膈下动脉参与供血的肺部出血性疾病的诊断及介入治疗

Inferior phrenic arteries supply to the pulmonary hemorrhagic lesions:angiographic identification and interventional management

目的观察膈下动脉(IPA)参与肺部出血性疾病病灶供血的表现,评价经导管栓塞IPA 的安全性和疗效。方法回顾性分析18例 IPA 参与肺部病变供血的肺出血性疾病患者的临床和影像资料。患者中肺部恶性肿瘤9例、支气管扩张7例、慢性炎症2例;对参与肺部病变供血的 IPA进行了选择性栓塞术,栓塞剂为聚乙烯醇微球(PVA)、明胶海绵颗粒和微型钢丝圈。结果选择性IPA 造影均显示 IPA 管径增粗、分支增多紊乱和不同程度的新生血管形成,伴有肿瘤血管和肿瘤染色者9例、IPA 供血区对比剂外溢6例、IPA 与肺动静脉异常交通或分流9例、非特异性片状对比剂浓染2例。18例患者的病灶均与胸膜关系密切,病变贴近膈胸膜者11例、纵隔胸膜者5例、下肺外侧胸膜者2例。本组患者均行供血 IPA 的栓塞术,同时栓塞胸廓内动脉7例、肋间动脉3例,术后咯血停止;随访8个月至4年,3例分别于术后1、2、6个月复发少量咯血,经保守治疗后停止;15例未再咯血。结论 IPA 可参与肺部出血性病变的供血,以邻近横隔和纵隔胸膜的病变多见,这是造成支气管动脉栓塞术治疗咯血失败的原因之一,行供血 IPA 栓塞术安全有效。

Objective To describe the manifestations of the inferior phrenic arteries （IPA） supply to the pulmonary hemorrhagic lesions and to evaluate the safety and efficacy of transcatheter arterial embolization （TAE） of the IPA. Methods The clinical data and imaging findings of eighteen patients with the additional blood supply to the pulmonary hemorrhagic lesions from the IPA were evaluated retrospectively. The causes of the bleeding were lung malignancies in 9, bronchiectasis in 7, and chronic inflammation in 2 patients. TAE supplementally was performed in patients with IPA supply to the pulmonary lesions, using polyvinyl alcohol particles, gelatin sponge particles, and microcoils. Results Selective arteriogram demonstrates an enlarged IPA, with numerous branches and hypervascularity in all 18 cases, with tumor staining in 9, the contrast material extravasation in 6, and non-specific staining in 2 cases. In addition, IPA-to-pulmonary shunting was found in 9 cases. All the lesions supplying by IPA were adjacent to the pleurae, including adjacent to the diaphragmatic pleura in 11, the mediastinal pleura in 5, and the lateral pleura of the lower lobe in 2 cases. Technical success of IPA embolization was achieved in the 18 cases. Embolization of other nonbronchial systemic arteries （the internal thoracic artery in 7 and intercostal artery in 3 ） was performed at the same session. All bleeding ceased immediately after supplemental IPA embolization. Follow-up time ranged from 8 months to 4 years. Mild recurrent hemoptysis occurred in 3 patients at 1,2, 6 months respectively, after the embolization. These patients were responsive to conservative management. Recurrent bleeding did not occur in 15 patients during the follow-up. Conclusion The pulmonary hemorrhagic lesions, especially adjacent to the diaphragmatic and mediastinal pleurae, can be supplied by IPA, and may result in clinical failure following BAE. Supplemental TAE of IPA is a safe and effective adjunct to BAE in the management of bronchial bleeding supplied by IPA.