L angiografia ha ancora un ruolo?
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2 Aggiornamenti di Radiologia Interventistica L angiografia ha ancora un ruolo? Roberto Iezzi Dipartimento di Bioimmagini e Scienze Radiologiche Istituto di Radiologia, Policlinico A. Gemelli Università Cattolica - Roma roberto.iezzi@rm.unicatt.it
3 DSA & Pulmonary District Systemic Circulation (Bronchial A.) Pulmonary Circulation Venous Circulation
4 DSA & Pulmonary District
5 multiple causes: parenchymal diseases airway diseases vascular diseases Tubercolosis Bronchiectasis Chronic Inflammatory Diseases Cystic Fibrosis Bronchogenic Carcinoma Aspergillosis DSA & Systemic Circulation Hemoptysis Bleeding that originates from the lower respiratory tract (massive: ml/24h)
6 DSA & Systemic Circulation Hemoptysis Pathophysiology: Pulmonary / Systemic A. Diseases that reduce pulmonary arterial supply (chronic PE, vasculitis)
7 DSA & Systemic Circulation Hemoptysis Pathophysiology: Pulmonary / Systemic A. Diseases that reduce pulmonary arterial supply (chronic PE, vasculitis) Chronic inflammatory diseases/neoplasms that lead to neovascularization
8 DSA & Systemic Circulation Hemoptysis Pathophysiology: Pulmonary / Systemic A. Diseases that reduce pulmonary arterial supply (chronic PE, vasculitis) Chronic inflammatory diseases/neoplasms that lead to neovascularization increased bronchial arterial blood supply with hypertrophy and rupture of anastomotic vessels Bruzzi JF, Radiographics 2006; 26:3
9 DSA & Systemic Circulation Hemoptysis Conservative Treatment High mortality rate: 55-95% Surgical Treatment Elective Surgery: mortality of 18% Emergent Surgery: mortality of 40% Najaraian et al. J Thorac Im 1998 Haponik et al. Chest 2000
10 DSA & Systemic Circulation Hemoptysis Systemic Circulation: 90-95% Bronchial Arteries (65-95%) Pulmonary Circulation: 5-10% Other Systemic Arteries (40-70%)
11 DSA & Systemic Circulation Hemoptysis & Bronchial Arteries 70% Desc Ao (Th5-6) Ectopic: Subclavian Internal Mammary Pericardiacophrenic Brachiocefalic Costocervical Trunk Inferior Phrenic Abdominal Aorta Walker CM et al. Radiographics 2015
12 DSA & Systemic Circulation Hemoptysis & Bronchial Arteries normal abnormal < 1.5 mm at the origin = 0.5 mm distally > 2 mm (potential source of hemoptysis) traceability to the hilum is more frequent for bronchial arteries causing hemoptysis (74%) contrast medium extravasation (4-11%)* *Chung MJ, AJR 2006; 186:649
13 DSA & Systemic Circulation Hemoptysis & BAE MDCT Workup Underlying Disease Bleeding Site Predict Culprit Vessel Road map for interventional rad
14 DSA & Systemic Circulation Hemoptysis & BAE First Bronchial Artery Embolization (BAE) J. Remy Ann Radiol 1974
15 DSA & Systemic Circulation Hemoptysis & BAE Embolic Materials Absorbable Gelatin Sponge Spherical Embolics ( micron) Liquid Agents Coils (proximal embolization/aneurysms)
16 DSA & Systemic Circulation Hemoptysis & BAE Results Control of Hemoptysis: 73% - 98% Park HS et al. CVIR 2007 Won S et al. Radiology 2013
17 DSA & Systemic Circulation Hemoptysis & BAE 49yo severe Hemoptysis
18 DSA & Systemic Circulation Hemoptysis & BAE 49yo severe Hemoptysis
19 DSA & Systemic Circulation Hemoptysis & BAE 49yo severe Hemoptysis
20 DSA & Systemic Circulation Hemoptysis & BAE 49yo severe Hemoptysis pre Post (48h)
21 DSA & Systemic Circulation Hemoptysis & BAE 64yo - smokers pre post
22 DSA & Systemic Circulation Hemoptysis & BAE
23 DSA & Systemic Circulation Hemoptysis & BAE
24 DSA & Systemic Circulation Hemoptysis & BAE
25 DSA & Systemic Circulation Hemoptysis & BAE Results Control of Hemoptysis: 73% - 98% Long-term Recurrent Rate: 10% - 52% Park HS et al. CVIR 2007 Won S et al. Radiology 2013
26 DSA & Systemic Circulation Hemoptysis & BAE Recurrent Hemoptysis Tubercolosis, Aspergilloma, Neoplasm Incomplete embolization Recanalization Revascularization by collaterals Progression of the Disease Won S et al. Radiology 2013
27 DSA & Systemic Circulation Hemoptysis & BAE Complications Chest Pain 24-91% Dysphagia 1-18% Dissection of bronchial arteries 1-11% Dissection of aorta 1-6% Spinal cord ischemia 1-6% Park HS et al. CVIR 2007 Won S et al. Radiology 2013
