this is another gentleman from this year in fact.
68 year old gentleman complicated with the history of prior technology of fill over pair had a small cell lung cancer and in January this year it was just a lesion without no abnormality, in case this [INAUDIBLE] pulmonary artery, but it was not blown out like it is here, presented
two months later now with this further encasement of his cancer as well secondary infected had a HeRO bleed, found this on CT imaging is transferred to our hospital for treatment, you can see catheterization of this large pulmonary pseudoaneurysm which
placed a number of framing coils, ultimately pack this and then on completion angiography we were able to stabilize this for this gentleman.
All right, so we talked a lot about bronchial embolization and now we're gonna shift gears and talk a little bit about pulmonary embolization and this is just a pretty straight forward example of a 32-year-old male who occasionally had epistaxis otherwise asymptomatic, he actually was a really active guy in fact run 10K's.
Clearly you know what I'm describing as the patient with HHT which this gentleman had and he came to our center because his sister was diagnosed and she had had epistaxis didn't realize that she had pulmonary BM's, got screen, got a CT, had pulmonary BM's, we treated and embolized her and she said I think my brother has this he
lived a couple of states away. And so she made him go get a CT scan, sent it to me, sure enough he had multiple pulmonary VMs including this one which was, you can see it's a pretty sizable one has a pretty big venous sack to it. So he came in for embolization. In this particular case it was pretty high flow and so we chose
to use the anchoring technique which I'll talk about more in just a second where we went to in adjacent branch with our catheter and that's where we started deploying our coils in order to prevent a none target embolization and this is what it looked like in the end where we just packed a whole bunch of coils, this was a really
Really, really high flow lesion and was able to get it completely occluded. So I don't wanna make this a big didactic on pulmonary VM's or anything so I'm just gonna hit some of the highlight. Pulmonary VM types there's really three types, there's the simple
type which you have a single artery, single draining vein just like the one I just showed you where the artery is coming down and it's going out into the vein and you may or may not have a venous sack aneurysm with it. Here's just another example single draining artery and sometimes
you'll even have multiple draining veins on this so it's not really the venous side isn't what's is important as the feeding arteries are. [BLANK_AUDIO] You can have complex AVMs in which you have multiple feeding arteries going out to these lesions and this is just again,
a diagrammatic illustration of what that would look like. These can be a little more challenging to treat, but unfortunately the majority of pulmonary VMs are simple. Here's just again, another example of a complex pulmonary VM. You can just see all these little feeding arteries within the pulmonary
VM. And then finally, the diffused type, which is the type we typically see more often in children and it kind of has this very unusual appearance is very diffusive appearance and these are just tiny, tiny little
fistulas throughout the lung parenchyma and these can be on the segmental lobe level or they can even be low bar level. So the key to successful embolization these lesions is to embolize close to the AV connection as possible and if you're using coils you wanna make sure that your coils are packed as densely
as possible. So this again and excuse my poor artwork, it is what it is. [LAUGH] But so this is, kind of what we don't wanna have happen. You put your catheter down, you get close to the Av connection,
you put your coil out and you're feeling good and then all of a sudden your coil leaves and takes off and next thing you know, your patient's had a big stroke. And so, there are some things you can do to avoid this and one of the techniques is the one that I just showed you earlier where you do the same
anchoring technique and you go into a little side branch near the ABF connection, and you start your coil there and then you coil back into the fitting artery and this will, by starting your coil on this other little branch it will stabilize the deployment.
Here's just another example. This is an older gentleman again had a very large, very high flow AVM. He didn't actually have a branch that was quite as close to the AV connection as I would have liked and it was a little
too torturous to get out there with a vascular plug or anything like that. In him I ended up having to embolize a little bit more proximally but again you can see starting the coil and the branch vessel and then coming back into the feeding artery. This is what that patient looked like post-embolization and the
reason why we want to be as close to the connection as possible is we worry about reperfusion on these lesions. They can occur in up to about 20% of cases. There was a study out in 2005 that looked at about 100 patients and found that the risk of reperfusion are gonna be based on the feeding artery diameter,
the number of coils whether the coils were over sized, proximal coil placement. Kind of the upshot is you need to have your coils as close to the connection as possible. You need to pack them in as much as possible and generally you need
to use more than one coil. Now the question comes do we retreat these? And I think this is a good one for discussion because, so say you have a patient like this,
where you've got flow going through this feeding artery but yet, you're not gonna have really significant clot that's gonna get through this coil, so what's the risk to the patient by not retreating?
I've got my own opinion but I'll like to hear from Steven Bill in terms of what they think on something like this. >> [INAUDIBLE] I agree theoretically it is kind of filtered but also could be an [INAUDIBLE] of thrombus where you see that flow and [INAUDIBLE] desirable situation [INAUDIBLE] >> Steve. >> Yeah, I agree, more and more of these given any small connection, I think it's important to shut it down, if we're worried about passing through [INAUDIBLE] >> Right and you take a case like this where you actually have a fairly lengthy vessel,
that's Unprotected distal to your coil and so I think it's within reason that thrombus could actually form distalLY to your coil pack and embolize as well. So I think my stance has always been along with those that if I see this I still treat it even though I don't really know what the risk long term is by leaving these untreated.
