Embolotherapy in the bronchial and pulmonary circulations

Pulmonary arterial hypertension in hereditary hemorrhagic telangiectasia associated with ACVRL1 mutation: a case report

INTRODUCTION

Hereditary hemorrhagic telangiectasia is an autosomal dominant condition with an estimated prevalence of 1 in 5000. It is characterized by the presence of abnormalities of vascular structures, and may affect many organ systems, including the lungs, brain, spinal cord, gastrointestinal tract, and liver. A causative mutation is identified in approximately 97% of patients with definite hereditary hemorrhagic telangiectasia in one of three genes including a mutation in endoglin, a mutation in a locus mapped to chromosome 5, and an activin receptor-like kinase-1 (ACVRL1) mutation that is associated with an increased incidence of primary pulmonary hypertension. Pulmonary arterial hypertension is a rare (15-25 cases per million people) but severe vascular disorder. Heritable pulmonary arterial hypertension is associated with several gene mutations, with 75% having a mutation in the bone morphogenetic protein receptor 2 (BMPR2). However, the remaining 25% of patients have other associated genetic mutations including ACVLR1, which is also associated with hereditary hemorrhagic telangiectasia. Pulmonary arterial hypertension is a rare complication in patients with hereditary hemorrhagic telangiectasia (< 1% of the hereditary hemorrhagic telangiectasia population). We describe a case report with this rare occurrence.

CASE PRESENTATION

A 70-year-old white/caucasian Irish male presented for screening for hereditary hemorrhagic telangiectasia due to a history of recurrent epistaxis (once/week) and a family history suggestive of pulmonary hypertension. Genetic testing confirmed an ACVRL1 mutation, while an echocardiogram and right heart catheterization confirmed pulmonary arterial hypertension. On examination, he had several mucocutaneous telangiectasia across his face. He was commenced on tadalafil and macitentan. However, this led to increased iron deficiency anemia and pedal edema. Selexipag was also added to his drug regime. He continues to require intermittent admissions for diuresis and blood transfusions.

CONCLUSION

The association of hereditary hemorrhagic telangiectasia and pulmonary arterial hypertension is rare (< 1%). Here we describe a case of hereditary hemorrhagic telangiectasia complicated with pulmonary arterial hypertension as a result of an ACVRL1 mutation. We also describe the clinical challenges of treating these two conditions together, as treatment options for pulmonary arterial hypertension tend to worsen hereditary hemorrhagic telangiectasia symptoms.

Treatment of pulmonary arteriovenous malformations: clinical experience using different embolization strategies

PURPOSE

To evaluate embolization efficacy of pulmonary arteriovenous malformations (PAVM) using Amplatzer vascular plugs (AVP) and coils.

MATERIALS AND METHODS

Eighty-eight embolized simple PAVMs in 38 patients were retrospectively analyzed by follow-up CT. Mean age was 50.2 ± 15.6 years and 22 (57.9%) patients were females. Mean follow-up interval was 38.2 ± 28.4 months (median 29.9 months). Embolization devices included AVP I, AVP II, AVP 4, and coils. Technical success was defined as no visualization of an early draining vein at angiography after embolization. Treatment success was defined as complete disappearance or decrease in size of the venous aneurysm ≥ 70% at follow-up CT.

RESULTS

Technical success rate was 100% and treatment success rate evaluated by CT for the various embolization strategies was 100% for AVP I (n = 6), 100% for AVP I + coils (n = 5), 83.3% for AVP II (n = 6), 40.0% for AVP II + coils (n = 5), 87.5% for AVP 4 (n = 8), 50.0% for AVP 4 + coils (n = 8), and 78.0% for coils alone (n = 50). No statistically significant difference in embolization efficacy was seen between different devices (P = 0.083). Although not statistically significant, combination use of coils with AVPs demonstrated lower rates of clinical embolization success (P = 0.053).

CONCLUSION

Embolization of PAVMs demonstrated high technical and treatment success rates with available embolic devices. No significant statistical differences were demonstrated between AVPs. However, the need for both coils and AVPs may suggest a more complicated underlying lesion at risk for recurrence.

