支氣管動脈栓塞術(shù)課件

1、支氣管動脈栓塞術(shù)contentsBronchial circulationBronchial Artery Embolization (BAE)IndicationsProcedureComplicationsTwo Circulations in the LungBronchial CirculationArises from the aorta.Part of systemic circulation.Receives about 2% of left ventricular output.Pulmonary CirculationArises from Right Ventricle.R

2、eceives 100% of blood flow.ANATOMICAL CONSIDERATION- Bronchial ArteryVariable anatomy in terms of origin, branching pattern, and course.Bronchial arteries usually arise as a pair or as a common trunk, from the descending thoracic aorta below the origin of left subclavian artery.The standard or ortho

3、topic origin is from the aorta between the levels of T5 and T6 (80%).ANOMALOUS Outside the levels of T5 and T6 .ANOMALOUS - Aortic arch, Internal mammary artery, Thyrocervical trunk, Subclavian, Costocervical trunk, Pericardicophrenic artery, Inferior phrenic artery.BRONCHIAL CIRCULATIONSometimes pa

4、rt of blood supply of anterior spinal artery come from bronchial vessels.When bronchial artery embolization is performed, consideration must be given to the arterial supply to the spinal cord.Most important is Anterior Spinal Artery.Anterior spinal artery receives contributions from the anterior rad

5、iculo medullary branches of the intercostals and lumbar arteries.ARTERY OF ADAMKIEWICZThe largest anterior medullary branch.Has variable origin from T5 L5 level, but most commonly from T8 L1 level.In 5 % of population Rt. IBT contributes to artery of Adamkiewicz. The left bronchial arteries very rar

6、ely contribute the anterior spinal artery. Topographical Facts:Normal Anatomy and VariationsBronchial artery branching patternCauldwell et al - four patterns:Type IType II Type III Type IVCauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an anatomic study of 105 human cadavers.

7、 Surg Gynecol Obstet 1948; 86:395412.Type IIncidence: 40.6% Left:2Right:1 intercostobronchial trunk (ICBT)Bronchial Artery- CourseLeave the aorta at an upward angle, against the direction of blood flow.Send braches to oesophagus, mediastinum, lymph nodes and nerves.On reaching the main bronchi divid

8、e into visceral pleural branches to the mediastinal pleura and true bronchial arteries to the bronchial tree.Bronchial Artery- CourseSpiral course around bronchi, one on either side of each other but anastomosing frequently with each otherThe vessels form an arterial plexus in the adventitia from wh

9、ich branches pierce the muscle layer to enter the submucosa, where they break up into capillary plexus.Supplies bronchi, nerves, walls of pulmonary vessels and intra pulmonary lymph nodes.Bronchial Artery- CourseArteriolar branches of the visceral pleural vessels pass along interlobular septa, reach

10、ing the interstitial tissue of the lung acinus.The true bronchial arteries reach as far down the airways as the terminal bronchiole.Much of the bronchial arterial blood, having gone through the submucosal capillaries, passes into the venous plexus in the adventitia.Veins from this plexus then join p

11、ulmonary venous system.Bronchial Artery EmbolizationMinimally invasive alternative to surgery. selective bronchial artery catheterization and angiography, followed by embolization of any identified abnormal vessels to stop the bleeding.Considered to be the most effective nonsurgical treatment in the

12、 management of massive and recurrent hemoptysis.Bronchial Artery EmbolizationFirst by Remy et al. in 1973.*Temporary or definitive Immediate control: 57100% of patients* Embolization : bronchial and nonbronchial Long-term control: 70%-88% Remy J, Voisin C, Dupuis C, et al: Traitement des hmoptysies

13、par embolisation de la circulation systmique. Ann Radiol (Paris) 1974; 17: 516. *Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 3337.IndicationsHaemoptysis-:Failure of conservative or bronchoscopic treatment to control bleeding.

14、ISRN Vascular MedicineVolume 2013, Article ID 263259, 7 pagesIndicationsManaging ruptured pulmonary artery venous malformation.To Stabilize patients before surgical resection or medical treatment.As a definitive therapeutic approach in patients: -Who refuse surgery -Who are not candidates for surger

15、y -Where surgery is contraindicatedBronchial artery embolization: Managing ruptured pulmonary artery venous malformation e A case report Dharitri Goswami a,*, Shantanu Das b,1, Ashok Parida c,2, Joy Sanyal c,3. Respiratory Medicine CME 4 (2011) 160e163poor lung function, bilateral pulmonary disease,

16、 co morbidities.WHY BAE ?1)Bronchial circulation (90% of cases) - Pulmonary circulation (5%) . - Aorta (5%)(eg, aorto bronchial fistula, ruptured aortic aneurysm).2) Surgery - Mortality 18% when performed electively, rising to 40% when performed emergently. - conservative approach , mortality risk o

17、f at least 50%.3) Minimally invasive - clinical success - 85% to 100%, - recurrence of hemorrhage 10%.BAE- TECHNIQUEPrior to the procedure, a brief neurological exam is performed to establish a baseline. Femoral route/Trans-Axillary routeMonitor vitals/spo2Sedation optionalClean groin with antisepti

18、cs.Adequate LAA preliminary descending thoracic aortogram (Ionic/non ionic contrast) can be performed as a roadmap to the bronchial arteries. BAE - TECHNIQUEBoth bronchial arteries and nonbronchial systemic arteries are opacified. The diagnostic angiographic injections are always selective into the

