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УДК 616.127- 089
Endovascular embolization of thyroid arteries with grave's disease
ArzykulovZh.A., Zhuraev Sh. Sh., Shokebayev A.A., Ormanov B.K., Lee A.I., Imammyrzayev N.E., Aliev A.K.
Background: The purpose of this study is to improve the results of treatment of patients with Graves' disease by applying Roentgen endovascular embolization (REE) thyroid arteries.
Materials and methods: REE thyroid arteries, we used as an independent method of treatment GD. Following this procedure the treatment of 27 patients received for the period from 2012 to July 2014 y. All patients hospitalized with a confirmed diagnosis. Among the 27 patients had 5 (18.5%) men and 22 (81.5%) of women aged 22 to 56 years. Treatment outcome was evaluated, including surgical complications, thyroid function, quality of life and patient satisfaction with the surgical result.
Results: Serious complications after REE were noted in 6 (22,2%) patients had severe pain on the front of the neck, parotid region, lower jaw, headaches, which were stopped analgesics, pain duration of 3-4 days. In 3 (11,1%) cases after embolization were transient phenomena after embolization thyroiditis, due to intoxication syndrome, which was also antibacterial cupping therapy. Length of hospital after surgery for thyroid nodules ranged from 5 to 7 days.
Conclusion: REE thyroid arteries effective treatment for Graves' disease is contemporary minimally invasive treatment. Its use is possible in severe forms of GD and the presence of severe concomitant diseases. The method facilitates fast enough cupping effects of hyperthyroidism, thyroid volume reduction. After embolization of thyroid arteries determined characteristic pathological changes in thyroid tissue, showing the effectiveness of the treatment.
Introduction
Thyroid disease - one of the most common diseases occurring in 5-15% of the population.
Drug therapy of diffuse toxic goiter has a sufficiently low efficiency and leads to a stable disappearance of hyperthyroidism only 40-45% of patients.
Kazakhstan also remains relevant surgery diffuse toxic goiter, which has a number of drawbacks, such as operating injuries, postoperative scar in the visible part of the neck, as well as possible violation of the vote. Total number of complications in the surgical treatment of diffuse toxic goiter ranges from 3 to 35%.
Recently, at leading universities and clinics in the USA, developed countries in Asia and the Pacific, as well as in some European countries are increasingly used innovative endovascular and endovideosurgical techniques in the treatment of various pathologies of the thyroid gland. These techniques are less traumatic and surgical treatment are based on the latest achievements of modern medicine. Endovascular embolization of thyroid arteries can make an involution of the thyroid tissue, which has a good therapeutic effect with diffuse toxic goiter and can be either a definitive treatment or like a preoperative stage before resection of the
thyroid gland.
Materials and methods
REE thyroid arteries, we used as an independent method of treatment GD. Following this procedure the treatment of 27 patients received for the period from 2012 to July 2014y.y. All patients hospitalized with a confirmed diagnosis, history of the disease ranged from 1.5-7 years. Preoperative evaluation included a research the functional condition of the thyroid gland, producing quantitative determination of thyroid hormones - T3, T4, TSH. Instrumental methods of research included: thyroid ultrasound to assess gland volume, the presence of thyroid parenchymal changes and radiological method - plain radiography. Indications for REE thyroid arteries were: 1) GD with severe concomitant diseases (myocardial infarction, recent stroke, hypertension stroke, heart disease, etc.), when operational risk is greater than the expected benefit to the patient. 2) Complicated forms of GD with decompensation (cardiomyopathy, chronic hepatitis). 3) If the patient's categorical refusal from traditional operations for cosmetic reasons. Among the 17 patients had 2 (14.3%) men and 15 (85.7%) of women aged 22 to 56 years. In the allocation of patients according to the degree of goiter classification O.V Nikolayev: goiter II degree - in 4 patients , III degree - in 9 patients, IV degree - in 4 patients.
To conduct REE, we used the traditional puncture access via the common femoral artery to the right with the installation Seldinger introducer. Through the introducer sheath was introduced angiographic catheter type «Pig Tail», which, together with the conductor under X-ray control was delivered to the aortic arch. Thoracic aortography and selective angiography of the aortic arch branches were performed to determine vascular architectonics of blood supply of the thyroid gland.
As a contrast agent used non-ionic iodine-containing solution, which does not bind to blood proteins and excreted by the kidneys unchanged. Research was conducted in
Figure 1 - Embolus «Biosphere» for thyroid arteries embolization
Журнал Национального научного центра хирургии им. А.Н. Сызганова
5
Figure 2
Figure 3
the frontal and lateral projections. REE thyroid artery were performed using embolus based on polyvinyl alcohol and gelatin Bead block size 700-900 jm, «Biosphere 700-900 |jm» (Figure 1). Length of hospital after surgery for thyroid nodules ranged from 5 to 7 days.
