrowhead) from left subclavian artery. Supply to left (red
arrowheads) and right lungs (white arrow)
Important common anastomoses exist between the bronchial arteries and the
following:
• Anterior spinal artery
◦ arise from central segments
◦ more common on the right
• Pulmonary artery
• Mediastinal (including esophageal)
• Coronary arteries
These all have the potential to
• Cause significant non-target embolization
• Result in incomplete embolization or recurrent bleeding
Equipment
Catheters
Non-selective Catheters
• Pigtail flush catheter.
356 S. McPherson
Selective Catheters
• Reversed curve catheters such as
◦ Amplatz left coronary 1
◦ Mikaelson
◦ Simmons (sidewinder)
allow a more stable ostial position than forward/upward facing catheters (e.g.,
Cobra).
• Microcatheters are required in the majority.
Sheaths and Guide Catheters
• Long sheaths or guiding catheters can be helpful to provide support or alter the
approach to a bronchial artery.
Embolic Agents
• Particles are the agent of choice. The aim is to permanently occlude the abnormal circulation distally but not at a level that will cause tissue necrosis. PVA
350–500 μm is most commonly used. Embolization is terminated when forward
flow is almost terminated.
• Larger particles may be used when large pulmonary arterial or venous shunts
are present. Gelfoam slurry or coils are occasionally used to occlude very large
shunts. Gelfoam slurry can be injected via a microcatheter, if a dilute slurry is
injected with an angioplasty indeflator. A distal position must be obtained to
minimize the risk of Gelfoam reflux.
• Coils (steel conventional or platinum micro coils) may also be used to
◦ Protect the distal circulation (Fig. 35.3b).
◦ Occlude abnormal vessels with spinal, esophageal or coronary supply – usu-
ally this would be done distally and then proximally to the branch. The
distal embolization prevents retrograde passage of particles and non-target
embolization when other pathological vessels are embolized.
◦ Coils should not be used to occlude proximal bronchial arteries, especially
when embolizing patients with chronic diseases. This proximal embolization
will lead to formation of significant collateral vessels, which are often much
more difficult to catheterize in the setting of recurrent hemoptysis.
Medication
• High-quality angiography is the key to safe BAE. This requires a co-operative
patient, and BAE may take 2 hours or more. If there is any doubt about the
patient’s ability to cope, then enlist the help of an anesthetist.
35 Bronchial Artery Embolization 357
• Patients who are in extremis may be managed with selective intubation to protect
the non-bleeding lung during BAE.
• Catheter-induced vasospasm can be treated with vasodilators. Vasospasm may
result in vessel recanalization and failed BAE.
Infection Control
◦ Patients with current infection should be on antibiotic treatment. Prophylactic
antibiotics are not required.
Hydration
◦ Adequate hydration aids airway clearance and reduces the risk of contrast
nephrotoxicity.
Angiography
Access and Angiography
• Common femoral 4Fr or 5Fr access is sufficient in the overwhelming majority.
• A flush aortic run, with a frame rate of 3–4 frames per second in shallow left ante-
rior oblique, may be useful to demonstrate the origins of the bronchial arteries.
The absence of abnormal circulation on this run does not exclude pathological
bronchial circulation.
• Selective catheterization is necessary to detect pathological circulation.
• Occasionally, arm access is required for aberrant vessels from the subclavian or
the inner curve of the aortic arch.
Angiographic Appearance
First look for pathological bronchial circulation. One or more of the following will
be seen.
• Enlarged main bronchial artery (<3 mm)
• Hypertrophied bronchial radicles (visualization of normal bronchial arteries
limited to medial 1/3 or 1/2 of lung field)
• Dense parenchymal blush
• Pulmonary arterial or venous shunting (Fig. 35.5)
• Pseudoaneurysms (rare) (Fig. 36.6)
• Active extravasation (very rare and NOT a prerequisite for embolization)
358 S. McPherson
a
Fig. 35.5 Communications with pulmonary vein and artery. (a) Late arterial phase. Parenchymal
stain (white arrowheads) and shunting into pulmonary vein (white arrows) (same patient as
in Fig. 35.1). (b) Filling of pulmonary artery (white arrows) during arterial phase of bronchial
angiography
b
Fig. 35.6 Bronchial artery false aneurysm (black arrowhead)