19、bronchial, intercostals, subclavian, internal mammary, intercostobronchial, and inferior phrenic arteries.Under X-Ray machine guidance (Digital cardiac imaging with digital subtraction facility)Reverse curve catheter mikaelsson, simmons 1, shepherds hook.Low arotic arch forward looking catheters ( c

20、obra or RC ) used.Angiographic signs of haemoptysisISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pagesBAE - TECHNIQUEThe left main stem bronchus serves as a convenient fluoroscopic landmark for the general location of the bronchial arteries The catheter is directed lateral or anterolatera

21、l for the right bronchial and more anterior for the left.Bronchial arteries course of main stem bronchi towards hila.Intercostal arteries initial cephalic course , then laterally along undersurface of ribBAE - TECHNIQUEThe embolization materials commonly used are non-absorbable particles of polyviny

22、l alcohol (PVA) (Ivalon; Nycomed SA; Paris, France), 355500 m in size (some larger vessels required particles as large as 2 mm), and fibred platinum coils of 2 and 3mm in size (MicroNester Embolization Coils; Cook, Bjaeverskov, Denmark).Catheters: Reverse-curved catheters (Mikaelson, Simmons I, SOS

23、Omni) Forward-looking catheters (Cobra, HIH,RC) Sizes: 4, 5, or 5.5 Fr are routinely used.Mikaelson catheterCobra type: curved catheter Most commonly usedMicrocatheterSuperselective catherizationLess complicationsEmbolizing materials:Absorbable gelatin spongeGelfoamPledgets (1 to 2 mm)ThrombinGlueRe

24、cently approved -Embospheres, -Spherical Poly vinyl alcohol(PVA) particlesPermanent occlusive agentsPolyvinyl alcohol (PVA), Trisacryl gelatin microspheres (TGM), GelfoamEmbolizing materials:PVA particles (350-500 mic) Most common & Safe Liquid embolic agents -ischemic necrosis Stainless steel plati

25、num coils -occlude more proximal vessels.Embolization coils: Platinum MicrocoilsEmbolizing materials:Particles 200 to 250 micr.m should be usedNo ischaemia and no neurologic damage Isobutyl-2 cyanoacrolate, Absolute alcohol Used in pulmonary artery aneurysms to avoid tissue ischemia and neurologic d

26、amageEmbolizing materials:Distal embolization : ideal Proximal occlusion: temporary relief particles 200 micr.m :avoided -Tissue infarctionLiquid embolic agents should always be avoided because these cause tissue infarction Clues to bronchial artery as the source of bleeding:34Parenchymal hypervascu

27、larityVascular hypertrophyaneurysm35The identification of extravasated dye -INFREQUENTBronchopulmonary shuntingNeovascularisationLeft upper lobe bronchial arteryAfter EmbolizationDecreased vascularity & hypertrophyTortous and hypertrophied vesselBefore EmbolizationRightLeftAbnormal circulationPre-em

28、bolisation bronchial angiogramNo abnormal circulationPost embolisation Bronchial artery aneurysmHypervascular lesion with aneurysmPre embolisationPost embolisationPVA particlesNo hypervascular lesion & aneurysmSuper selective Embolization of intercostal arteryHypervascular areas and a small amount o

29、f pulmonary arterial shuntingDecreased vasularity POST EMBOLIZATIONPRE EMBOLIZATIONRadicular arteriesINTERCOSTAL ARTERYMicro catheter passed beyond radicular arteryBronchial Artery EmbolizationSuccess rates : 64% to 100%. Recurrent non-massive bleeding :1646%Recurrence of haemoptysis may be due to:I

30、ncomplete embolization of the bronchial vesselsRecannalization of the embolized arteries.Presence of non-bronchial systemic arteries.Development of collateral circulation in response to continuing pulmonary inflammation. Bronchial Artery EmbolizationTechnical failure: 13% Technical failure is caused

31、 by non-bronchial artery collaterals from systemic vessels such as the phrenic, intercostal, mammary,(PLEURA) or subclavian Arteries.Complications of BAETransversemyelitis The most feared complication due to non target occlusion of branches. When the anterior spinal artery is identified as originati

32、ng from the bronchial artery, embolisation is often deferred owing to the risk of infaction and paraparesis. The anterior spinal artery is the blood vessel that supplies the anterior portion of the spinal cord. It arises from branches of the vertebral arteries and is supplied by the anterior segment

33、al medullary arteries, including the artery of Adamkiewicz, and courses along the anterior aspect of the spinal cord.Disruption of the anterior spinal cord leads to bilateral disruption of the corticospinal tract, causing motor deficits, and bilateral disruption of the spinothalamic tract, causing s

34、ensory deficits in the form of pain/temperature sense lossComplications of BAEComplications of BAEComplications of BAEChest pain is the most common complication.Dysphagia due to embolization of esophageal branches may also be encountered. Rare complications Aortic and bronchial necrosisBronchoesopha

35、geal fistulaNontarget organ embolization (eg, ischemic colitis) Pulmonary infarction.References1) Haponik E F, Fein A, Chin R. Managing life-threatening hemoptysis: has anything really changed? Chest. 2000;118(5):14311435.2)Shigemura N, Wan I Y, Yu S C, et al. Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience. Ann Thorac Surg. 2009;87(3):849853.3)Marshall T J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization for haemoptysis. Eur Radiol