Asymptomatic pulmonary arteriovenous malformations in children with hereditary hemorrhagic telangiectasia

BACKGROUND

Children with Hereditary Hemorrhagic Telangiectasia (HHT) may have pulmonary arteriovenous malformations (AVMs), which can lead to symptoms of shortness of breath, exercise intolerance, clubbing, cyanosis and hemoptysis. However, some patients with pulmonary AVMs may be asymptomatic, placing them at risk for complications such as stroke or brain abscess if they are not identified and treated. This study examines the incidence of signs and symptoms associated with pulmonary AVMs in children with HHT known to have pulmonary AVMs.

METHOD

Sixty-one children with HHT and documented pulmonary AVMs were questioned for any symptoms possibly associated with their pulmonary AVMs, prior to embolization.

RESULTS

The results show that the majority of these children were asymptomatic (56%), and their AVMs were discovered by routine screening. Those who did experience symptoms most often complained of shortness of breath and exercise intolerance, although there was a tendency to blame other conditions, such as asthma or deconditioning (being out of shape), for these symptoms. Migraine headaches were common in those with pulmonary AVMs, regardless of whether they were symptomatic or not (17 of 61 children, 28%), although they were more common in those who were symptomatic (10 of 27, 37%) versus those who were asymptomatic (7 of 34, 21%).

CONCLUSION

Children with HHT and pulmonary AVMs are often asymptomatic. Routine screening for the presence of AVMs should be performed regardless of symptomatology.

Persistence of pulmonary arteriovenous malformations after successful embolotherapy with Amplatzer vascular plug: long-term results

PURPOSE

We aimed to evaluate the frequency of persistence and complication rates of pulmonary arteriovenous malformations (PAVMs) treated with Amplatzer vascular plug (AVP) or Amplatzer vascular plug type 2 (AVP2).

METHODS

We retrospectively reviewed a total of 22 patients with 54 PAVMs between June 2004 and June 2014. We included 12 patients with 35 PAVMs who received percutaneous embolization using AVP or AVP2 only without the use of any other embolic devices. The mean follow-up was 54±24.3 months (range, 31-97 months). The primary end-points of the study were the efficacy of embolotherapy, the increase in oxygen saturation, and the persistence of PAVM on follow-up. Secondary end point was the incidence of complications.

RESULTS

The study included 10 female and two male patients with a mean age of 50.2±13.7 years (range, 21-66 years). All PAVMs had a simple angioarchitecture. The technical success of the procedure for PAVM occlusion was 100%. There was a significant increase in the oxygen saturation following embolotherapy (P < 0.0001). Follow-up computed tomography angiography revealed successful treatment in 34 PAVMs (97%) and failed treatment in one PAVM (3%). Twenty-three aneurysmal sacs (67%) showed complete disappearance. The failed treatment was due to persistence of PAVM caused by subsequent development of systemic reperfusion, which did not require further intervention. There were two minor complications but no major complications were encountered.

CONCLUSION

Embolotherapy of PAVMs using AVP or AVP2 devices is safe and effective, with high technical success rate, low persistence and complication rates, and with excellent long-term results.

Management of Life-Threatening Hemoptysis

From June 1993 to June 1998, 50 patients were admitted with life-threatening hemoptysis (> 150 mL blood in 24 hours) due to pulmonary tuberculosis in 40, malignancy in 5, nontuberculous bronchiectasis in 4, and lung sequestration in 1. All patients had bronchial angiography with one session of embolization in 35 and more than one session in 11; no embolization was required in 4 cases. Surgery was necessary for recurrent hemoptysis in 6 patients. There were significant recurrences in 19 patients, of whom 5 died. Predictors of recurrence were the presence of mycetoma and presentation in a state of collapse. The fatal recurrences all took place within 1 week of the initial embolization and were probably due to incomplete embolization. In patients restudied after significant recurrences within 1 week of embolization, new vessels needed to be embolized in addition to previously treated vessels. It is postulated that some bleeding vessels may be missed at initial angiography, possibly due to vasospasm or low flow, and these may resume bleeding when the patient's hemodynamic status improves. An angiogram within 24 hours of embolization could identify such patients and they should be offered surgery if they are fit.

Bronchial artery embolization in life-threatening massive hemoptysis

Background

Massive hemoptysis is a potentially life threatening respiratory emergency and mandates immediate investigation and intervention. There is no universal consensus regarding the optimal management of these patients, and there are no large series of patients studied.

Objectives

Here we reported thirty Iranian patients who were managed with bronchial artery embolization.

Patients and Methods

All the patients had already been assessed by computerized tomography (CT) to localize and delineate the underlying etiology except 2 patients who had not undergone CT scan.

