Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization

Bronchial artery embolization in life-threatening massive hemoptysis

Background

Massive hemoptysis is a potentially life threatening respiratory emergency and mandates immediate investigation and intervention. There is no universal consensus regarding the optimal management of these patients, and there are no large series of patients studied.

Objectives

Here we reported thirty Iranian patients who were managed with bronchial artery embolization.

Patients and Methods

All the patients had already been assessed by computerized tomography (CT) to localize and delineate the underlying etiology except 2 patients who had not undergone CT scan.

Results

Tuberculosis, bronchiectasis, and lung cancer/metastasis were the most common causes, detected in 14(47%), 5(17%) and 4(13%) patients respectively. Other causes of hemoptysis including chronic bronchitis, interlobar artery aneurysm, hydatid cyst, arteriovenous fistula, pulmonary embolism, and exposure to chemical weapons each detected in one patient separately. All of them had abnormal chest CT scans, except for 2 patients who had not undergone CT scan (one with hydatid cyst and another with bronchial tumor diagnosed with bronchoscopy). Bleeding location which has been confirmed with angiography could be predicted with CT scan among 7 of 14 patients with TB, (sensitivity=50%). While this rate was 100% among all other patients with other diagnosis who had undergone CT scan.

Conclusions

In conclusion complementary to the previous studies our results have demonstrated that bronchial artery embolization remains as one of the most efficient procedures in managing massive hemoptysis, with minimal rate of complications.

A case of tracheal varices in an adolescent patient with cyanotic heart disease

Tracheal varices and bronchial varices are infrequently reported in adults as a complication of an underlying vascular obstruction, including portal hypertension, pulmonary arterial hypertension, or pulmonary venous hypertension. Tracheal varices and bronchial varices have been reported in adults with failing Fontan physiology, but this occurrence is rare in children. We report the unusual presentation of tracheal-bronchial varices due to veno-venous collaterals in an adolescent patient with Glenn physiology for double-inlet left ventricle and portal hypertension secondary to cardiac cirrhosis. We document complete resolution of these varices after heart and liver transplantation.

Multidetector computed tomography in life-threatening hemoptysis

Life-threatening hemoptysis is a severe condition that requires rapid diagnosis and treatment. One of the treatments of choice is embolization. The initial assessment aims to locate the origin and cause of bleeding. The technological advance of the development of multidetector computed tomography (MDCT) has changed the management of patients with life-threatening hemoptysis. MDCT angiography makes it possible to evaluate the cause of bleeding and locate the vessels involved both rapidly and noninvasively; it is particularly useful for detecting ectopic bronchial arteries, nonbronchial systemic arteries, and pulmonary pseudoaneurysms. Performing MDCT angiography systematically before embolization enables better treatment planning. In this article, we review the pathophysiology and causes of life-threatening hemoptysis (including cryptogenic hemoptysis) and the MDCT angiography technique, and we review how to systematically evaluate the images (lung parenchyma, airways, and vascular structures).

Bronchial and Nonbronchial Systemic Artery Embolization in Management of Hemoptysis: Experience with 348 Patients

Background. We aimed to report our experience with bronchial artery embolization (BAE) in the management of moderate recurrent and/or life-threatening hemoptysis. Methods. We evaluated the demographics, clinical presentation, radiographic studies, short- and long-term efficacy, and complications in patients Who underwent BAE, at a tertiary university hospital, from 2003 to 2012. Results. Three hundred forty-one patients underwent BAE for the management of moderate recurrent or life-threatening hemoptysis. Pulmonary TB and bronchiectasis were the most common etiologies for hemoptysis in our locality. The most common angiographic signs for hemoptysis were hypervascularity and systemic-pulmonary artery shunt. BAE was successful in controlling hemoptysis immediately in 95% of patients and at 1 month in 90% of patients. Recurrence of hemoptysis was observed in 9.6% of patients, and reembolization was indicated in 85% of those cases. Complications of BAE were self-limited acute and subacute complications, while chronic complications were not recorded during this study. Conclusions. TB and bronchiectasis are the commonest etiologies for moderate recurrent or life-threatening hemoptysis in our locality. Hypervascular lesions from the bronchial arteries and nonbronchial systemic arteries represented the major vascular abnormalities. Bronchial and nonbronchial systemic artery embolizations were effective to control both acute and chronic hemoptyses, with no serious complications.