Results: Serious complications after REE were noted in 6 patients had severe pain on the front of the neck, parotid region, lower jaw, headaches, which were stopped analgesics, pain duration of 3-4 days. In 3 cases after embolization were transient phenomena after embolization thyroiditis, due to intoxication syndrome, which was also antibacterial cupping therapy. In the study of the hormonal status of free fractions of T3 and T4 in the dynamics on the 5th day in almost all cases a marked increase in the level of hormones, but clinical patients reported satisfactory general condition was not thyrotoxicosis phenomena. (Table #1)
Table#1
Free Т3 (nmol/l) Free Т4 (nmol/l)
№ Before On After Before On After
REE 5-th day 6 weeks REE 5-th day 6 weeks
1 17,03 50 4,03 53,62 100 11,27
2 8,83 2,87 2,83 39,95 261,6 14,70
3 3,89 8,48 5,89 16,70 25,18 9,85
4 13,0 29,57 6,0 29,31 100,0 16,90
When monitoring the Doppler ultrasound scan of the thyroid gland 7 - night revealed the absence of blood flow in the gland, and thyroid volume reduction is 30-35 %. (Table#2)
Table#2
№ Before REE On 5-th day after REE
1 30,18 cm3 18,6 cm3
2 20,03 сф 15,8 cm3
3 27,5 cm 3 15,1 cm3
4 30,2 cm 18,2 cm3
On the 7th day after the REE held needle aspiration biopsy of thyroid. Histological research noted the destruction and melting of the cells of the follicular epithelium with mild polymorphism nuclei and degenerative changes. (Figure 2, Figure 3)
On the 30th day after embolization, downward trend in the levels of the hormone. (Table#1). Achieved clinically compensation phenomena thyrotoxicosis, thyreostatics therapy abolished.
Conclusion: REE thyroid arteries effective treatment for Graves' disease is contemporary minimally invasive treatment. Its use is possible in severe forms of GD and the presence of severe concomitant diseases. Efficiency of
endovascular occlusion of the arteries of the thyroid gland, as a treatment for diffuse toxic goiter, confirmed by morphological research of received material. The method facilitates fast enough cupping effects of hyperthyroidism, thyroid volume reduction. After embolization of thyroid arteries determined characteristic pathological changes in thyroid tissue, showing the effectiveness of the treatment. REE thyroid arteries i s an effective method in social and economic terms, using this method has l ed to the recovery of all patients with rehabilitation and improve quality of their life.
References
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Грейвс ауруы кезндег калканша без артериясынын эмболизациясы.
Арзыкулов Ж.А., Жураев Ш.Ш., Шокебаев А.А., Орманов Б. К., Ли А. И., Имаммырзаев Н.Е.,Алиев А. К.
А.Н.Сызганов атындагы улттык гылыми хирургия орталыгы, Алматы каласы, Казакстан
Кiрiспе. Грейвс ауруымен сыркаттанатын наукастарга калканша без артериясынын Рентгенд1 энедоваскулярлы эмболизациясы (REE) квмегмен емнщ ти1мд1л1г1н арттыру зерттеу жумыстарымыздын нег зг максаты болып табылады.
Материалдар жэне эд1'стер. ГА ем1ндег1 нег1зг1 эд1стерд1н б1р1 рет1нде б1з REE колдандык. 2012 жылдан 2014 жылдын ш1лде айы аралыгында осы емшара квмегмен 27 наукас емдел1п шыкты. Барлык наукастар нактыланган диагноздарымен ауруханага
жаткызылды. 27 наукастын арасында 22 жэне 56 жас аралыгындагы 5 (18.5%) ер жэне 22 (81.5%) эйелдi камтиды. Хирургиялык аскынуларды, калканша безнщ кызмет/', вм1р сапасын коса алганда наукастардын хирургиялык ем нэтижелер/'не канагаттануы коса багаланды.
Нэтижелер1: REE кей1нг1 kyрделi аскынулар 6 (22,2%) наукаста ауыру агымы 3-4 kyнге созыла-тын, ягни анальгетиктер квмег/'мен басылатын алдынгы мойын,кулак калканы маны безi, твменг1 жак, бас ауруынын каркынды ауыруы токтатылды. 3 (11%) эмболизациядан кей/'нг/' тироидит жагдайы эмболизациядан кей1нг1 втпелi квр1н1 с бер/'п,
антибактерилды еммен ыгыстырылып, интоксикация синдромы жойылды. Наукастардагы калканша безнщ ем/'нен кей1нг ауруханада ем кабылдауы 5-7 кунд1 курады.
Корытынды: Гоейвс ауруынын REE заманауи калканша без артериясынын минималды инвазивт емд1к эд/'сi болып табылады. REE ГА ку,рделi жэне косалкы курделi турлер1н1н ем/'нде колдануы ти/'мдi болып саналады. Бул эд/'с гипертиреоидизм, калканша без квлемнн к/'ш/'рею/'н жылдам басу уш1н колдануда вте ти/'мд/'. Калканша без артериясынын эмболизациясынан кей нг калканша без ндег патологиялык взгер стерд сипаттауга, емнщ тшмдлан кврсетуге эсер/'н тиг1зед1.
