Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review

Intercostal artery pseudoaneurysm in pulmonary tuberculosis - A rare cause of hemoptysis: A case report with review of the literature

Pulmonary tuberculosis (TB) is one of the common causes of life-threatening hemoptysis, particularly in developing countries. Bronchial and pulmonary arteries are the major source of hemoptysis in pulmonary TB. Intercostal artery pseudoaneurysm as a cause of hemoptysis in pulmonary TB is extremely rare, with only a few reported cases. We describe a case of intercostal artery pseudoaneurysm in a patient of pulmonary TB, presenting as massive hemoptysis. Computed tomography bronchial angiography (CTBA) revealed a contrast-filled outpouching in a left upper lobe cavity. Catheter angiography revealed a pseudoaneurysm arising from one of the left intercostal arteries, which was managed subsequently by endovascular embolization. Pseudoaneurysm from visceral arteries is an extremely rare but important cause of massive hemoptysis in pulmonary TB, which if not managed promptly may prove fatal.

The Diagnosis and Treatment of Hemoptysis

BACKGROUND

Hemoptysis, i.e., the expectoration of blood from the lower airways, has an annual incidence of approximately 0.1% in ambulatory patients and 0.2% in inpatients. It is a potentially life-threatening medical emergency and carries a high mortality.

METHODS

This review article is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

Hemoptysis can be a sign of many different diseases. Its cause remains unknown in about half of all cases. Its more common recognized causes include infectious and inflammatory airway diseases (25.8%) and cancer (17.4%). Mild hemoptysis is self-limited in 90% of cases; massive hemoptysis carries a worse prognosis. In patients whose life is threatened by massive hemoptysis, adequate oxygenation must be achieved through the administration of oxygen, positioning of the patient with the bleeding side down (if known), and temporary intubation if necessary. A thorough diagnostic evaluation is needed to identify the underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be planned. The evaluation should include conventional chest x-rays in two planes, contrastenhanced multislice computerized tomography, and bronchoscopy. Hemostasis can be achieved at bronchoscopically accessible bleeding sites with interventionalbronchoscopic local treatment. Bronchial artery embolization is the first line of treatment for hemorrhage from the pulmonary periphery; it is performed to treat massive or recurrent hemoptysis or as a presurgical measure and provides successful hemostasis in 75-98% of cases. Surgery is indicated if bronchial artery embolization alone is not successful, or for special indications (traumatic or iatrogenic pulmonary/vascular injury, refractory asper gilloma).

CONCLUSION

The successful treatment of hemoptysis requires thorough diagnostic evaluation and close interdisciplinary collaboration among pulmonologists, radiologists, and thoracic surgeons.

Oncologic Emergencies-The Old, the New, and the Deadly

Cancer continues to be a leading cause of death despite a broader understanding of its biology and the development of novel therapies. Nonetheless, with an increasing survival of this population, intensivists must be aware of the associated emergencies, both old and new. Oncologic emergencies can be seen as an initial presentation of the disease or precipitated by its treatment. In this review, we present key oncologic emergencies that may be encountered in daily practice, complications associated with innovative therapies, and treatment-related adverse events.

A novel approach to the diagnosis and treatment of hemoptysis in infants: A case series

INTRODUCTION

Hemoptysis in children is an uncommon presenting symptom but can be life-threatening if massive. Cardiac catheterization and coil embolization of aorto-pulmonary collateral vessels (APCs) is uncommon in pediatric hemoptysis patients without congenital heart disease.

METHODS

We present a series of seven infants (≤12 months of age) with hemoptysis, all of whom underwent cardiac catheterization to look for and intervene upon APCs, if found. Only those patients who underwent both bronchoscopy as well as cardiac catheterization from January 1995 to January 2015 were included in this retrospective review.

RESULTS

Seven patients met inclusion criteria, and three had a history of recurrent hemoptysis. The mean age was 3 months. Four had evidence of bleeding on bronchoscopy. All seven had respiratory distress which necessitated ICU admission; five required mechanical ventilation. Cardiac catheterization showed significant APCs (>2 mm) in six of the seven studied patients, all of which were coil embolized. One patient had no significant APCs and therefore, no embolization. All patients had complete resolution with no recurrences during the 10-20-year outpatient follow-up period. Chest CT scans were not helpful in delineating the site or etiology of bleeding in any patient.