Results

Tuberculosis, bronchiectasis, and lung cancer/metastasis were the most common causes, detected in 14(47%), 5(17%) and 4(13%) patients respectively. Other causes of hemoptysis including chronic bronchitis, interlobar artery aneurysm, hydatid cyst, arteriovenous fistula, pulmonary embolism, and exposure to chemical weapons each detected in one patient separately. All of them had abnormal chest CT scans, except for 2 patients who had not undergone CT scan (one with hydatid cyst and another with bronchial tumor diagnosed with bronchoscopy). Bleeding location which has been confirmed with angiography could be predicted with CT scan among 7 of 14 patients with TB, (sensitivity=50%). While this rate was 100% among all other patients with other diagnosis who had undergone CT scan.

Conclusions

In conclusion complementary to the previous studies our results have demonstrated that bronchial artery embolization remains as one of the most efficient procedures in managing massive hemoptysis, with minimal rate of complications.

Bronchial and Nonbronchial Systemic Artery Embolization in Management of Hemoptysis: Experience with 348 Patients

Background. We aimed to report our experience with bronchial artery embolization (BAE) in the management of moderate recurrent and/or life-threatening hemoptysis. Methods. We evaluated the demographics, clinical presentation, radiographic studies, short- and long-term efficacy, and complications in patients Who underwent BAE, at a tertiary university hospital, from 2003 to 2012. Results. Three hundred forty-one patients underwent BAE for the management of moderate recurrent or life-threatening hemoptysis. Pulmonary TB and bronchiectasis were the most common etiologies for hemoptysis in our locality. The most common angiographic signs for hemoptysis were hypervascularity and systemic-pulmonary artery shunt. BAE was successful in controlling hemoptysis immediately in 95% of patients and at 1 month in 90% of patients. Recurrence of hemoptysis was observed in 9.6% of patients, and reembolization was indicated in 85% of those cases. Complications of BAE were self-limited acute and subacute complications, while chronic complications were not recorded during this study. Conclusions. TB and bronchiectasis are the commonest etiologies for moderate recurrent or life-threatening hemoptysis in our locality. Hypervascular lesions from the bronchial arteries and nonbronchial systemic arteries represented the major vascular abnormalities. Bronchial and nonbronchial systemic artery embolizations were effective to control both acute and chronic hemoptyses, with no serious complications.

Preoperative embolization in surgical management of massive thoracic tumors

BACKGROUND

The surgical excision of a highly vascular giant tumor may be challenging. The aim of this study was to describe our experience with preoperative percutaneous embolization of massive vascular chest tumors before surgical excision.

METHODS

From 2009 to 2011, 8 cases of giant vascular thoracic tumor were treated at Assiut University Hospital, Assiut, Egypt, by preoperative embolization of the feeding arteries followed by successful excision after 48 h.

RESULTS

The median age of the 8 patients was 39 years. Embolization of their tumors resulted in a reduction of tumor size, and minimal blood loss was observed perioperatively. Perilesional edema and easy differentiation of ischemic tissue facilitated complete surgical removal of the tumors.

CONCLUSIONS

Preoperative embolization of giant vascular thoracic tumors is useful to decrease perioperative blood loss and facilitate total excision.

Transseptal guidewire stabilization for device closure of a large pulmonary arteriovenous malformation

A 46-year-old man presenting with massive hemoptysis was found to have a large pulmonary arteriovenous malformation (PAVM) in the right lung. Closure of the PAVM with an Amplatzer-type duct occluder was hampered by inability to advance the device delivery sheath into the PAVM due to vessel tortuosity and inadequate guidewire support. Atrial septal puncture was performed and a femorofemoral arteriovenous guidewire loop through the right pulmonary artery, PAVM, and left atrium was created. Traction on both ends of the guidewire loop allowed advancement of the device delivery sheath into the PAVM and successful completion of the procedure. Transseptal guidewire stabilization can be a valuable option during device closure of large PAVMs when advancement, stability, or kinking of the device delivery sheath is an issue.