[BLANK_AUDIO]. So to prevent reperfusion people talked about using different embolic agents and then there's some technique, things that we can also do to try to prevent reperfusion. When we talked about different embolic agents one of the ones that
has become very popular in treating pulmonary VM's is the implant's vascular plug and more recently there's the MVP vascular plug that's been released that I haven't really seen any data on and pulmonary circulation but certainly looks interesting but you can see the data's pretty sparse, fairly small studies 2011 was one of the
early studies looking at the AVP plug and they had one recarnalization after 36 months. Scott went back later and added a coil using the AVB and had no recarnalization, that's really the technique that I followed is essentially deploying the plug putting the coil behind it and that seems to be sufficient.
>> What about the [INAUDIBLE] system have you done for all that? >> For the AVPs? >> Yeah. >> So in terms of how we do our selective catherization we tend to use the white set which is a 7 French guiding catheter with with a 5 French multipurpose catheter with no 38 lumen,
so we'll use that to get as close to the AV connection as possible, occasionally have to use a micro-catheter but it's pretty unusual and then we'll put an AVP for it which will go through an 038 catheter through that and do our embolization. How are you doing anything different than
that. >> Yeah, I don't use plugs primarily, I use mostly master coils, sometimes plugs if it's really central [INAUDIBLE] the problem is if it's a bigger one the fluid goes on to a separate lumen, so you've got one where you're oversizing [INAUDIBLE] then it works >> Right, so you can use the seven french guiding catheter to deliver an AVP 2. The problems I run into are
particularly if it's a more distal one and you have a little bit of vessel tortuosity is they don't always detach. You kind of just build up torque in the releasing wire, and I've had a couple that I've tried to use and then I've had to pull it
out because it just wouldn't release, which kind of makes me uncomfortable. >> [INAUDIBLE] I like to use this for a lot of tortuosity [INAUDIBLE] I like to use a lot of them, even though they are expensive. >> Yeah >> The other thing when I first started using the plug
[INAUDIBLE] you just inject right after you place the plug where it has occluded, often times I often found ourselves using a coil behind it- >> Yeah I usually would just go ahead and head and as part of my standard practice go ahead and put a coil and behind it but you are right even with that usually will end up waiting a good couple of minutes before we do our follow up injection because plugs really don't do anything for at list two or three minutes. [BLANK_AUDIO]
So this is just showing an animation format using the plug. Again you put your catheter down as close as you can to the lesion let's see if this would work. The plugs deployed by withdrawing the catheter. And then again I tend to put a coil pack behind it and here is just been an example of a patient that we treated with
a plug. You can see this left lower lobe pulmonary VM. It's that same patient I showed you earlier she had a pretty diffuse pulmonary VM. Sometimes if you have a lot of time you can go into some of these individual connections but typically
we'll end up just treating this more proximally I don't know what you do with the complex once. >> Sort of a little bit depends on if the patient has multiple lesions and if that's the only lesion you can do whatever you [INAUDIBLE] If a patient has multiple [INAUDIBLE] can try not to knock out as necessary- >> And some of it depends on where the feeding arteries are arising so if you have a feeding artery that's coming off fairly
proxmimally and then the mouth formation is down here, then I'd be more inclined to go into the separate one. But if it's something like this where all the feeding arteries are coming of pretty peripherally then we are inclined to just do with a single embolization. And here is just a video showing us
releasing the plug it's a little hard to see. But again just unsheathing that and this was using the AVP2. And then again we put a coil back behind it. This was an early follow up. Before we had occlusion. [BLANK_AUDIO]
and then she was breathing a little bit but this vessel we finally got stasis on this vessel and interestingly after we occluded this one, we found another separate pulmonary VM, that was adjacent to it, then we went it and we put in a bunch of coils.
Probably more coils than we typically use. This is another more recent case of a patient that's got this right lower lobe pulmonary VM. We almost missed it on our initial NGO. [BLANK AUDIO].
We got more selective, deployed our vascular, plug and this is just showing us detaching it by, you can twist it counter clockwise again it feels like eternity and it takes about ten seconds. Deployed our coil, and this is what it looked like in the post and you can see we had complete occlusion.
The other thing to keep in mind is that some times technique can help reduce the risk of recanalization and there's been a couple of studies that have looked at venus sack embolization for these lesions. First described in 1966, and then another article came out in Japan
in 2012, but both of these articles had very very good success rates and really it's been described for patients to have large outflow vessels, short feeding arteries, this is a patient that we had at our institution that had this really very high flow, very large out flow vessel,
for a pulmonary VM and this is what, it looked like on CT. And so, in this particular case it had actually a fairly short feeding artery and we went in and we started in the venous sack and placed some very large coils and then worked our way back across the connection.