CONCLUSIONS

APCs should be considered as a differential diagnosis for pulmonary hemorrhage in infants after more common causes have been ruled out.

Pictorial review of the pulmonary vasculature: from arteries to veins

Pathology of the pulmonary vasculature involves an impressive array of both congenital and acquired conditions. While some of these disorders are benign, disruption of the pulmonary vasculature is often incompatible with life, making these conditions critical to identify on imaging. Many reviews of pulmonary vascular pathology approach the pulmonary arteries, pulmonary veins and bronchial arteries as individual topics. The goal of this review is to provide an integrated overview of the high-yield features of all major disorders of the pulmonary vasculature. This approach provides a more cohesive and comprehensive conceptualisation of respiratory pathology. In this review, we present both the salient clinical and imaging features of congenital and acquired disorders of the pulmonary vasculature, to assist the radiologist in identifying pathology and forming a robust differential diagnosis tailored to the presenting patient. TEACHING POINTS: • Abnormalities of the pulmonary vasculature are both congenital and acquired. • Pathology of a single pulmonary vascular territory often affects the entire pulmonary vasculature. • Anomalous pulmonary venous flow is named as a function of its location and severity. • Bronchial arteries often undergo dilatation secondary to cardio-respiratory pathology.

Dealing with technical challenges in embolization of a rare aberrant left inferior bronchial artery arising from the left gastric artery in a patient with massive hemoptysis

Bronchial artery embolization is an established intervention for management of recurrent massive hemoptysis in a majority of patients. The source of bleeding in a majority of cases is systemic arteries – orthotopic bronchial arteries, anomalous bronchial arteries, or nonbronchial systemic collaterals. We report a case of an aberrant left inferior bronchial artery arising from the left gastric artery (LGA) in a patient with massive hemoptysis. Such origin from infradiaphragmatic vessels and specially left gastric arteries is very rare and needs to be considered by interventional radiologists and pulmonologists in case with hemoptysis disproportionate to supply by orthotopic arteries. Technical challenges were present in the present case in the form of an aneurysm in the aberrant artery and nontarget hepatic and gastric branches arising from LGA. Appropriate selection of hardware and embolic agents was done to deal with the clinical situation.

An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ^©RSNA, 2018.

Rasmussen's pseudoaneurysm- case report

Background

Pulmonary aneurysms and pseudoaneurysms have various etiologies; however, the term Rasmussen's pseudoaneurysm refers specifically to a focal dilatation of a branch of the pulmonary artery into adjacent tuberculous cavity. The incidence of such tuberculosis related pulmonary vascular complication is extremely rare, hence, under recognized by many physicians. Management of pulmonary pseudoaneurysms is challenging as they present by life-threatening hemoptysis. Furthermore, contrary to the most causes of massive hemoptysis their bleeding is of pulmonary rather than bronchial artery origin. Prompt diagnosis and early interventions are needed as a very high mortality rate is associated with this illness.

Case description

We are reporting on a case of a young male who was presented to our hospital with recurrent episodes of massive hemoptysis and was diagnosed to have pulmonary tuberculosis. Despite being actively treated, his hemoptysis persisted. We describe in this case the role of different diagnostic modalities and the available therapeutic options.

Conclusion

Rasmussen's psudoaneurysm is rare and potentially lethal pulmonary vascular complication of tuberculosis. It should be considered in the differential diagnosis of hemoptysis in patients known or suspected to have pulmonary tuberculosis. In such cases, multidetector computed tomography (MDCT) scanning is the investigation of choice to confirm the diagnosis and to localize the source of bleeding prior to the therapeutic interventions. Head to head comparison between interventional radiology procedures and surgery in treatment of pulmonary psudoaneurysms is lacking, thus, choice depend on the availability and local expertise.