Predictors of recanalization in patients with life-threatening hemoptysis requiring artery embolization

INTRODUCTION

Artery embolization (AE) is a safe and useful procedure in the management of massive hemoptysis. The objective of our study was to describe the experience of AE in a tertiary referral center, to characterize angiographic findings at the time of recurrence, and to analyze factors associated with these findings.

MATERIAL AND METHODS

Observational retrospective study of patients presenting with life-threatening hemoptysis. All consecutive patients with at least one episode of hemoptysis that required AE during a 13-year period were included. The effects of i)time to recurrence; ii)use of coils, and iii)number of arteries embolized on the likelihood that the recurrence was secondary to recanalization were assessed.

RESULTS

One hundred seventy-six patients were included in the study. Twenty-two patients (12.5%) died due to hemoptysis. Probability of recurrence-free survival at one month was 0.91 (95%CI: 0.87 to 0.95), at 12months was 0.85 (95%CI: 0.79 to 0.91), and after 3 years was 0.75 (95%CI: 0.66 to 0.83). A longer time to recurrence was associated with a higher probability that the hemorrhage affected the same artery (estimate=0.0157, z-value=2.41, p-value=0.016).

CONCLUSION

AE is a safe and useful technique in the management of massive and recurrent hemoptysis. Nevertheless, recurrence after embolization is not uncommon. Recurring hemoptysis due to recanalization is related to time to recurrence, but not to the use of coils or number of arteries embolized.

Impact of multidetector CT-angiography on the emergency management of severe hemoptysis

BACKGROUND

Multidetector CT-angiography (MDCTA) is commonly used in patients with severe haemoptysis requiring admission to intensive care unit. However, the impact of MDCTA on the management of severe haemoptysis in emergency setting is poorly evaluated.

METHODS

We prospectively compared data provided by clinical bedside evaluation (clinical examination, chest-X-ray and fiberoptic bronchoscopy) to MDCTA data in terms of lateralization, location of the bleeding site, etiology as well as impact on the treatment choice.

RESULTS

Over a 13-month period, 87 patients (men n=58, median age=61 years, median haemoptysis expectorated volume=180 mL) were included. Etiology was mainly (67%) bronchiectasis, tuberculosis sequelae and tumor. MDCTA and clinical bedside evaluation were equally effective in determining lateralization (87.4% and 93.1%, respectively, p=0.23) and location (85% and 82.7%, respectively, p=0.82) of the bleeding site. MDCTA was significantly more accurate than the clinical bedside strategy in determining the haemoptysis cause (86% and 70%, respectively, p=0.007). Moreover, MDCTA suggested the involvement of systemic arteries as bleeding mechanism in 92% of cases, leading to the modification of the treatment initially considered after bedside evaluation in 21.8% of patients.

CONCLUSION

MDCTA provides useful information for the management of patients with severe haemoptysis, especially in the treatment choice. Thus, in the absence of emergency fiberoptic bronchoscopy (FOB) requirement for airways management, MDCTA should be the first-line procedure performed in emergency clinical setting.

Massive hemoptysis from pulmonary ligament artery supplying abnormal basal segments of the lower lobe

BACKGROUND

Non-bronchial systemic arteries can be a significant source of massive hemoptysis in patients with marked pleural involvement. However, in some cases without pleural involvement, the pulmonary ligament artery (PLA) can also enter the abnormal lung parenchyma and be responsible for hemoptysis.

PURPOSE

To discuss the factors influencing the development of a blood supply from the PLA in patients with hemoptysis.

MATERIAL AND METHODS

Seventy-five consecutive patients who underwent bronchial artery embolization (BAE) for massive hemoptysis were evaluated between January 2006 and December 2011 retrospectively. Selective arteriography showed an enlarged and tortuous PLA in five patients. CT was done to determine the site and extent of the underlying diseases before BAE in all patients. Angiographic and CT images were analyzed to determine if there was a relationship between PLA supply and location of the underlying disease or mediastinal pleural involvement.

RESULTS

The underlying lesions of six patients involved the basal segments of the lower lobe without marked mediastinal pleural thickening or adhesion, but diaphragmatic and lateral pleural thickening was observed in one case. Of these six patients, the PLA supplied blood to the lesions related to the hemoptysis in five patients. No patient with massive hemoptysis whose underlying lesions involved other segments of lung had a PLA supplying the lesions.

CONCLUSION

Even though pleural involvement is absent, underlying lesions involving the basal segments of the lower lobe could be a good indicator that the PLA is the cause of bleeding in patients with massive hemoptysis.

Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles

PURPOSE

To retrospectively compare safety and effectiveness of embolic agents polyvinyl alcohol (PVA) particles versus n-butyl-2-cyanoacrylate (NBCA) for bronchial artery embolization (BAE) for control of hemoptysis.

MATERIALS AND METHODS

Institutional review board approved this retrospective study; informed consent was waived. From January 2005 to December 2008, 406 patients (242 men, 164 women; age range, 6-92 years) with major hemoptysis underwent BAE by using PVA particles (n = 293) or NBCA (n = 113). Technical and clinical success, complications, hemoptysis-free survival rates, and causes of recurrent hemoptysis were compared between PVA and NBCA groups. The differences in hemoptysis-free survival rates were assessed between subgroups stratified to underlying diseases. The predictive factor for recurrent hemoptysis was identified with Cox proportional hazard regression model.

RESULTS

Technical success was achieved in 93.9% (275 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .463); clinical success was achieved in 92.2% (270 of 293) and 96.5% (109 of 113) of patients for PVA and NBCA, respectively (P = .180). Overall and major complication rates were not statistically different (overall complication rates: 34.1% for PVA, 31.0% for NBCA; P = .56; major complication rates: 0.3% for PVA, 0% for NBCA; P > .999). The 1-, 3-, and 5-year hemoptysis-free survival rates were, respectively, 77%, 68%, and 66% for PVA and 88%, 85%, and 83% for NBCA (P = .01). Recanalization of previously embolized vessels was more frequent in PVA group (21.5%) than in NBCA group (1.8%; P < .001). NBCA group showed hemoptysis-free survival rates superior to PVA group in patients with bronchiectasis (P = .016). PVA (P = .050) and aspergilloma (P < .001) were predictive factors for recurrent hemoptysis.

CONCLUSION

BAE with NBCA provided higher hemoptysis-free survival rates compared with PVA particles without increasing complication rates. This improvement was evident in patients with bronchiectasis and was caused by more durable embolic effect than PVA particles.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.13130046/-/DC1.

Proximal interruption of the pulmonary artery: Transcatheter embolization for emergent management of massive hemoptysis

Transcatheter embolization is the first-line treatment for massive hemoptysis and recurrent intractable hemoptysis. Proximal interruption of the pulmonary artery is a rare congenital anomaly characterized by hypertrophy and neovasculsarity of bronchial and nonbronchial aortopulmonary collaterals; hemoptysis complicates a minority of cases. We present a case of unilateral proximal interruption of the left pulmonary artery associated with a right-sided aorta, presenting in adulthood with hemoptysis. The patient was managed emergently with bronchial, intercostal, and inferior phrenic artery embolization.

Endovascular treatment of haemoptysis: medium and long-term assessment

PURPOSE

To assess the short, medium and long-term results of bronchial artery embolisation (BAE) and identify the factors favouring the recurrence of haemoptysis.

PATIENTS AND METHODS

This is a retrospective study, between January 2001 and June 2010, comprising 53 consecutive patients with BAE. The mean age was 53.8 years. There were 15 women (28.30%) and 38 men (71.69%).

RESULTS

The aetiologies of haemoptysis were dominated by the residual signs of pulmonary tuberculosis: 18 cases (33.96%), bronchial dilations: 12 cases (22.64%) and aspergilloma: five cases (9.43%). The bronchial arteriography showed signs of bronchial hypervascularisation in 92.45% of the cases. Forty-six patients had a first embolisation (86.79%) with immediate efficacy in 84.90% of the cases (n=45). This efficacy was noted after more than 3 years in 60.08% of the cases. Short (< 30 days) and medium-term (> 30 days and < 3 years) recurrence of haemoptysis were noted in 17.39% and 8.69% of the cases respectively. A statistically significant correlation between aspergilloma and the immediate recurrence was found (P=0.013). The risk of medium and long-term recurrence (> 3 years) was correlated with age. The survival without recurrence was statistically higher when the age was less than 60 years (P=0.0041).

CONCLUSION

BAE is an effective treatment. Aspergilloma is a major risk factor in the recurrence of haemoptysis. Repeated embolisation may be proposed for these patients.

Temporal patterns in severe hemoptysis requiring bronchial artery embolization

Background

Although some authors have suggested that there is some seasonal periodicity in hemoptysis, temporal patterns of hemoptysis have been poorly investigated. The aim of this study is to describe the temporal pattern of severe hemoptysis which required bronchial artery embolization (BAE).