So that's for some of these that are really gonna be very tricky, and you don't have a lot of room to work, if you do have a venous aneurysm then that's also an effective technique. Okay any questions about the pulmonary VMs? Yes sir.
>> Which [INAUDIBLE] regimen do you recommend in absolute? >> So we heparinize all of our patients before we do, the embolization with just with standard heperine as long they are not allergic and I do not routinely put them on anticoagulation after the embolization. >> [INAUDIBLE AUDIO]
Here is a 30 year old male bronchiectasis.
He has the middle lobe of right lung receptive for massive hemorrhage in 2008 in other hospitals and before it's from other hospitals with hemorrhage recurring up to two BAE procedures performed in the same month respectively and RBA and RIMA were implied reportedly. [BLANK_AUDIO]
That's the prior CT scan and so we saw the image, we can see that there are main coils in the upper part of the right chest. [BLANK_AUDIO] And CTA both will show the pulmonary artery and the systemic artery. We can see the patients,
the right chest is smaller, than the left chest, and there are, [BLANK_AUDIO] So the right lung architectural distortion and also we can see atelectasis and bronchiectasis and hypervascular changes including BA and NBSA.
And in 2004 we performed the first in our hospital, performed the first BAE. BAE, I don't think the AE is enough to describe this patient because [LAUGH]
>> It's big. >> It changed this idea of before and many abnormal arteries in the chest. So we use the four French Yashiro and Cobra and Progreat microcatheter to insert the coil inside. Actually the micro wire can go through the coin into the distal of the artery and then we use
100 and 200 to embolize the pathological artery. Now that's the left lung artery. There's some sample of re-check DSA. After we've embolized, performed the embolization we do a Re-check DSA that tells that the target arteries are invisible it's clear.
And then the patient keep stable for at least seven months and then another haemorrhage episode experience. So he come to our hospital for another BAE. So we found there were some vasculization in the right chest and other area. Still have a new occurent/g pathological artery,
so we use the same material to embolize this artery. [BLANK_AUDIO] And new found intercostal artery here this time. [BLANK_AUDIO] and in the 2015 8th,
August we decide to take the right lung out. So after the operation for preventing the [INAUDIBLE] breathing in the surgery we do embolization again. And that's the operating finding. The right thoracic cavity decrease significantly in size and the narrow intercostal spaces and the parietal pleura
was markedly and diffused thickening, [COUGH] The right upper loop of the lung was difficult diffusely consolidate with multi cystic lesions, and convolute and market it thickening right, bronchi artery, that's the inter operated fungi. So that's the growth lung and the growth fiber being as the same
as inter operating thriving and microscopic fiber [BLANK_AUDIO] that's from- [BLANK_AUDIO] for the show, the growth sample [BLANK_AUDIO]
The important point here, the west gutter was thickening and hyalinization are seen without intravascular foreign materials or thrombi. And luckily the lumen of small artery up to 18 mm in diameter that run along bronchi and their branches,
and those in subpleural space. This one was 7.13 subpleural among these foreign materials. That's PVA. No such foreign materials are seen within capillaries. So that's the small vessel, the small artery we've seen the lumen/g,
we can see PVA here. That's the pleural [BLANK_AUDIO] Another vessel enlarged. We can see very clearly the PVA here inside the lumen of the
artery. And that's the diameter of the small artery. The small artery [UNKNOWN] is 138 [UNKNOWN] and this one is 86.25 [UNKNOWN] There's no a such PVA in the airspace. [BLANK_AUDIO] And we found out intravascular thrombosis underwent
organization and that means the process by which foreign material replaced by granulation tissues, and recanalization I don't think it is recanalization but vascularization. The formation of new vascular space, so that's the capillary around the [UNKNOWN] plus low foreign material.
So, that's the pathology diagnosis. According to this case, that's my sort one the prior has CTA can help mapping a normal systemic artery feeding the C lung, especially B-P shant, and appropriate embloic materials is very important for
effective embolization. So [UNKNOWN] is useful, and usable, and size, a safe size of embolic particle. Now the common sense is unless you've got larger than 350 mil is safe but I use a lot 100 and 200.
So, what is the safe side? I don't know. I think needs more pathological observation to prove it. And, PVA is not a permanent embolic material according to my case and VAE may confine clinical thinking and many doctors are saying VAE, is okay for control the bronchial artery breathing.
But we do a lot MBSA embolization. So we use PAE as a interventional name for hemorrhage interventinal treatment. Everything is okay. [LAUGH] So I think it's time for terminology change.
[BLANK_AUDIO] We don't think BAE is enough to be supplied this per season. >> Right. I understand what you're saying that the word Bronchial Artery Embolization implies that you're permanently blocking the arteries and stopping
bleeding, and in fact if you look at the tissue what you're saying is recanalization or vessel in growth across, and so is not permanent occlusion of the arteries. Very good >>So, that's where the CT in our hospital
now. >> We expand the courage book with the body. [BLANK_AUDIO] Okay we'll have to stop there and ask if there's any questions. Dr.
