Bronchial Artery Embolization- By Dr.Tinku Joseph

BRONCHIAL ARTERY EMBOLIZATION

DR TINKU JOSEPH

DM ResidentDepartment of Pulmonary Medicine

AIMS, Kochin

Email-: tinkujoseph2010@gmail.com

contents

Bronchial circulation

Bronchial Artery Embolization (BAE)

Indications

Procedure

Complications

Two Circulations in the Lung

• Bronchial Circulation

– Arises from the aorta.

– Part of systemic circulation.

– Receives about 2% of left ventricular output.

• Pulmonary Circulation

– Arises 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 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, 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.

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 medullarybranch.

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.

Topographical Facts:Normal Anatomy and Variations

Bronchial artery branching pattern

Cauldwell et al - four patterns:

Type I

Type II

Type III

Type IV

Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395–412.

Type I

• Incidence: 40.6%

• Left:2

• Right:1 {intercostobronchialtrunk (ICBT)}

Bronchial Artery- Course

Leave 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 divide into visceral pleural branches to the mediastinalpleura and true bronchial arteries to the bronchial tree.

Bronchial Artery- Course

Spiral course around bronchi, one on either side of each other but anastomosing frequently with each other

The 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 lymph 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 gone 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 embolization 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: 57–100% of patients**

Embolization : bronchial and nonbronchial

Long-term control: 70%-88%

Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris) 1974; 17: 5–16.

**Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.

Indications

• Haemoptysis-:Failure of conservative or bronchoscopictreatment to control bleeding.

ISRN Vascular MedicineVolume 2013, Article ID 263259, 7 pages

Indications

Managing 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 surgery

-Where surgery is contraindicated

Bronchial 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) 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) 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 exam is performed to establish a baseline.

Femoral route/Trans-Axillary route

Monitor vitals/spo2

Sedation optional

Clean groin with antiseptics.

Adequate LA

A preliminary descending thoracic aortogram(Ionic/non ionic contrast) can be performed as a roadmap to the bronchial arteries.

BAE - TECHNIQUE

Both 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 with digital subtraction facility)

Reverse curve catheter – mikaelsson, simmons 1, shepherd’s 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 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.

Intercostal arteries – initial cephalic course , 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), 355–500 𝜇m 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 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 used

Microcatheter

Superselectivecatherization

Less complications

Embolizing materials:

• Absorbable gelatin sponge

• Gelfoam

• Pledgets (1 to 2 mm)

• Thrombin

• Glue

• Recently approved

-Embospheres,

-Spherical Poly vinyl alcohol(PVA) particles

Permanent occlusive agentsPolyvinyl alcohol (PVA), Trisacryl gelatin microspheres (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 used

No 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 infarction

Liquid embolic agents should always be avoided because these cause tissue infarction

Clues to bronchial artery as the source of bleeding:

34

Parenchymal hypervascularityVascular hypertrophy

aneurysm

35

The identification of extravasateddye --INFREQUENT

Bronchopulmonary shunting

Neovascularisation

Left upper lobe bronchial artery

After Embolization

Decreased vascularity & hypertrophyTortous and hypertrophied vessel

Before Embolization

Right

Left

Abnormal circulation

Pre-embolisation bronchial angiogram

No abnormal circulation

Post embolisation

Bronchial artery aneurysm

Hypervascular lesion with aneurysm

Pre embolisation Post embolisationPVA particles

No hypervascular lesion & aneurysm

Super selective Embolization of intercostal artery

Hypervascular areas and a small amount of pulmonary arterial shunting

Decreased vasularity

POST EMBOLIZATIONPRE EMBOLIZATION

Radicular arteries

INTERCOSTAL ARTERY

Micro catheter passed beyond radicular artery

Bronchial Artery Embolization

Success rates : 64% to 100%.

Recurrent non-massive bleeding :16–46%• Recurrence of haemoptysis may be due to: Incomplete embolization of the bronchial

vessels Recannalization of the embolized arteries. Presence of non-bronchial 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) or subclavianArteries.

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 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 segmental 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 spinothalamictract, causing sensory deficits in the form of pain/temperature sense loss

Complications of BAE

Complications of BAE

Complications 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 necrosis

Bronchoesophageal fistula

Non–target organ embolization (eg, ischemic colitis)

Pulmonary infarction.

References

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.

References

CONCLUSION

1) The development of bronchial artery embolization techniques has revolutionized the approach to hemoptysis patients.

2) Bronchial artery embolizationpossesses 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 embolisationis not possible due technical difficulty and in case of embolisation failure. Otherwise bronchial artery embolisation is considered as the mainstay treatment for hemoptysis.

CONCLUSION