咯血患者病理性内乳动脉参与肺内供血的介入诊疗分析

Pathologic Internal Mammary Arteries Supply to the Pulmonary Lesions in Hemoptysis:Analysis of Endovascular Interventional Management

目的:分析咯血患者出现病理性内乳动脉(IMA)参与肺内供血的血管造影表现和影响因素,探讨对其行经导管动脉栓塞术(TAE)的方法,评价疗效和安全性。方法:336例咯血患者的TAE中,发现30例(9.8%)病理性IMA参与肺内供血。基础疾病包括肺结核19例,支气管扩张8例,支气管肺癌2例,支气管肺癌外科手术后1例,其中2例有先天性心血管病史。IMA插管成功者行TAE,分析血管造影表现、影响因素和插管失败的原因,并随访观察疗效和并发症。结果:共34支病理性IMA,主要表现为主干增粗,分支增多、增生、扭曲、紊乱、肺循环分流等。6支病理性右支气管动脉(BA)异位起源于同侧IMA,2支左IMA发出病理性同侧异位起源BA或心包膈动脉可能。肺结核者均存在以上肺为主的纤维化,相邻胸膜严重增厚粘连,部分合并空洞、曲菌球以及胸壁组织外科手术后改变,1例支气管肺癌者的病灶位于肺上叶。2例有先天性心血管病史者均出现IMA在内的"主-肺动脉侧支"。经股动脉入路,IMA及分支插管失败3例,1例为头臂干和锁骨下动脉严重扭曲,2例为异位起源于右IMA根部的病理性BA。栓塞成功27例,疗效满意,除1例因术前肺功能较差者在术后发生呼吸衰竭外,无严重并发症。结论:诸多因素可致咯血患者的IMA发生病理性改变并参与肺内供血,TAE治疗咯血应详细了解病史、分析基础病变,术中仔细观察血管造影影像,尽量行相应的锁骨下动脉造影。

Purpose： To analyze the angiographic manifestations and influential factors of the pathologic internal mammary arteries （IMA）which supplied to the pulmonary lesions in hemoptysis, and to investigate the technique and to evaluate the efficacy and safety of transcatheter arterial embolization （TAE） of the IMA. Methods ： In a series of 336 patients with hemoptysis who underwent TAE, we found 30 cases （9.8%） whose pathologic IMAs supply to the pulmonary lesions, Patients were pulmonary tuberculosis in 19, bronchiectasis in 8, bronchiogenic carcinoma in 2 and bronchiogenic carcinoma with post - tumorectomy in 1. Among them, 2 cases had supervened congenital cardiovascular diseases. TAE was performed in patients if IMA catheterization was successful. The angiographic manifestations, influential factors and reasons of aborted IMA catheterization were studied. The clinical results and complications were observed in all patients. Results： Thirty - four pathologic IMAs showed hypertrophy, hypervascularization, IMA- pulmonary shunting and anastomoses with other systemic arteries. Six right pathologic anomalous origin of right bronchial arteries （BA） were arised form the ipsilateral IMAs. Two IMAs took off ipsilateral pathologic pericardiacophrenic arteries or anomalous origin of bronchial arteries possibly. All cases of pulmonary tuberculosis had severe pulmonary fibrosis and proximal pleural thickening or complicated with cavity, aspergilloma, and postoperative thorax. One case of bronchiogenic carcinoma whose tumor was located in superior pulmonary lobar. Tow cases had supervened congenital cardiovas- cular diseases who were found ＇ major aorto - pulmonary collateral arteries＇ including the IMAs. Three cases whose selective and hyper - selective IMA catheterization were failure with the femoral approach because brachiocephalic trunk and subclavian artery were evident tortuosity in one and anomalous origin of BA from the right IMA closed to the origin of the subclavian artery in two. The clinical result was satisfactory and no severe complications were occurred. Conclusion： Most influential factors can lead to pathologic IMA and supply to the pulmonary lesions in hemoptysis. During TAE for hemoptysis, patients＇ history, lesions and angiographic images should be analyzed carefully and the corresponding subclavian artery angiography should be performed.