Kampi >> We get new patients who [INAUDIBLE] when you re analyze them, when you preduded them in hand. Was it the same artery completely open and did you have to reambolize that same artery? >> That's quite common.
>> That's what I thought now to follow that up then If you were to embolize the particles until there is almost stasis, almost no flow. Then you put in either blue [INAUDIBLE] either blue or or anus.
>> No. >> If you did that you think that will change the possibility of recumbolization in that statement. >> [COUGH] >> Maybe. I don't have experience about that.
>> You know of anyone who has done that? >> No >> I think that historically it's being fear of spinal artery complications which has kept people, right? But it depends where the catheter is delivering the embolic.
But the're similar pathologic findings with circle embolics. They've seen the same thing where if you look at the histology late. There's vessel growth around the embolic/g and in fact it's a permanent embolic/g but the vessels find their way back to the target tissue so this is very useful we need to work on learning better, what happens to our embolyte pathologically so I applaud your efforts
done to understand that better, thank you very much.
again it's interesting, the whole session on embolization of chest is cool, because it's not something that comes up everyday. So a lot of times as with this case you kind of have to figure things out as you go because these aren't necessarily things that we do
on a real regular basis. I mean we're not doing bronchial embolization everyday, we're not treating chest wall vascular malformations everyday. So this is the lady who had a cough, it wasn't getting better, she kept
chest x-ray and had this right infrahilar mass here and of course we're not to have a CT scan and you can see here that she's got massively hypertrophied bronchi arteries here and this structure here which looks a little strange. And so get some 3D reconstructions of this, so you can see this
incredible nest of hypertrophied bronchi arteries here, and then this aneurysm, so eventually we kind of figured out from the recons that this was actually a bronchi artery to pulmonary artery fistula. No history of trauma or infection just probably congenital with a big bronchial artery aneurysm right next to the fistula.
And that's the only way that you would get obviously a bronchial artery to get to be that big if you have shunting from a high flow to a low flow high pressure structure, so this is definitely something that the surgeon weren't really excited about looking at.
This was a relatively young lady, and even though she was healthy and everything, they said let's see whether we can embolize this. And just, I think basic principle whenever, except the pulmonary AVMs, which I really architecturally AV fistula when you're treating
AV fistula, it's always nice to be able to get access from both sides to have control of the situation as best you can. So in this situation, we went first. So here's coming from the aorta side from the bronchial artery side. Just the really predicted well by the CT.
Again, huge aneurysm here after this just a few turns of the bronchial artery and then a big fistula between the bronchial artery aneurysm and the pulmonary artery. So we started by after that ago, went on pulmonary artery side and we found our way back into this aneurysm and this diameter
here of this connection between the bronchial artery aneurysm and pulmonary artery was 24 millimeters, it was huge. And we so obviously way too big for any [UNKNOWN] actually not too big potentially for an ASD occlusion device, but the problem was that
the delivery system to try and get an ASD occlutor across, that's what she actually tried to do, wouldn't make this last big turn, into this structure. So we kind of aborted that, we couldn't close it that way, and went
to work then starting to really basically embolize this from both directions so we first of all tried with a microcatheter as far as we could from the, the arterial side and tried put some coils we shot one through all the way into the pulmonary artery and it didn't do anything so then started working from the pulmonary artery side to close down
that big aneurysm and just packed a bunch of 20 millimeter next to another other coils into the aneurysm and then also left a bunch of coils in the bronchial artery and this was the sort of end result of that and she actually had, it was hard to follow her obviously with CT cause of the coil, cause of the artifact from all the
coils and everything but she did actually really well and we followed her for a couple of years in clinic and then discharged her because she was doing great and there was no evidence recurrence. So kind of a weird case but I think one of the principals from this is whenever there is an AV fistula you can have access from both sides.
It gives you the options Just that you need to really be able to have control of the situation and try to fix it. Because ever seen anything like this kind of a weird,
bit of time, before I move to the next speaker. This is a pulmonary artery pseudoaneurysm,
We don't see these a lot. I don't have, it was an older case, but this was, it was from a Swan-Ganz catheter. So the patient had a big pulmonary artery aneurysm from a Swan-Ganz catheter. It's so big, you'd think, man that's just gonna be easy.
