White R I, Pollak J S, Wirth J A
Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT 06520, USA.
J Vasc Interv Radiol. 1996 Nov-Dec;7(6):787-804. doi: 10.1016/s1051-0443(96)70851-5.
The recent long-term studies from England, France, and the Netherlands, as well as our own, indicate that transcatheter embolotherapy is definitive treatment for PAVM. More recently, Puskas et al have questioned transcatheter embolotherapy as a primary treatment for patients with PAVM (4,56). Their opinion was based on two recurrences among five patients treated with transcatheter embolotherapy. It is not clear why one of the late recurrences in the series by Puskas et al happened, and the other recurrence could have been dut to early deflation of the balloon. Nevertheless, we believe that the collective experience in the larger series reporting on transcatheter embolotherapy of PAVM supports the use of embolotherapy as a primary modality of treatment. Because many patients have bilateral pulmonary malformations and many pulmonary malformations will grow with time, repeated surgical intervention is not ideal therapy. The recurrence rate of 8% reported by Remy et al using coils, and 2% reported by Pollak et al using balloons and coils supports our contention that transcatheter embolotherapy is durable and should be the initial treatment. Also, recurrences are easily retreated by transcatheter embolotherapy with durable results (54). We favor detachable balloons over coils for occluding PAVMs because immediate cross-sectional occlusion of the segmental artery is obtained in a position that preserves the most normal branches. The necessity for repeated introduction of coils, when using the coil method, contributes to longer procedure times with an increased risk of air introduction and, in our experience, a greater risk of postprocedure pleurisy. At the same time, we appreciate that approximately 70% of PAVMs can be occluded equally well with balloons or coils. We also believe that coils have unique advantages over balloons in specific anatomic situations including oversized arteries (where coils are the only option) and for occlusion of the aneurysm of a PAVM. As with all forms of embolotherapy, the interventionalist is best served by having more than one option of treatment, which for PAVM includes both balloons and coils. In summary, PAVMs are effectively managed by means of transcatheter embolotherapy. This therapy has been demonstrated to be safe and durable. Careful technique with modifications depending on the angioarchitecture of the PAVM is required. Patients with PAVMs require follow-up at 1 month and 1 year. While observations documenting serial growth of small PAVMs are somewhat limited, there is published evidence to support their growth with time (35,36). Because of these reports and our unpublished observations, we believe that patients with treated PAVM need long-term follow-up every 5 years to detect growth of small PAVMs that will ultimately reach a size where they may cause paradoxical embolization and stroke (1).
来自英国、法国和荷兰的近期长期研究以及我们自己的研究表明，经导管栓塞疗法是肺动静脉畸形（PAVM）的确定性治疗方法。最近，普斯卡什等人对经导管栓塞疗法作为PAVM患者的主要治疗方法提出了质疑（4,56）。他们的观点基于5例接受经导管栓塞疗法治疗的患者中有2例复发。目前尚不清楚普斯卡什等人系列研究中晚期复发中的一例为何发生，另一例复发可能是由于球囊过早放气。然而，我们认为，关于PAVM经导管栓塞疗法的大型系列研究的总体经验支持将栓塞疗法作为主要治疗方式。由于许多患者有双侧肺部畸形，而且许多肺部畸形会随时间增长，反复进行手术干预并非理想的治疗方法。雷米等人使用弹簧圈报告的复发率为8%，波拉克等人使用球囊和弹簧圈报告的复发率为2%，这支持了我们的观点，即经导管栓塞疗法效果持久，应作为初始治疗方法。此外，复发很容易通过经导管栓塞疗法再次治疗，且效果持久（54）。对于封堵PAVM，我们更倾向于使用可脱卸球囊而非弹簧圈，因为在能保留最正常分支的位置可立即实现节段动脉的横断面封堵。使用弹簧圈方法时，需要反复引入弹簧圈，这会导致手术时间延长，增加空气进入的风险，根据我们的经验，术后发生胸膜炎的风险也更高。同时，我们认识到大约70%的PAVM使用球囊或弹簧圈封堵效果相当。我们还认为，在特定解剖情况下，弹簧圈相对于球囊具有独特优势，包括动脉过大（此时弹簧圈是唯一选择）以及封堵PAVM的动脉瘤。与所有形式的栓塞疗法一样，对于PAVM，介入医生最好有多种治疗选择，包括球囊和弹簧圈。总之，经导管栓塞疗法可有效治疗PAVM。已证明这种疗法安全且效果持久。需要根据PAVM的血管结构进行仔细操作并加以调整。PAVM患者需要在1个月和1年时进行随访。虽然记录小型PAVM连续生长的观察资料有限，但有已发表的证据支持它们会随时间增长（35,36）。基于这些报告以及我们未发表的观察结果，我们认为接受治疗的PAVM患者需要每5年进行长期随访，以检测小型PAVM的生长情况，这些小型PAVM最终可能会长大到导致反常栓塞和中风的大小（1）。
