1、BRONCHIAL ARTERY EMBOLIZATION,DR TINKU JOSEPHDM ResidentDepartment of Pulmonary MedicineAIMS, KochinEmail-: ,contents,Bronchial circulationBronchial Artery Embolization (BAE)IndicationsProcedureComplications,Two Circulations in the Lung,Bronchial CirculationArises from the aorta.Part of systemic cir
2、culation.Receives about 2% of left ventricular output.Pulmonary CirculationArises from Right Ventricle.Receives 100% of blood flow.,ANATOMICAL CONSIDERATION- Bronchial Artery,Variable anatomy in terms of origin, branching pattern, and course.Bronchial arteries usually arise as a pair or as a common
3、trunk, from the descending thoracic aorta below the origin of left subclavian artery.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,
4、 Costocervical trunk, Pericardicophrenic artery, Inferior phrenic artery.,BRONCHIAL CIRCULATION,Sometimes part 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.
5、Most important is Anterior Spinal Artery.Anterior spinal artery receives contributions from the anterior radiculo medullary branches of the intercostals and lumbar arteries.,ARTERY OF ADAMKIEWICZ,The largest anterior medullary branch.Has variable origin from T5 L5 level, but most commonly from T8 L1
6、 level.In 5 % of population Rt. IBT contributes to artery of Adamkiewicz. The left bronchial arteries very rarely contribute the anterior spinal artery.,Topographical Facts:Normal Anatomy and Variations,Bronchial artery branching pattern,Cauldwell et al - four patterns:,Type IType II Type III Type I
7、V,Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395412.,Type I,Incidence: 40.6% Left:2Right:1 intercostobronchial trunk (ICBT),Bronchial Artery- Course,Leave the aorta at an upward angle, against the dire
8、ction of blood flow.Send braches to oesophagus, mediastinum, lymph nodes and nerves.On reaching the main bronchi divide into visceral pleural branches to the mediastinal pleura and true bronchial arteries to the bronchial tree.,Bronchial Artery- Course,Spiral course around bronchi, one on either sid
9、e of each other but anastomosing frequently with each otherThe vessels form an arterial plexus in the adventitia from which 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 lymp
10、h nodes.,Bronchial Artery- Course,Arteriolar branches of the visceral pleural vessels pass along interlobular septa, reaching 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 g
11、one through the submucosal capillaries, passes into the venous plexus in the adventitia.Veins from this plexus then join pulmonary venous system.,Bronchial Artery Embolization,Minimally invasive alternative to surgery. selective bronchial artery catheterization and angiography, followed by embolizat
12、ion of any identified abnormal vessels to stop the bleeding.Considered to be the most effective nonsurgical treatment in the management of massive and recurrent hemoptysis.,Bronchial Artery Embolization,First by Remy et al. in 1973.*Temporary or definitive Immediate control: 57100% of patients* Embo
13、lization : bronchial and nonbronchial Long-term control: 70%-88%,Remy J, Voisin C, Dupuis C, et al: Traitement des hmoptysies 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 arter
14、ies. Radiology 1977; 122: 3337.,Indications,Haemoptysis-:Failure of conservative or bronchoscopic treatment to control bleeding.,ISRN Vascular MedicineVolume 2013, Article ID 263259, 7 pages,Indications,Managing ruptured pulmonary artery venous malformation.To Stabilize patients before surgical rese
15、ction or medical treatment.As a definitive therapeutic approach in patients: -Who refuse surgery -Who are not candidates for surgery -Where surgery is contraindicated,Bronchial artery embolization: Managing ruptured pulmonary artery venous malformation e A case report Dharitri Goswami a,*, Shantanu
16、Das b,1, Ashok Parida c,2, Joy Sanyal c,3. Respiratory Medicine CME 4 (2011) 160e163,poor lung function, bilateral pulmonary disease, co morbidities.,WHY BAE ?,1)Bronchial circulation (90% of cases) - Pulmonary circulation (5%) . - Aorta (5%)(eg, aorto bronchial fistula, ruptured aortic aneurysm).2)
17、 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%.,BAE- TECHNIQUE,Prior to the procedure, a brief neurological ex
18、am is performed to establish a baseline. Femoral route/Trans-Axillary routeMonitor vitals/spo2Sedation optionalClean groin with antiseptics.Adequate LAA preliminary descending thoracic aortogram (Ionic/non ionic contrast) can be performed as a roadmap to the bronchial arteries.,BAE - TECHNIQUE,Both
19、bronchial arteries and nonbronchial systemic arteries are opacified. The diagnostic angiographic injections are always selective into the bronchial, intercostals, subclavian, internal mammary, intercostobronchial, and inferior phrenic arteries.Under X-Ray machine guidance (Digital cardiac imaging wi
20、th digital subtraction facility)Reverse curve catheter mikaelsson, simmons 1, shepherds hook.Low arotic arch forward looking catheters ( cobra or RC ) used.,Angiographic signs of haemoptysis,ISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pages,BAE - TECHNIQUE,The left main stem bronchus se