You do a pulmonary angiogram, and you get in there, and you coil it. A bunch of us tried over multiple sessions, we just, we couldn't get into it. And so we just ended up doing a percutaneous access to that, and we're able to coil it that way. So that's another thing
to consider. We use coils, I guess if you had a small neck, you could consider using thrombin or other types of agents like glue. But we had to resort to that. And it such a big aneurysm, and then it closed up pretty nicely. So those are rare, they're often associated with nowadays Swan-Ganz catheters, but they used to be associated more
with TB, so Rasmussen aneurysm. >> Can I just make a comment? Before you leave the bronchial arteries staff like think yeah, you said a couple of things, I just wanna clarify. First of all, I think a lot of the diseases that we get asked, that a lot of people will present with hemoptysis, bronchial embolization use the first line treatment. There are some things where their difference is go for surgery,or variation or medical treatment or whatever. But for a lot of these people that have chronic inflammatory conditions, chronic [UNKNOWN], tumor,[INAUDIBLE AUDIO] whatever really bronchial artery embolization is a treatment of choice. And you really aren't[INAUDIBLE AUDIO] your options. So I guess I wanted to really make a comment about, just to make a comment about, do you only take people for bronchial embolization if they've had massive hemoptysis or if you've got something, let's they've got a big chronic [UNKNOWN] and then start having a little bit of hemoptysis, they've got this big risk factor, right? Do you absolutely say, hey, this person hasn't bled enough, so I'm not gonna do the embolization or do you say, look this is kinda of a herold lead, and I'm ready to go ahead and take them in and do this? >> Yeah, that's a great point. And we absolutely try to get to these before they go down hill. Absolutely, especially cystic fibrosis patient. It's just amazing these patients, they can tell, they can almost localize it when they start having
hemoptysis. They know when it's gonna get bad. So a lot of times, they'll call their pulmonologist and say, oh my hemoptysis is getting worse. It's not masses/g, they're not even in the hospital yet. Then we get a call and say hey, let's get work, it's not gonna get
better on it's own, and you're just waiting for it. Another thing especially, to keep a good relationship with your clinical colleagues, and your diagnostic radiology colleagues, just like when they see an abscess on a CT on Friday afternoon,
you wanna get the heads up about it. And then may be you can call the ER, hey, do you guys think you're gonna wanna drain here? Just like when they see a case like this with a huge aspergilloma, cystic fibrosis, the indication for the study is hemoptysis, maybe make a call say,
how's this patient being managed with hemoptysis? How are they doing? Are they gonna need to go to the ICU? You'd much rather take them to your angio suite, before they're in really bad shape, and then your anesthesia support, and all that so, I mean it's
a good point. Okay, Charles you wanna go next? Sure, okay. >> Just have a question. >> Yeah. >> This a hard one. I find it really hard, finding it, and fitting in it and whatever. I need tricks, other tricks, a really hard patient scan and see who gets in, not blinded, whatever. >> Yeah, no I think, these can really be technically challenging.
Sometimes you feel like you can get into, you just see the artery, know exactly where you go, you wanna get in there, and then you can never get distal enough, you don't feel comfortable embolizing, and I'm gonna shower say
aorta with particles, stuff like that, so. I think the most useful thing for me, was to have the CT, and to get an idea of the anatomy. The other thing is, in my practice, I don't do a lot of peripheral
arterial work, but with doing these, I like to use guiding catheters and guiding sheaths a lot, just to help direct catheters more. I don't have a ton of experience for that, cuz I usually for like a interventional oncology application. The other things I'm doing, I don't need those. I just go right to a five French catheter, and
get them what I need to. But some of the guiding catheters that have the right shape, I think helps stabilize everything, and just help you find the thing. I don't know, if you guys have any technical tricks, when you have
tough bronchial anatomy. >> So it depends on the condition that you're treating for a lot of our patients. We're a big CF center, so we see a ton of patients with CF. And these bronchioles tend to be fairly hyper to feed. And it doesn't tend to be as much of a challenge, to get at
least a five French catheter into the origin. And then run a microcatheter through that, to get a little more distal for your embolization. For the more challenging ones, if you're having a hard time localizing it, that's the time that we'll go ahead and do a non selective aortagram, and try to find it that way.
Particularly, if you don't have a CTA in advance. Bill, do you have any pointers? >> I think, I agree with what you said. I think a little hard, first of all, if you know where to look, and you're looking at the right place, and you're not finding bronchial arteries,
it may not actually be the source. Usually with the bronchial artery the source of the hemoptysis is [UNKNOWN] And if you look in the right place you can find a [UNKNOWN].I think the hard ones technically for me are when it's [INAUDIBLE AUDIO] it has a [UNKNOWN] arch and the bronchial origins are starting to be [INAUDIBLE AUDIO] Those ones are starting [INAUDIBLE AUDIO] harder. [INAUDIBLE AUDIO] So that can be hard. You're trying to put your catheter [INAUDIBLE AUDIO] I like the Nickleson in my face. That kinda stuff and [INAUDIBLE AUDIO] I think if you just, If you look in the right [INAUDIBLE AUDIO] But there can be [UNKNOWN] sometimes.
Here's a companion case.
So take a look at this. This is a young female. She had a large subcarinal mass. And then she went for a VATS biopsy. And then started getting uncontrollable hemorrhage. So take a look at this. First, I read diagnostic too and I read chest. Try to think first in your head, where you think this might be.
This is a contrast and hair study. Big, solitary subcarinal mass in a 26-year-old woman. She goes in for a biopsy. They've uncontrollable bleeding. She gets sent then to us, to just basically try to control the bleeding. Now look at how vascular this is.
You could tell by it's location, that it's gonna really get a lot of supply off the bronchial arteries. And then you could see nicely, the enhancement, just from the CT, and how that correlates really well with the bronchial anatomy. We embolize the hairs/g one. And then here's another artery, how big that is, and it's showing nicely the perfusion.