Bronchial artery embolization for hemoptysis

Bronchial artery bleeding is the most common cause of life-threatening hemoptysis. The most common underlying etiologies include tuberculosis, bronchiectasis, aspergillosis, and cystic fibrosis. Bronchial artery embolization is an important treatment for significant hemoptysis, given its high early success rate and relatively low risk compared with alternative medical and surgical treatments. In this article, the relevant anatomy and pathophysiology leading to bronchial artery bleeding is discussed, including the roles of parenchymal lung diseases and of collateral and aberrant vessels. The indications for treatment, success rate, and complication rate for bronchial artery embolization are reviewed. Preprocedure clinical stabilization and evaluation, including the roles of radiographs, bronchoscopy, and computed tomography examination are evaluated. Details of technique, including the published variety of approaches, and an emphasis on avoidance of nontarget embolization of important mediastinal structures and of the anterior spinal artery are discussed.

Complications of embolization

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Nine-Year Single-Center Experience With Transcatheter Arterial Embolization for Hemoptysis: Medium-Term Outcomes

Purpose: To determine the medium-term efficacy of transcatheter arterial embolization (TAE) for hemoptysis. Materials and Methods: A total of 128 TAE were performed from April 1999 to April 2008 in 58 patients (30:28 F:M) with mean age of 49 (range:16-89). Major causes of hemoptysis included cystic fibrosis/bronchiectasis (24 of 58); lung metastasis (8 of 58); lung cancer (7 of 58); fungal infection (4 of 58). Follow-up was available in 57 of 58 for a median of 1.28 years. Primary and secondary efficacy of TAE for hemoptysis was calculated using Kaplan-Meier estimates. Results: Technical and clinical successes were estimated at 58 (100%) of 58 and 57 (98%) of 58, respectively. Recurrent hemoptysis occurred in 40% (23 of 58). In all, 34% (20 of 58) died during follow-up. Kaplan-Meier estimates for primary and secondary efficacy of TAE at 2, 4, 6, and 8 years were 0.82, 0.46, 0.17, and 0.09 (benign disease) and 0.30, 0, 0, and 0 (malignant disease), respectively. Conclusion: TAE is an effective treatment for hemoptysis in both short- and medium-terms, especially in benign lung disease.

Embolization of pulmonary arteriovenous malformations with amplatzer vascular plugs: safety and midterm effectiveness

PURPOSE

To evaluate the safety and effectiveness of Amplatzer vascular plugs (AVPs) for percutaneous closure of arteries feeding pulmonary arteriovenous malformations (PAVMs).

MATERIALS AND METHODS

Over a 45-month period, 24 consecutive patients with at least one PAVM treated with an AVP were selected from a database on patients with a PAVM who received embolotherapy. Immediate technical success was defined as the complete absence of flow through the PAVM after embolization without the need for additional embolization material. Success on follow-up imaging was defined as a reduction in size of at least 70% of the aneurysm or draining vein on follow-up computed tomography or the absence of flow through the PAVM on a subsequent pulmonary angiogram.

RESULTS

Thirty-seven AVPs were used to close 36 feeding arteries in 35 PAVMs in seven male and 17 female patients aged 11-86 years (mean age, 50 y). Technical success was achieved in 35 feeding arteries (97%). One feeding artery required two AVPs for closure. There were no immediate procedure-related complications. At a mean clinical follow-up of 322 days (range, 1-1,126 d), all patients were alive without new PAVM-related complications. Imaging follow-up was available for 29 embolized vessels (81%) with a mean follow-up of 418 days (range, 40-937 d), and recanalization occurred in two treated vessels (7%).

CONCLUSIONS

AVPs are safe and effective for closure of PAVMs feeding vessels that can be reached with a guiding catheter, with an acceptable rate of recanalization.

An Association of Migraine with Hereditary Haemorrhagic Telangiectasia Independently of Pulmonary Right-to-Left Shunts

Hereditary haemorrhagic telangiectasia (HHT) is a genetic disorder characterized by epistaxis, telangiectasia and visceral vascular manifestations. It is associated with migraine with aura due to pulmonary arteriovenous malformations (pAVMs). The aim of the study was to evaluate headache prevalence in 106 consecutive HHT patients (67 female, 39 male, age 53.5 ± 14.5 years) and age- and gender-matched controls. An extensive clinical work-up was performed and headache prevalence was determined. Lifetime prevalence of migraine was higher in HHT patients (39.6%) than in controls (19.8%) [ P < 0.001, χ2 = 12.17, odds ratio (OR) 3.0; 95% confidence interval 1.6 < OR < 5.7]. A positive association was confirmed between HHT patients with pAVMs and migraine with aura (38.5% vs. 10%). Furthermore, HHT patients without pAVMs had a higher prevalence of migraine without aura (11.5% vs. 26.3%; χ2 = 11.85; d.f. = 2; P = 0.003). We speculate that pathophysiological mechanisms, including dysfunction of the transforming growth factor-beta pathways and resulting vascular changes, contribute to the higher prevalence of migraine without aura in HHT patients without pAVMs.