28 DSA & Pulmonary Circulation Pulmonary AVM Direct connection between pulmonary artery and vein 80-90% associated with HHT
29 DSA & Pulmonary Circulation Pulmonary AVM Hereditary Hemorrhagic Teleangiectasia Autosomal Dominant Disorder Vascular Malformations (Skin / Mucous Membranes / Internal organs) Symptoms (Bleeding - symptoms associated with PAVM s)
30 DSA & Pulmonary Circulation Pulmonary AVM Symptoms: Right to Left Shunt Hypoxemia Dyspnea/fatigue Cyanosis Polyglobulia Migraine Often Asymptomatic (30-60%)
31 DSA & Pulmonary Circulation Paradoxical Emboli TIA / Stroke Brain Abscess Pulmonary AVM Complications Conservative Treatment Mortality Rate: 4-40% Treatment: Recommended for Feeding art >3mm
32 DSA & Pulmonary Circulation Pulmonary AVM MDCT Workup Careful Attention to Angioarchitecture Simple (90%) Complex (10%)
33 DSA & Pulmonary Circulation Pulmonary AVM Embolic Materials Coils Detachable (non coil) devices
34 DSA & Pulmonary Circulation Pulmonary AVM 61yo - asymptomatic Simple PAVM
35 DSA & Pulmonary Circulation Pulmonary AVM 58yo chest pain SaO2 94% 60% ox mask Complex PAVM
36 DSA & Pulmonary Circulation Pulmonary AVM
37 DSA & Pulmonary Circulation Pulmonary AVM Sac Embolization Popular in Japan Reperfusion 50% FA vs 0% sac Acknowledge sac embo more time consulming, more expensive FA embo still the Gold Standard
38 DSA & Venous Circulation Retrieval of Intravascular Foreign Bodies First report in 1964 Catheter fracture / migration Right atrium / Main pulmonary trunk / Caval System
39 DSA & Venous Circulation Retrieval of Intravascular Foreign Bodies Successful retrieval reported: % Minor Complications: <6%
40 DSA & Venous Circulation Retrieval of Intravascular Foreign Bodies
41 DSA & Venous Circulation Retrieval of Intravascular Foreign Bodies
42 DSA & Venous Circulation Retrieval of Intravascular Foreign Bodies
43 DSA & Future Prospectives Pulmonary Embolism cases/year in the European Union PE & lower limb deep vein thrombosis (DVT)
44 DSA & Future Prospectives Pulmonary Embolism
45 DSA & Future Prospectives Pulmonary Embolism cases/year in the European Union PE & lower limb deep vein thrombosis (DVT) Low Risk Stratification Intermediate (submassive PE) High (massive PE) BP >90mmHg biomarkers - ECHO - BP >90mmHg biomarkers + ECHO + BP <90mmHg Shock CPR
46 DSA & Future Prospectives Pulmonary Embolism
47 DSA & Future Prospectives Pulmonary Embolism 2014 ESC Guidelines: Massive PE
48 DSA & Future Prospectives Pulmonary Embolism 2014 ESC Guidelines: Low/Intermediate
49 DSA & Future Prospectives Pulmonary Embolism 2014 ESC Guidelines: Low/Intermediate RV/LV ratio > 0.9 is an independent predictor of mortality CM in IVC
50 DSA & Future Prospectives Pulmonary Embolism Goals of Catheter Embolectomy Decrease in pulmonary vascular resistance and pulmonary artery pressure Recovery of right ventricular dysfunction Increase in systemic arterial pressure Improvement of symptoms and survival
51 DSA & Future Prospectives Pulmonary Embolism Catheter-Directed Low-Dose Fibrinolysis Avoids the high risk of major bleeding associated with systemic fibrinolysis More complete thrombus resolution More effective for subacute thrombus
52 DSA & Future Prospectives Pulmonary Chemoembolization Unresectable Primary/Secondary Lung Tumors Transcatheter chemotherapeutic drug injection + Intra-arterial Embolization (feeding artery) Selective CHT Ischemia Tumoral Necrosis
53 DSA & Future Prospectives Mitomycin C Doxorubicin Irinotecan Cisplatin Lipiodol Microspheres
54 DSA & Future Prospectives 17 patients (6, 66.5yo; 44-81yo) 20 nodules (3.2±0.7cm) Primary: 3 - Secondary: 17 SPACE + RFA (to reduce heat-sink effect)
55 DSA & Future Prospectives 67yo Recurrent Primary Lung Cancer (NSCLC) Gadaleta et al. Radiology 2013
56 DSA & Future Prospectives Technical Success: 100% Survival Rate: 53% (Mean FU: 21 mo) Electrical Impedence Electrical Impedence CR (6mo) 65%
57 Conclusions Interventional Radiology & Lung Percutaneous & Intra-vascular Technological Innovation Tailored Procedure (Imaging Workup) Safety and Efficacy Multimodality / Multidisciplinarity
58
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