We embolized it, for the goal of just stopping the emerging hemoptysis that was occurring. This is a case of Castleman's disease, angiofollicular lymph node hyperplasia. But turns out over time, this thing started to shrink, and we followed it every six
months. She was on and off some of these different therapies, you can have from it, but over time this did go down, so. That may in your mind think, well. hey, we do a lot of embolization for liver tumors. Can you do embolization for lung cancers or tumors in the
chest? So some groups have written that up. I don't have any first hand experience with it. But a group has looked at RFA with bronchial artery chemoembolization, right? So they've/g a chemoembolization they do in RFA.
Now the other question is, which artery do you put the key find? Here's another group, and they looked at transpulmonary chemoembolization, where they gave mitomycin C and iodized oil with particles through the pulmonary artery.
So these are all things maybe you wanna consider. If you have a research interest in it too, that's definitely not widely accepted, but people are looking at those things as well. I mentioned getting a CT, I really think it's useful.
We're so used to having a lot of pre procedural imaging, that it can really help you during your procedures. You might identify pathology that's not seen on chest X-ray or bronchoscopy. They may help you identify interstitial lung disease, and the location. So the group looked at how helpful that was. And it was quite helpful to have high rise CT.
The benefits of getting a CTA, it might help you show the bronchial artery number. As we talked, there's a lot of variability about bronchial artery anatomy, the location, the orientation.
Maybe there's an AVM. Maybe there's alternative suppliers. Maybe there's an aneurysm, they're rare. So it's just, it's really helpful to know before you go in there, how it looks. So when you get a CT, and then you know exactly
kinda, how are things supposed to look on my angiogram, when I get in there, and is it covering the right area? So if the patient's stable enough, I strongly recommend getting an angiogram. There's a study looking at the evaluation, a bedside evaluation with CT on that, and it really helped lateralize and localize these cases.
And then also modified treatment in some cases. The other thing I like is, sometimes especially when, if you're doing patient set, the more for cancer than bronchiectasis, the bronchial arteries aren't really that hypotrophied, and it can
be a little bit difficult to get into them. I like having the anatomy ahead of time. And then I know what type of catheter I'm gonna use. And I know a little bit, what angle everything's gonna be coming at. So I can have a little bit of a game plan beforehand. When you see it's really pointed, more superiorly, than we
can choose the right type of reverse care of catheter, you get in there. So it's really, it just really helps a lot. And so, just to, we're gonna move on from bronchial artery embolization to some of the other embolotherapies in the chest.
But just remember that massive hemoptysis is commonly seen with bronchitis. When you have massive hemoptysis, it's most commonly associated with bronchitis or bronchiectasis. And even though it's not really a first line treatment, it has a good safety profile, and success rate for malignancy. And recurrent hemoptysis,
be prepared for it, and then that might affect what you're gonna use to treat it. The sources of bleeding is typically the bronchial arteries. The preprocedure CT is extremely helpful for planning. Beware of rapid
shunting to the systemic veins. You could consider coils or just using larger particles to close the shunt in larger cases. I've one companion case, cuz I have a little
So this is a case, this is a male, 75-years-old with lung cancer in
the left lower lobe, and he's getting chemo and radiation. And then starts to develop massive hemoptysis. He's too unstable for bronchoscopy. So he gets sent to us. And here we go, here's a big mass. It's very near the mainstem bronchus bifurcation. So we go right to our bronchial embolization which shows bronchial artery, and the blush that you get from the tumor there. And then we go ahead and
embolize it. And it was successful. We do this usually with moderate sedation, as I'm sure most of you do. After the procedure though, in the holding room, he developed altered mental status. He gets a full work up. And it turns out he get's a small stroke, likely related to our procedure.
A lot of different ways that you could think this might have happened, maybe at some point when, if we were working up in the arch, something could have happened. But I wanna show you some cases, and alert you to some things that might happen that could cause this. So one is shunting. Now we didn't really see it that well, on that
bronchial artery embolization, I showed there in the left. But here's a different case, patient with chronic lung disease. And here we're doing an embolization in the bronchial. And you can clearly see the pulmonary venous drainage, and how easily using particles that would go through. So when you guys see shunts, like Charles,
what do you do if you're doing one of these, then you see a pretty obviously shunt like that, how do you proceed? >> I'm sure you'll serve it with large particles. >> Large particles. And Bill how about you? >> Yeah, so I was gonna ask you. What did you use in that first case? What's-
>> The first case, 700, 900 microns embosphere. So the bigger ones, and that still was an issue. So that's a good point. So some people say, if you use larger particles, it'll probably close the shunt, I mean you save. But others have advocated trying to close the
shunt, or just using coils approximately. We'll talk a little bit about difference in using coils and particles there. In this case we used coils. Here's another case where you can see the drainage pretty well. >> One of them, [INAUDIBLE AUDIO] particle and ATR, bring them together [INAUDIBLE AUDIO] in common cases.