Methods

All consecutive patients with at least one episode of hemoptysis which required BAE during a 13-year period were included. Recurring hemoptysis requiring BAE in a patient with previous embolization was included as a new hemoptysis event, unless it occurred within one month from the prior event. Lineal regression was applied to compute the tendency of occurrence of cases along 13 years of record data. The daily and monthly distributions of embolizations were used to study the weekly and monthly seasonal indexes.

Results

Hemoptysis requiring BAE occurred with some monthly variation demonstrated with two monthly peaks, with the first one occurring during April and the second one during November.

Conclusion

Hemoptysis occurred with two monthly peaks. This seasonal trend might be due to different prevalence of respiratory tract infections or to some weather variables. Identification of significant environmental factors could be useful to improve preventive measures.

Cystic fibrosis: management of haemoptysis

Haemoptysis is a common complication in cystic fibrosis (CF), occurring in approximately 9% of the population. Massive haemoptysis is associated with older patients, more severe disease and carries a high mortality rate. Despite this there are few robust published studies of effective treatments and knowledge of the precise pathogenesis is limited. Current guidelines for treatment from the Cystic Fibrosis Foundation (CFF) are based on consensus opinion of experts. Patients with massive haemoptysis who do not respond to initial medical treatments should undergo bronchial artery embolization. This will control the bleeding in the majority of cases but recurrence rates are high and there are little data to support long-term improved outcomes. Surgery is a last resort in patients with CF.

Posterior circulation stroke after bronchial artery embolization. A rare but serious complication

Bronchial artery embolization (BAE) is the treatment of choice for massive hemoptysis with rare complications that generally are mild and transient. There are few references in the medical literature with acute cerebral embolization as a complication of BAE. We report a case of intracranial posterior territory infarctions as a complication BAE in a patient with hemoptysis due to bronchiectasis.

Clinical impact of multidetector row computed tomography before bronchial artery embolization in patients with hemoptysis: a prospective study

PURPOSE

To evaluate prospectively the role and impact of multidetector row computed tomography (MDCT) before bronchial artery embolization (BAE) in patients with hemoptysis.

METHODS

MDCT of the thorax was performed in 27 patients (21 men, 6 women; age range, 22-70 years; mean, 39 years) with hemoptysis who were referred for BAE. Transverse, multiplanar reconstruction, and 3-dimensional reconstruction (maximum intensity projection and volume rendered) images were analysed to identify the abnormal hypertrophied bronchial and nonbronchial systemic arteries causing hemoptysis, their origin and course were noted. Digital subtraction angiography was performed with the knowledge of findings of MDCT. Selective arteriogram of abnormal bronchial as well as nonbronchial arteries was performed. Embolization was attempted in 25 of these patients (92.6%) by using polyvinyl alcohol particles (350-500 μm), Gelfoam or Embospheres (400-700 μm). Follow-up was done for a mean period of 20.5 months.

RESULTS

Based on MDCT, 2 of 27 patients were found unsuitable for BAE. On computed tomography, 38 arteries (27 bronchial and 11 nonbronchial systemic arteries) were identified as abnormal hypertrophied vessels. On angiography, 34 of these arteries (25 bronchial and 9 nonbronchial systemic arteries) were found to be responsible for hemoptysis. Three of these arteries could not be evaluated during angiography, and 1 artery that was identified as abnormal on computed tomography was found normal on angiography. All 25 bronchial and 9 nonbronchial systemic arteries that cause hemoptysis were detected at MDCT. Embolization was successful in 23 of 25 patients.

CONCLUSION

MDCT enables detection and depiction of all bronchial and nonbronchial systemic arteries causing hemoptysis.

Predicting and managing the risk of pulmonary haemorrhage in patients with NSCLC treated with bevacizumab: a consensus report from a panel of experts

BACKGROUND

Bevacizumab is a monoclonal antibody against vascular endothelial growth factor. Severe pulmonary haemorrhage (PH) is a rare but serious potential adverse event associated with bevacizumab therapy for advanced non-squamous non-small-cell lung cancer (NSCLC).

METHODS

A panel of expert oncologists, pulmonologists and radiologists reviewed the available data to identify predictive factors for PH in order to help guide physicians using bevacizumab in patients with NSCLC.

RESULTS

Patients with NSCLC are at an increased risk of PH owing to the underlying disease process. Patients with squamous histology and/or a history of grade ≥ 2 haemoptysis (≥ 2.5 ml per event) should not receive bevacizumab. No clinical or radiological features (including cavitation and central tumour location) reliably predict severe PH in bevacizumab-treated patients. Major blood vessel infiltration and bronchial vessel infiltration, encasement and abutting may predict PH; however, standardised radiological criteria for defining infiltration have not been established. Eligibility for bevacizumab is not affected by patient age, performance status or anticoagulation or antiplatelet therapy.