Hereditary haemorrhagic telangiectasia: a cause of preventable morbidity and mortality

Hereditary haemorrhagic telangiectasia (HHT) is an autosomal dominant condition whose effects are mediated through deficient blood vessel formation and regeneration, with multisystem involvement. Patients are usually aware of resulting skin telangiectasia and epistaxis, but are also exposed to dangers posed by occult vascular malformations in other organs. About 15-35% of HHT patients have pulmonary AVMs (PAVMs), 10% have cerebral AVMs (CAVMs), 25-33% suffer significant GI blood loss from GI tract telangiectasia, and an unknown but high percentage have liver involvement. In total, 10% of affected individuals die prematurely or suffer major disability from HHT, largely because of bleeding from CAVMs and PAVMs, or paradoxical embolization through PAVMs. Screening for and early intervention to treat occult PAVMs and CAVMs can largely eliminate these risks, and should be undertaken in a specialist centre. The National HHT Center in The Mercy University Hospital in Cork is the referral centre for HHT screening in Ireland.

Pulmonary Vascular Disease

The pulmonary vasculature is an anatomic compartment that is frequently overlooked in the histologic review of lung biopsy samples, other than those obtained specifically to assess pulmonary vascular disease.1 Though often of a nonspecific nature, the histologic pattern of vascular remodeling may at times suggest its underlying pathogenesis and provide clues to the cause of pulmonary hypertension.2 Disproportionately severe vascular pathology may further indicate alternate disease processes, such as congestive heart failure or thromboemboli, contributing to the patient’s overall respiratory condition.

Bronchial Artery and Systemic Artery Embolization in the Management of Primary Lung Cancer Patients with Hemoptysis

PURPOSE

To assess the safety and effectiveness of arterial embolization in lung cancer patients with hemoptysis.

METHODS

Nineteen primary lung cancer patients with hemoptysis underwent bronchial artery and systemic artery embolization from April 2002 to March 2005. There were 17 men and 2 women, with a mean age of 59 years. Histologic analysis revealed squamous cell carcinoma in 10 patients and poorly differentiated adenocarcinoma in 9 patients. The amount of hemoptysis was bleeding of 25-50 ml within 24 hr in 8 patients, recurrent blood-tinged sputum in 6, and bleeding of 100 ml or more per 24 hr in 5. Embolization was done with a superselective technique using a microcatheter and polyvinyl alcohol particles to occlude the affected vessels.

RESULTS

Arterial embolization was technically successful in all patients and clinically successful in 15 patients (79%). The average number of arteries embolized was 1.2. Bronchial arteriography revealed staining (all patients), dilatation of the artery or hypervascularity (10 patients), and bronchopulmonary shunt (6 patients). The recurrence rate was 33% (5/15) and 11 patients were alive with a mean follow-up time of 148 days (30-349 days).

CONCLUSION

Arterial embolotherapy for hemoptysis in patients with primary lung cancer is an effective, safe therapeutic modality despite the fact the vascular changes are subtle on angiography.

Transcatheter closure of pulmonary arteriovenous malformations with amplatzer devices

OBJECTIVE

To review the authors' experience with transcatheter closure of pulmonary arteriovenous malformations (PAVMs) using amplatzer duct occluder (ADO) devices and vascular plugs (AGA Medical, Golden Valley, MN) and present a novel technique for delivery sheath placement and device delivery.

BACKGROUND

PAVMs can cause cyanosis, fatigue, polycythemia, and thromboembolic phenomena. Transcatheter closure using coils, detachable balloons, and various devices has replaced surgery as the preferred therapy.

METHODS

Between January 2001 and December 2004, five patients (2M, 3F) of median age 33 years (14-49) were referred for transcatheter closure of multiple PAVMs. All patients were diagnosed previously with hereditary hemorrhagic telangectasia. The procedures were performed with sedation using a percutaneous transcatheter technique via the femoral vein under fluoroscopic guidance.