>> Yeah, if you're comfortable using glue, I mean this would be a great instance for that. You could get embolization, and then you wouldn't have to worry about necessarily these small particles getting through.
So just to quickly review massive hemoptysis. The exact definition varies in literature. Most people use about 300 cc over 24 hours. And the mortality results from asphyxiation, rather than just a blood a loss and exsanguination. The management mostly, these patients, if they're unstable, they get ICU support, bronchoscopy/intubation,
and then they try to get them to us. You don't wanna wait too long. When they're more stable then they get a work up like that. So mostly you're gonna be doing these for bronchiectasis, TB, chronic lung diseases, but
lung cancer and other tumors can account for hemoptysis. And bronchial artery embolization in these cases, is still a really viable alternative to treat these. The sources of bleeding is usually the bronchioles, but the pulmonary arteries and nonbronchial systemic arteries can cause a sort/g. In malignancy
maybe a little different. Usually hemoptysis occurs cuz of local necrosis in vessel inflammation, rather than a direct tumor invasion of an artery. And obviously we're talking about embolotherapy. But the interventional bronchoscopy's based on what's locally available, have a lot of
toys to play with too with this. We looked at bronchial artery embolization for malignant hemoptysis, so lung cancer patients. And it's very similar to looking at bronchial artery embolization for all commas/g cystic fibrosis, or patients with bronchiectasis. You have good technical success rate,
low complication rate, but the recurrence rate is relatively high, and so you might need to go back in. The mortality rate is high. Another- >> Have you heard times where, you showed that case when you quoted coil, and where we saw us some shunting, have you heard cases where you quoted coil incision, and you heard/g in your access- >> Yeah, yes we have.
And that's the main hesitation we always have about using a coil. It's like you feel safe at that time, but you know this patient will probably come back. And the chances of you getting back through there are tough, and then you've got to look for other arteries that feed it. Another group looked at as
well, where they had a good technical success rate, but had a high recurrence rate. This is all commas. And the other thing that's interesting to look at, the embolic material look at, it's all over. Even the same groups are using combination of gelatin and PVA,
some glues out there, coils. So I think there is a lot of different options out there for you. And it's a memory of a good clinical success rate, but your recurrence rate is gonna be a little bit higher.
So these are some of the complications that we mentioned, the CNS complication. One other thing is the anatomy, and the bronchial artery anatomy, it can be variable. Mostly we're gonna be looking in the descending aorta around like
T5, T6. Now remember the bronchial arteries also supply the visceral pleura, great vessel vasa vasorum, mediastinum, middle third of the esophagus. There's an abstract in one of the other sessions, a group from Asia, they made a point to look for the esophageal artery to
try to embolize that, from lower lobe branches that they were doing. A lot of these are, the remaining 20% are gonna be from either thoracic or abdominal branches. And then the bronchial venous return is via the pulmonary veins. But there is some minor drainage to the SVC, the azygos etc.
But you shouldn't see the rapid shunting. You should see like in a normal angiogram, the venous phase come a little later, not a direct thing. So, here's just some other drawings to show nicely the anatomy. And there's a lot of variabilities, especially when patients have
advanced lung disease, and you get a lot of neovascularity. And then you eventually can develop nonsystemic bronchial feeders like the internal mammary, branches of subclivian, the inferior phrenic artery, these can all feed there. So
just wanted to ask my co-presenters, when we get a case of bronchial artery embolization, we usually identify the bronchial arteries, embolize those, and then if we're happy with that, we're done, and we don't go on a hunt for other arteries.
Do you guys do something similar or do you try to be more complete when you first start? >> In general, we do something, somewhat a better case of my presentation, where we'll show when we do go for other arteries. But usually if the bronchial looks like it's covering the distribution throughout then we'll keep them coming/g. >> Yeah, Phil/g. >> Yeah, I think if it's a first time case, we hit the bronchioles first, and see how the patient responds. There are some patients that are coming back multiple
times. And we know when we absolutely look for some of these transportal collaterals. And especially like you just said is, if the person with perfused lung disease, and if the area they're bleeding from isn't really being perfused in the bronchioles, then I think that makes us fulfill- >> Right. >> Or something- >> Good. So the bronchial artery anatomy, a lot of this comes to a relatively old cadaver study, but these are the main variance of the bronchial artery anatomy. This is the most common. We have an intercostobronchial trunk, and then two left bronchials. But just be aware that there's a lot
of variance of this. And I really like to have a CT scan before hemorrhage. Mostly it's patients where will have, and in cases with hypertrophy bronchial artery, you can usually pick them off the aorta, and I'll show you some cases. So the goal is really to get a durable occlusion without affecting
the capillary bed. There's really no single embolic agent that has shown clear superiority. Most people use particle embolics. The dogma is that metallic coils should be avoided, because you only get a proximal occlusion, you kinda burn your bridge, and then collateral pathways develop. I put a couple of asterisks there. I was at a session
where the group from Pittsburgh showed that using coils, they were using them mostly because of shunts, and they had good outcomes with that. So we'll have to see how that goes. Gelfoam, liquid embolics has also been reported.