21、rves 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.Intercostal arteries initial cephalic cou
22、rse , then laterally along undersurface of rib,BAE - TECHNIQUE,The embolization materials commonly used are non-absorbable particles of polyvinyl 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 o
23、f 2 and 3mm in size (MicroNester Embolization Coils; Cook, Bjaeverskov, Denmark).,Catheters:,Reverse-curved catheters (Mikaelson, Simmons I, SOS Omni) Forward-looking catheters (Cobra, HIH,RC) Sizes: 4, 5, or 5.5 Fr are routinely used.,Mikaelson catheter,Cobra type: curved catheter,Most commonly use
24、dMicrocatheterSuperselective catherizationLess complications,Embolizing materials:,Absorbable gelatin spongeGelfoamPledgets (1 to 2 mm)Thrombin,GlueRecently approved -Embospheres, -Spherical Poly vinyl alcohol(PVA) particles,Permanent occlusive agentsPolyvinyl alcohol (PVA), Trisacryl gelatin micros
25、pheres (TGM), Gelfoam,Embolizing materials:,PVA particles (350-500 mic) Most common & Safe Liquid embolic agents -ischemic necrosis Stainless steel platinum coils -occlude more proximal vessels.,Embolization coils: Platinum Microcoils,Embolizing materials:,Particles 200 to 250 micr.m should be usedN
26、o ischaemia and no neurologic damage Isobutyl-2 cyanoacrolate, Absolute alcohol Used in pulmonary artery aneurysms to avoid tissue ischemia and neurologic damage,Embolizing materials:,Distal embolization : ideal Proximal occlusion: temporary relief particles 200 micr.m :avoided -Tissue infarctionLiq
27、uid embolic agents should always be avoided because these cause tissue infarction,Clues to bronchial artery as the source of bleeding:,34,Parenchymal hypervascularity,Vascular hypertrophy,aneurysm,35,The identification of extravasated dye -INFREQUENT,Bronchopulmonary shunting,Neovascularisation,Left
28、 upper lobe bronchial artery,After Embolization,Decreased vascularity & hypertrophy,Tortous and hypertrophied vessel,Before Embolization,Right,Left,Abnormal circulation,Pre-embolisation bronchial angiogram,No abnormal circulation,Post embolisation,Bronchial artery aneurysm,Hypervascular lesion with
29、aneurysm,Pre embolisation,Post embolisation,PVA particles,No hypervascular lesion & aneurysm,Super selective Embolization of intercostal artery,Hypervascular areas and a small amount of pulmonary arterial shunting,Decreased vasularity,POST EMBOLIZATION,PRE EMBOLIZATION,Radicular arteries,INTERCOSTAL
30、 ARTERY,Micro catheter passed beyond radicular artery,Bronchial Artery Embolization,Success rates : 64% to 100%. Recurrent non-massive bleeding :1646%Recurrence of haemoptysis may be due to:Incomplete embolization of the bronchial vesselsRecannalization of the embolized arteries.Presence of non-bron
31、chial systemic arteries.Development of collateral circulation in response to continuing pulmonary inflammation.,Bronchial Artery Embolization,Technical failure: 13% Technical failure is caused by non-bronchial artery collaterals from systemic vessels such as the phrenic, intercostal, mammary,(PLEURA
32、) or subclavian Arteries.,Complications of BAE,Transversemyelitis The most feared complication due to non target occlusion of branches. When the anterior spinal artery is identified as originating from the bronchial artery, embolisation is often deferred owing to the risk of infaction and paraparesi
33、s.,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 segmental medullary arteries, including the artery of Adamkiewicz, and courses along the anterior aspect of the s
34、pinal 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 sensory deficits in the form of pain/temperature sense loss,Complications of BAE,Complications of BAE,Compl
35、ications of BAE,Chest pain is the most common complication.Dysphagia due to embolization of esophageal branches may also be encountered. Rare complications Aortic and bronchial necrosisBronchoesophageal fistulaNontarget organ embolization (eg, ischemic colitis) Pulmonary infarction.,References,1) Ha
36、ponik 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
37、J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization for haemoptysis. Eur Radiol. 1997;7(8):12211227.,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. Radiog
38、raphics. 2002;22(6):13951409.5)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):8628666)Ramakantan R, Bandekar V G, Gandhi M S, Aulakh B G, Deshmukh H L. Massive hemoptysis due to pulmonary tuberculosis: cont
39、rol with bronchial artery embolization. Radiology. 1996;200(3):691694.,References,CONCLUSION,The development of bronchial artery embolization techniques has revolutionized the approach to hemoptysis patients. Bronchial artery embolization possesses high rates of immediate clinical success coupled wi
40、th low complication rates. 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 is not possible due technical difficulty and in case of embolisation failure. Otherwise bronchial artery embolisation is considered as the mainstay treatment for hemoptysis.,CONCLUSION,