CONCLUSIONS

An individualised risk-benefit assessment should be undertaken in all patients with NSCLC in whom bevacizumab is being considered. Further research is required to elucidate the mechanisms underlying PH and the clinical risk factors.

Novel approaches to the patient with massive hemoptysis

Massive hemoptysis is a life-threatening condition with a high mortality when treated conservatively. Several modalities have been described in the treatment of hemoptysis with varying results. Endobronchial therapy has traditionally been performed with rigid bronchoscopy. This requires both specialized training and equipment that is not readily available in many centers. The role of fiberoptic bronchoscopy (FOB) is unclear in these situations but is more widely accessible. We describe three cases of the successful treatment of hemoptysis with FOB. These patients were treated with a combination of techniques described previously in the literature; however, these methods failed to result in cessation of the bleeding. Therefore, we employed alternative strategies not described in the literature, using oxidized regenerated cellulose with FOB alone as well as in conjunction with endobronchial placement of vascular embolization coils. These additional techniques may offer other options when rigid bronchoscopy or other modalities are not readily available.

[Management of massive hemoptysis]

Massive hemoptyses are serious clinical conditions that can quickly jeopardize the vital prognosis. The major risk is asphyxiation, due to the bleeding into the tracheobronchial tree. The clinician should provide in parallel support for diagnosis and treatment, locating the bleeding but also finding its cause. Such patients should be cared for by a multidisciplinary team, having quick access to an important technical support. The association fiberoptic bronchoscopy-chest CT scan seems to be the most effective to locate and identify the cause of the bleeding. The development of bronchial artery embolization has revolutionized the management of these patients, replacing surgery in many of its indications. The latter still keeps a place in the management of these patients. Indeed, it is the main etiological treatment, preventing the vast majority of recidivism. It is absolutely indicated in the treatment of bleeding from the pulmonary vessels, and in case of failure of other techniques. It should be performed whenever possible away from the episode of hemoptysis, in order to minimize the operative risk.

Endovascular therapy of bronchial artery aneurysm: five cases with six aneurysms

The objective of this study was to investigate the effect of transcatheter arterial embolization (TAE) with N-butyl-2-cyanoacrylate (NBCA)-Lipiodol mixture in patients with bronchial artery aneurysm (BAA). From January 2005 to January 2010, five patients presenting hemoptysis with six BAAs were treated with NBCA-Lipiodol mixture, including intra-aneurysm embolization (IAE) in one patient. Adjuvant embolization with spherical polyvinyl alcohol (PVA) embolic microparticles or NBCA was first performed to embolize the distal engorged bronchiectatic arteries. Bronchial arterial angiography showed six BAAs (four in the right lobe and two in the left lobe) and some engorged, tortuous bronchial arteries. TAE through microcatheter was successful in all cases. Postembolization angiogram demonstrated the NBCA cast and total occlusion of BAAs and bronchiectatic engorged vessels. After these procedures, hemoptysis completely disappeared in all patients. Follow-up computed tomography (CT) scan was performed at an average of 3 months (range 2 to 6), which showed no enhancement of BAAs and accumulation of NBCA. TAE is a minimally invasive, effective, and reliable approach for treatment for patients with BAA. NBCA-Lipiodol mixture provides a good choice for treatment of BAA, especially when catheterization of the efferent branches is impossible.

[Life threatening hemoptysis and aberrant bronchial artery. A case report]

Hemoptysis and pulmonary hemorrhage are rare pathological entities in childhood, however, both can be life threatening respiratory emergencies and can signify potentially serious underlying intrathoracic disease. We report an 11 year old female who had four episodes of hemoptysis (50 mL of bright red blood within 48 hours) without previous recurrent respiratory problems. The assessment by chest radiography, bronchoscopy and computed tomography (CT) was needed to diagnose the nature of the problem and to indicate the site and extent of the bleeding. The CT angiography of the thorax showed a right bronchial artery hypertrophy, abnormally originated from the aortic arch, next to an aberrant right subclavian artery. The bleeding was successfully controlled by right bronchial arterial embolization with 500-700 μm polyvinyl alcohol (PVA) microspheres. The course was uncomplicated. The bronchial artery embolization is effective in controlling hemoptysis and complications are uncommon in the hand of an experienced operator.