Published on March 3, 2014
BRONCHIAL ARTERY EMBOLISATION IN HAEMOPTYSIS DR.P.SABHARISUNDARAVEL JUNIOR RESIDENT( RADIODIAGNOSIS) MEDICAL COLLEGE, KOLKATA
INTRODUCTION • Massive hemoptysis or chronic recurrent hemoptysis are potentially life-threatening conditions. • Despite advances in medical and intensive care unit management, massive hemoptysis remains a serious threat. Mortality rate for patients with massive hemoptysis can be as high as 75% . • Superselective catheterization of the bronchial arteries feeding the affected areas followed by particulate embolization has proven to be an effective treatment for the control of bleeding.
WHY ?? 1) Bronchial circulation (90% of cases) - Pulmonary circulation (5%) . - Aorta (5%)(eg, aortobronchial fistula, ruptured aortic aneurysm). 2) Surgery - Mortality ~18% when performed electively, rising to 40% when performed emergently. - conservative approach , mortality risk of at least 50%. 3) Minimally invasive - clinical success - 85% to 100%, - recurrence of hemorrhage – 10%.
ANATOMICAL CONSIDERATION • Variable anatomy in terms of origin, branching pattern, and course. • The standard or orthotopic 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.
BRANCHING PATTERN (CAULDWELL) Type 1 (40.6 %) . one right bronchial artery from ICBT .Two left bronchial arteries Type 2(21.3 %) .one on the right from ICBT .One on the left Type 3(20.6 %) .Two on the right (1 from ICBT & 1 bronchial artery) . Two on the left. Type 4(9.7 %) .Two on the right (1 from ICBT & 1 bronchial artery). .one on the left.
SPINAL ARTERIES • 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 radiculomedullary branches of the intercostals and lumbar arteries. • 6-8 , hairpin loop course.
ARTERY OF ADAMKIEWICZ •The 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 rarely contribute the anterior spinal artery.
Source : internet.
TECHNIQUE • Prior to the procedure, a brief neurological exam is performed to establish a baseline. • Femoral route. • A preliminary descending thoracic aortogram can be performed as a roadmap to the bronchial arteries. • Reverse curve catheter – mikaelsson, simmons 1, shepherd’s hook. • Low arotic arch – forward looking catheters ( cobra or RC ) used.
The left main stem bronchus serves as a convenient fluoroscopic landmark for the general location of the bronchial arteries The catheter is directed lateral or anterolateral for the right bronchial and more anterior for the left. Bronchial arteries – course of main stem bronchi towards hila. Intercoastal arteries – initial cephalic course , then laterally along undersurface of rib
REVERSE CURVE COBRA HEAD
COMPLICATIONS • Chest pain is the most common complication. • Dysphagia due to embolization of esophageal branches may also be encountered. • The most disastrous complication is spinal cord ischemia due to the inadvertent occlusion of spinal arteries. When the artery of Adamkiewicz is visualized at angiography, embolization should not be performed. • Other rare complications include aortic and bronchial necrosis, bronchoesophageal fistula, non–target organ embolization (eg, ischemic colitis), pulmonary infarction.
REPORT • 9 cases (march-september). • All electively. • Prior HRCT – all cases. Bronchiectasis with alveolar opacities . Mass like lesion – two cases. Tuberculosis. • Right -6 • Left – 2 • Bilateral - 1
Embolisation • Polyvinyl alcohol (PVA) particles- 300 to 500 μm. • 1mm PVA – one case . Right bronchial artery alone – 3 Left bronchial artery alone – 1 B/L Bronchial artery – 2 Left Bronchial and LIMA – 1. Left Axillary , Left LIMA and B/L Bronchial – 1 Incomplete – 1.
60 YR MALE C/O HEMOPTYSIS - 3YRS. KNOWN TUBERCULAR AND SMOKER
25 YR/FEMALE C/O HEMOPTYSIS – 2YRS. K/C/O TUBERCULOSIS
47YR/MALE HEMOPTYSIS – 6 MONTHS K/C/O TUBERCULOSIS
REPORT • INCOMPLETE EMBOLISATION – 1. SURGERY • SUCEESFUL EMBLOISATION – 8. • FOLLOW UP – 7 clinical success
CONCLUSION 1. The development of bronchial artery embolization techniques has revolutionized the approach to hemoptysis patients. 2. Bronchial artery embolization possesses high rates of immediate clinical success coupled with low complication rates. 3. When bronchial artery angiography and embolization is performed, consideration must be given to the arterial supply to the spine. 4. Surgery should be considered only in case where embolisation not possible due technical difficulty and in case of embolisation failure. Otherwise bronchial artery embolisation is considered as the mainstay treatment for hemoptysis.
REFERNCES • 1) Haponik E F, Fein A, Chin R. Managing life-threatening hemoptysis: has anything really changed? Chest. 2000;118(5):1431–1435. • 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):849–853. • 3)Marshall T J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization for haemoptysis. Eur Radiol. 1997;7(8):1221–1227. • 4)Yoon W, Kim J K, Kim Y H, Chung T W, Kang H K. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22(6):1395–1409. • 5)Fernando H C, Stein M, Benfield J R, Link D P. Role of bronchial artery embolization in the management of hemoptysis. Arch Surg. 1998;133(8):862–866 • 6)Ramakantan R, Bandekar V G, Gandhi M S, Aulakh B G, Deshmukh H L. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology. 1996;200(3):691–694.
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