Here's a case of, I have asterisks again, but why surgery or just ligating something very approximately doesn't work. This patient had a clip right here. So it did absolutely nothing, right? It just finds a way around there. So it's just too proximal an embolization. You need to get in
there with particles to do it. Here is a patient that had a lung transplant on the left, and in the native fibrotic doing so. When you get called in, the bleeding from the right, to take care of that. And then they don't transplant the bronchi artery. They don't reanastomos/g that. These things find their way to this transplanted lung, over
the bronchial artery there. So it's just amazing how much collateralization can occur, and you just need to be cognizant on that. The other thing people talk about, we talked about a stroke, or other CNS complications of bronchial artery embolization, is
the spinal cord influx. So people are worried about the anterior spinal artery. Just to review some of the anatomy. It courses along the ventral surface of the cord. And you get a bunch of these segmental medullary arteries along the entire course. And it has this classic hairpin configuration.
Now the most prominent of these is the artery of Adamkiewicz. It's usually gonna be lower than where you're looking. So remember, we're gonna be in the T4 to 6 range usually for our bronchioles, but this is gonna be a little bit lower. Though a small percentage maybe off the intercostobronchial trunk.
I don't see these a lot. Here's what it looks like, just off an intercostal, the classic hairpin appearance. You could see it's a little bit lower than we'd be looking at. Here's another classic hairpin occurrence.
I very rarely see it. A fellow then, he went to California, his first week of practice, he said, oh look at my first bronchial artery embolization, and he did see it there. So in these cases, there are a few options. You could be pretty conservative, and basically not treat it.
Some people say, you can go beyond the spinal artery, and try to embolize it, and be very careful about getting any reflux, which is what we usually try to do. You could maybe try to use coils as well in that case. But you just have to be aware of it,
you gotta look for it, and just make sure that you don't have that complication, when you go ahead. >> You can coil the origin of it. And then use particles for your [INAUDIBLE AUDIO]. >> Okay, yeah, so that's a good point. You could coil it near the
origin, then protect that, and then get your particles to there. And then the coiling at the origin won't cause an influx, cuz you're not causing ischemia there.
or two more. This is kind of a wild case, this is a gentleman that came in with a huge chest wall AVM, 41-year-old gentleman who came to the emergency department complaining of chest pain and a mass and
he said the mass had been there for a long time, noticed it started to grow about three years earlier. He was going though some social issues, I think he was going through
a divorce and moving in back with his mom and so forth and so he just never did anything about it until it started really causing him a lot of pain, and here's one image from the CT scan and you can just see this pretty sizable AVM that he had on, anterior chest wall.
So he never saw an MD for the mass, had really significant growth over the past two months, limited range of motion of his right arm, paresthesias of his right hand, here's some additional CT images
and had this pretty sizable aneurysmal component to it, but again there is just this really massive chest wall AVM. So in this particular case, this is a case done by one of my colleagues we knew that we weren't going to be able to completely embolize
this entire AVM in a single setting, so we went in to it knowing that we were going to stage the procedure. And we started with the area that was in most concern namely this large aneurysmal component. So we went in with the 5 French diagnostic
catheter and a micro catheter and started selecting multiple branches that were supplying this AVM, and then embolizing it with glue. This is after the first session, this is showing some of these glue casein, his pain actually got significantly better and he was able to go home although he still
had limited range of motion and paresthesias in his right arm. So we gave him a rest and I can't remember exactly and I can't remember exactly how long it was I think it was a couple of weeks and we brought him back and we started working on some of his shoulder AVM and again this was a very high flow lesion so you can see injecting through this micro catheter how quickly some of these stuff is
getting washed out. But again we embolized it with glue. You can see a pretty sizable glue cast here and that's a pretty convectional way to treat these AVMs. And just go in and use glue or some prefer to use alcohol, although
alcohol has pretty high complication rates but it does tend to be pretty effective, now the question becomes for these AVMs for peripheral AVMs is there a better way, and there has been several studies that have looked at treating high flow vascular
malformations from the venous side rather than from the arterial side, and here are just pictures from this article. This is Dr. Jackson who is a big advocate of treating high flow arterial venous malformation by sclerosing the venous outflow of vessels. And so he put an occlusion balloon up.
It gets basically venous outflow spaces and then injects sort of like a retrograde into the outflow veins and sclerocism and has had very impressive results. So I guess my question to the audience is when you're faced with somebody who has very complex high flow AVM's, should we be treating them from the arterial side or
should we start looking at treating them from the venous side? I don't know. Does anyone have any comments? >> I started doing a lot more of these from the venous side. The rationale that you can get rid of that sum, it will [INAUDIBLE]
while this complex ones you get in there and you feel like you're touching 5% of that and it's nastier and it's dangerous other arteries are occluded. It does concern [INAUDIBLE]. Does any one else have any comments. >> Yeah I think it depends on the architecture and whether or not you can consolidate either into [INAUDIBLE] venous, consolidate
[INAUDIBLE] >> Okay, all right,
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