Diagnostic Value of Dual-input Computed Tomography Perfusion on Detecting Bronchial-Pulmonary Artery Fistula in Tuberculosis Patients with Massive Hemoptysis

RATIONALE AND OBJECTIVES

This prospective study aimed to evaluate the diagnostic performance of dual-input computed tomography perfusion technique (DI-CTP) in identifying the bronchial-pulmonary artery fistula in patients tuberculosis with massive hemoptysis.

MATERIAL AND METHODS

Twenty patients with tuberculosis with massive hemoptysis were enrolled from January 2015 to December 2015. The association between DI-CTP parameters and the diagnostic outcomes of digital subtraction angiography was assessed. Diagnostic efficacy of DI-CTP was evaluated by receiver operating curve (ROC) analyses using the diagnostic outcomes of digital subtraction angiography, which is the gold standard for identifying bronchial-pulmonary artery fistula.

RESULTS

Compared to lung segments with normal blood flow (n = 304), those with bronchial-pulmonary artery fistula (n = 164) had a reduced pulmonary flow value, perfusion index (PI) value, and an elevated bronchial artery (BF) value in the DI-CTP scan, which was further confirmed by multivariate logistic regression. ROC analysis showed that PI and bronchial artery has an excellent diagnostic performance (both area under the ROC curve > 0.9, P < .001) and high sensitivity and specificity (from 0.79 to 0.95 at the optimal cutoff). PI has the best diagnostic performance, with an overall diagnostic accuracy of 0.91.

CONCLUSIONS

DI-CTP scan possesses the diagnostic value for detecting bronchial-pulmonary artery fistula in patients with tuberculosis with massive hemoptysis, providing an alternative diagnostic method.

Mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation: a single-centre retrospective observational study

Objectives

In recognition of the significant impairment caused by haemoptysis on a patient’s quality of life, bronchial artery embolisation has been introduced worldwide as one of the first-line treatment options. Since little evidence is available on the mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation (ssBACE), the purpose of the present study is to evaluate these.

Methods

We retrospectively evaluated the mechanisms of recurrent haemoptysis using both enhanced computed tomography and cineangiography following ssBACE by reviewing 299 haemoptysis-related arteries (HRAs) in 57 consecutive patients who underwent 2nd series ssBACE for the management of recurrent haemoptysis between April 2010 and December 2015.

Results

Median age of patients was 69 (interquartile range 64–74) years, and 43.9% were men. This study revealed that (1) recanalisation was the most common mechanism (45.2%) followed by development of new HRA (38.5%), bridging collaterals (14.7%) and conventional collaterals (1.7%); (2) these trends could be modified in several situations such as with antiplatelet or anticoagulant medications; (3) relatively large-diameter HRAs were more likely to recanalise compared with small-diameter HRAs and (4) recurrent haemoptysis could be managed by 2nd series ssBACE with a procedural success rate of 97.7% without any major complications.

Conclusions

Recanalisation was the most common mechanism of recurrent haemoptysis after ssBACE. Our results provide interventionists with indispensable insights.

Key Points

• Recanalisation was the most common mechanism of recurrent haemoptysis after super-selective bronchial artery coil embolisation, followed by development of new haemoptysis-related arteries

• These trends could be modified in several situations such as with antiplatelet or anticoagulant medications

• Recurrent haemoptysis could be managed by 2nd series super-selective bronchial artery coil embolisation with a procedural success rate of 97.7% without any major complications.

Single-phase Split-bolus Dual Energy Computed Tomography Angiography for Evaluation of Hemoptysis: A Novel Application

PURPOSE

The purpose of this study was to assess feasibility and overall utility of single-phase split-bolus dual energy computed tomography (DECT) angiography (DECTA) for evaluation of hemoptysis, and to establish an injection protocol for evaluation of hemoptysis, by comparing 2 contrast injection protocols.

MATERIALS AND METHODS

Using dual-source (80 and 140 kV), 2×128-slice equipment, DECTA was performed using 400 mg iodine/mL, 50 to 80 mL iodinated contrast in 257 patients (189 male individuals, 68 female individuals, age range: 15 to 76 y) presenting with hemoptysis. Initially, 50 patients were randomized into 2 groups for 2 different injection protocols (A and B). Images were assessed quantitative and qualitatively. Later, 207 patients were randomized using protocol B, which was technically simpler, and single-CT acquisition, for simultaneous opacification of systemic and pulmonary vessels.

