选择性动脉栓塞术治疗支气管扩张咯血患者的效果分析

Clinical effect of selective arterial embolization in treatment of hemoptysis caused by bronchiectasis and correlation factors analysis of recurrent hemoptysis

目的选择性动脉栓塞术(SAE)在支扩咯血治疗中的价值逐渐得到重视。文中探讨SAE治疗支气管扩张咯血患者的疗效,并对咯血复发的相关因素进行分析。方法收集阜阳市人民医院2016年3月-2017年1月收治的53例行SAE支气管扩张咯血患者临床资料,包括手术情况、术后止血率、相关并发症及责任血管数量、来源和造影表现等。分别采用Kaplan-Meier检验和Cox回归模型对介入术后止血率的影响因素进行分析。结果53例患者均成功实施SAE,共栓塞136支咯血责任动脉,每例1~5支,其中1支7例、2支19例、3支18例、4支8例、5支1例。在136支病变血管中,92支(67.6%)为支气管动脉,44支(32.4%)为非支气管体循环动脉(NBSA)。51例栓塞后即刻止血,止血率为96.2%,2例咯血减少(责任血管数量分别为3支和4支,均为重度支气管扩张)。无患者出现截瘫等严重并发症,5例患者出现不同程度的胸痛,经对症处理后缓解。本组患者随访期间共11例咯血复发,复发率21.6%。其中6例患者再次接受SAE治疗,截至随访终点均未出现咯血复发。全组患者半年、1年和2年一期累积止血率分别为98.0%、96.1%和81.8%,二期累积止血率分别为98.0%、98.0%和93.9%。单因素分析显示,不同病变血管数量(RR=11.577,95%CI=1.481,90.508)、支气管扩张分级(RR=18.637,95%CI=5.387,64.479)和栓塞剂材料(RR=0.163,95%CI=0.035,0.756)患者的止血率差异有统计学意义(P<0.05)。Cox多因素分析显示,病变血管数量、支气管扩张分级和栓塞剂材料是介入术后止血率的独立影响因素(P<0.05)。结论SAE治疗支气管扩张咯血患者安全、有效,具有较好的中远期止血率。NBSA是支气管扩张咯血的重要来源。其彻底栓塞有助于保证疗效和减少复发。病变血管数量、支气管扩张分级和栓塞剂材料是介入术后止血率的独立影响因素。

Objective To investigate the efficacy of selective arterial embolization(SAE)in the treatment of patients with hemoptysis due to bronchiectasis,and to analyze the related factors of hemoptysis recurrence.Methods A total of 53 patients with bronchiectasis and hemoptysis treated in our hospital from March 2016 to January 2017 were collected,and SAE was performed on all patients.The operation situation,postoperative hemostasis rate,related complications and the number and source of responsible vessels and angiographic manifestations were recorded.Kaplan-Meier test and Cox regression model were used to analyze the influencing factors of hemostasis rate after intervention.Results All 53 patients successfully underwent SAE.A total of 136 hemoptysis arteries was embolized,1 to 5 in each case,including 1 in 7 cases,2 in 19 cases,3 in 18 cases,4 in 8 cases and 5 in 1 case.Of the 136 diseased vessels,92(67.6%)were bronchial artery(BA),and 44(32.4%)were non-bronchial systemic arteries(NBSA).The direct signs of the responsible blood vessel are contrast medium overflow,and the indirect signs are thickening and tortuosity of the arterial trunk,bronchial artery-pulmonary shunt,and increased,dilated,and disordered distal small blood vessels.Twenty-five patients were treated with gelatin sponge particles and 28 patients were treated with polyvinyl alcohol(PVA)particles.Fifty-one patients had hemostasis immediately after embolization.The hemostatic rate was 96.2%(51/53),and hemoptysis was reduced in 2 patients(the number of responsible blood vessels was 3 and 4 respectively,all of which were severe bronchiectasis).No patient experienced severe complications such as paraplegia,and 5 patients complained chest pain of varying degrees,which was relieved after symptomatic treatment.The 51 patients with successful hemostasis were followed up for 2 to 31 months,with a median follow-up time of 25 months.During the follow-up period,a total of 11 patients experienced recurrent hemoptysis with a recurrence rate of 21.6%(11/51),of which 6 patients received SAE treatment again,and no hemoptysis recurrence occurred at the end of the follow-up.The cumulative hemostasis rates for the first stage of half year,1 year,and 2 years were 98.0%,96.1%,and 81.8%,and the cumulative hemostasis rates for the second stage were 98.0%,98.0%,and 93.9%.Univariate analysis showed no significant difference in hemostatic rate between patients of different genders and ages(P>0.05).The hemostatic rate of patients with different number of embolic vessels,grades of bronchiectasis,and embolic material was statistically significant(P<0.05).Cox multivariate analysis showed that the number of diseased blood vessels,grade of bronchiectasis,and embolic material were independent influencing factors of hemostasis rate after intervention(P<0.05).Conclusion SAE is safe and effective in treating patients with bronchiectasis and hemoptysis,which has a good mid-term and long-term hemostasis rate.NBSA is an important source of hemoptysis in patients with bronchiectasis,and its thorough embolization may help ensure efficacy and reduce recurrence.The number of diseased blood vessels,grade of bronchiectasis,and embolic material were independent influencing factors of hemostasis rate after intervention.