RESULTS

A total of 14 PAVMs (11 ADO and 3 plugs) were closed in five patients. Three patients required two procedures after developing additional PAVMs. All attempts at PAVM closure were successful. Oxygen saturation increased from 88.4 +/- 6.1 to 96.4 +/- 0.5 (P < 0.05). No complications, including air or thromboembolism, hemoptysis, or chest pain, occurred. At median follow-up of 3.4 years (1.4-3.6), all patients are alive and have suffered no embolic phenomena or infection.

CONCLUSION

Amplatzer patent ductus arteriosus occluders and vascular plugs are safe and effective in the closure of PAVMs in the acute setting and at intermediate follow-up. Placement of a long delivery sheath can be facilitated by the methods outlined. Though promising, further clinical evaluation of these devices is required. Their apparent advantages must be compared to other techniques and devices for transcatheter PAVM closure.

Multi-detector row CT of hemoptysis

Hemoptysis is symptomatic of a potentially life-threatening condition and warrants urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multi-detector row computed tomographic (CT) angiography is a very useful noninvasive imaging modality for initial assessment of hemoptysis. The combined use of thin-section axial scans and more complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be the source of hemorrhage and that may require embolization. Conditions such as bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT. "Cryptogenic" hemoptysis is common among smokers and warrants subsequent follow-up imaging to exclude possible underlying malignancy. The bronchial arteries are the source of bleeding in most cases of hemoptysis. Contributions from the non-bronchial systemic arterial system represent an important cause of recurrent hemoptysis following apparently successful bronchial artery embolization. Vascular anomalies such as pulmonary arteriovenous malformations and bronchial artery aneurysms are other important causes of hemoptysis. Multi-detector row CT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management.

Management of pediatric hemoptysis: review and a case of isolated unilateral pulmonary artery agenesis

OBJECTIVES

Management of hemoptysis in the pediatric patient requires an otolaryngologist knowledgeable and skilled in the causes and management of this potentially life-threatening condition. This paper will discuss the management of pediatric hemoptysis by the otolaryngologist through an index case of massive hemoptysis seen in a child with isolated unilateral pulmonary artery agenesis (IUPAA).

STUDY DESIGN

Literature review and index case.

METHODS

Through a Medline search and the experience of the author (A.J.M.), we reviewed the causes and treatment options for hemoptysis in the pediatric patient.

RESULTS

Management of hemoptysis by the otolaryngologist requires prompt diagnosis and patient stabilization. This allows the patient access to multiple treatment options which may include diagnostic or therapeutic bronchoscopy, angiography with embolization, and surgical intervention such as resection or revascularization. IUPAA is an unusual, and potentially life-threatening cause of hemoptysis in the pediatric patient.

CONCLUSION

Hemoptysis in the pediatric patient requires prompt and thorough evaluation and treatment. An approach for the management of pediatric hemoptysis, including massive hemoptysis, is described.

Transpleural ultrasound diagnosis of a pulmonary arteriovenous malformation

Pulmonary arteriovenous malformations (PAVMs) are rare. We discuss a case of an 81-year-old female who attended hospital with a haemothorax. Ultrasound not only demonstrated an echogenic effusion in the right pleural space, but also identified an associated tubular structure. Doppler was applied to this structure, which exhibited pulsatile flow. This raised the possibility of a PAVM, which was subsequently confirmed on CT and angiography. Although, PAVM is a rare cause of haemothorax, the diagnosis should still be considered and transpleural ultrasound can detect these malformations non-invasively by the bedside.

Embolotherapy of Pulmonary Arteriovenous Malformations: Efficacy of Platinum versus Stainless Steel Coils

PURPOSE

To compare the results of embolotherapy of pulmonary arteriovenous malformations (PAVMs) with use of platinum versus stainless-steel coils.

MATERIALS AND METHODS

From a database of 78 consecutive patients with PAVMs treated by embolotherapy between May 1992 and September 2001, 54 patients with 306 PAVMs were selected for retrospective evaluation. Exclusion criteria were PAVMs with less than 12 months of follow-up computed tomography (CT) of the thorax (n = 15), embolotherapy with a mixture of embolic materials (n = 8), and repeat embolotherapy for previous treatment failures (n = 1). Successful treatment was defined as complete resolution of the aneurysm sac and draining vein on follow-up CT (all patients) and/or absence of contrast material flow through the PAVM on pulmonary angiography (n = 27).

RESULTS

Of 267 PAVMs embolized with stainless-steel coils, 249 (93.3%) were successfully occluded (mean follow-up, 3.1 years). Of 39 PAVMs embolized with platinum coils, 35 (89.7%) were successfully occluded (mean follow-up, 2.1 years). There was no significant difference in success between the two groups (P =.5). The mean feeding artery size was significantly larger (P <.0001) in the platinum group (4.3 mm) than in the stainless-steel group (3.5 mm). Potentially serious complications included coil reflux (n = 3), PAVM perforation (n = 2), self-limited neurologic deficit (n = 2), and systemic embolization of a coil (n = 1) in the stainless-steel group, and PAVM perforation (n = 2) in the platinum group. There were no long-term sequelae.

CONCLUSIONS

Coil embolotherapy is highly efficacious, with no statistically significant difference between platinum and stainless-steel coils. The slightly higher proportion of sustained occlusion with stainless-steel coils may be partly explained by the larger mean feeding artery size in the platinum group. The study is limited by the small sample size of the platinum group.

Micronester—A New Pushable Fibered Microcoil for Embolotherapy

A prototype 0.018 pushable fibered microcoil with an extended length of 14 cm was developed and used successfully for the first time to treat a patient with bilateral varicocele. This new coil provides immediate cross-sectional occlusion when "nested" into a densely packed coil mass. Potential uses of this new microcoil are discussed.

Bronchial artery embolization : experience with 54 patients

OBJECTIVES

To report our experience with bronchial arteriography and bronchial artery embolization (BAE).

MATERIALS AND METHODS

A review of clinical experience to evaluate the demographics, clinical presentation, radiographic studies, bronchoscopy, and complications of bronchial arteriography and BAE at Mayo Medical Center, Rochester, MN, from 1981 to 2000.

RESULTS

Fifty-four patients underwent bronchial arteriography. There were 34 men and 20 women with a mean age of 53 years. Hemoptysis was the most common indication in 53 patients (98%). Hemoptysis was caused by bronchiectasis (9 patients), pulmonary hypertension (9 patients), malignancy (7 patients), mycetoma (7 patients), and other identified causes (14 patients). The cause could not be identified in eight patients. Bronchoscopy was performed in 49 patients (92%), and the results identified the bleeding lobe in 32 patients, lateralized the side of the bleeding in 5 patients, and were not helpful in 12 patients. Bronchial arteriography revealed hypervascularity (45 patients), bronchial artery hypertrophy (17 patients), hypervascularity with shunting (15 patients), dense soft tissue staining (8 patients), vascular abnormalities (7 patients), and extravasation of contrast (1 patient). BAE was attempted in 54 patients, completed in 51 patients, and was unsuccessful in 3 patients. Overall, 72 embolization sessions were performed with a total of 131 arteries embolized, and the average number of arteries embolized per patient was 2.5. Control of hemoptysis was observed in 46 patients (85%) at 1 month. Rebleeding occurred within 30 days in five patients. Eight patients had recurrent hemoptysis that occurred 30 days after the procedure. The complications of embolization included subintimal dissection of a bronchial artery (two patients), bronchial arterial perforation by a guidewire (one patient), and the reflux of embolic material into the aorta without adverse sequelae (one patient).

CONCLUSIONS

BAE is a useful therapy to control both acute and chronic hemoptysis. BAE may help to avoid surgery in patients who are not good surgical candidates. Should hemoptysis recur in these patients, repeat embolization can be performed safely.

Imaging guided thoracic interventions

Interventional Radiology is a technique based medical specialty, using all available imaging modalities (fluoroscopy, ultrasound, computed tomography, magnetic resonance, angiography) for guidance of interventional techniques for diagnostic or therapeutic purposes. Actual, percutaneous transthoracic needle biopsy includes core needle biopsy besides fine needle aspiration. Any pleural, pulmonary or mediastinal fluid or gas collection is amenable to percutaneous pulmonary catheter drainage. Treatment of haemoptysis of the bronchial artery or pulmonary artery origin, transcatheter embolization of pulmonary arteriovenous malformations and pseudoaneurysms, angioplasty and stenting of the superior vena caval system and percutaneous foreign body retrieval are well established routine procedures, precluding unnecessary surgery. These techniques are safe and effective in experienced hands. Computed tomography is helpful in pre- and postoperative imaging of patients being considered for endobronchial stenting. Many procedures can be performed on an outpatient basis, thus increasing the cost-effectiveness of radiologically guided interventions in the thorax.