RESULTS

Injection protocol A resulted in higher vessel attenuation, both in the aorta and in the pulmonary artery and its segmental branches; however, the difference was not statistically significant. No significant difference was noted in signal-to-noise ratio, contrast-to-noise ratio, as well as subjective image quality parameters. Overall optimal opacification of both systemic and pulmonary arteries was achieved in 247/257 patients. A total of 308 abnormal bronchial arteries were noted. A total of 392 nonbronchial systemic arteries were noted, the majority arising from posterior intercostals and subclavian artery branches. The pulmonary source of hemoptysis was identified in 9 patients (3 pulmonary thromboembolisms, 5 pulmonary artery pseudoaneurysms, and 1 pulmonary venous ectasia).

CONCLUSION

Combined DECTA is a novel technique that enables simultaneous evaluation of both systemic and pulmonary vascular cause of hemoptysis in a single acquisition with small contrast dose. Both injection protocols "A" and "B" were equally efficacious in simultaneous opacification of both the aorta and pulmonary arteries. To the best of our knowledge, such a protocol has never been described for hemoptysis evaluation.

Pulmonary hemangioma mimicking bronchiectasis: A case report

RATIONALE

Pulmonary hemangioma is a rare thoracic condition that can lead to hemoptysis. Here we report a case that presented with lumen dilatation suggestive of bronchiectasis on high-resolution computed tomography (CT) and was misdiagnosed as bronchiectasis for more than 10 years.

PATIENT CONCERNS

A 41-year-old female patient was admitted to the Department of Respiratory Medicine due to hemoptysis.

DIAGNOSES

The patient was misdiagnosed as having bronchiectasis for more than 10 years. Enhanced chest CT was not performed until treatment of recurrent hemoptysis with antibiotics and hemostatic therapy was no longer effective. With lumen dilation and the "signet ring" sign as the main findings on CT, pulmonary hemangiomas are easily misdiagnosed.

INTERVENTIONS

A left lower lobe lobectomy was performed, and the postoperative pathology revealed a hemangioma of the left lower lobe of the lung without bronchiectasis.

OUTCOME

After treatment, the patient no longer had hemoptysis.

LESSONS

Therefore, in the clinical diagnosis and treatment of patients presenting with hemoptysis, enhanced CT/CT angiography (CTA) is necessary for differential diagnosis.

Surgery for hemoptysis in patients with benign lung disease

Background

Hemoptysis can be a life-threatening condition that requires urgent treatment. Surgery still plays an important role in managing this critical situation, although previous reports have reported high postoperative morbidity and mortality rates. We report our experience with surgical resection for hemoptysis caused by benign lung diseases.

Methods

We reviewed the retrospectively collected data from 94 patients undergoing pulmonary resection for various benign lung diseases with hemoptysis at a single institution from 2010 to 2016. Baseline characteristics, surgical factors, and postoperative outcomes (morbidity and mortality rates) were analyzed.

Results

The ratio of male to female patients was 1:1, and the mean age was 58.2±11.1 (range, 29-79) years. The etiology of hemoptysis included aspergilloma in 58 patients (61.7%), bronchiectasis in 10, tuberculosis in 7, necrotizing bronchiolitis in 6, and other inflammatory disease in 13. A total of 21 patients (22.3%) underwent emergency operation, and 73 (77.7%) had an elective operation. Pulmonary resection was performed by thoracotomy (n=53, 56.4%) and video-assisted thoracoscopic surgery (VATS) (n=41, 43.6%). Sublobar resection (n=50, 53.2%, segmentectomy in 19 and wedge resection in 31) was performed more often than lobectomy (n=35, 37.2%). Pneumonectomy was performed in 7 patients, and bilobectomy was performed in 2. Postoperative morbidity occurred in 23 patients (24.5%), with prolonged air leak being the most frequent complication (n=14, 14.9%). The in-hospital mortality rate was 3.2% (n=3). Complications were less frequent in patients undergoing an elective operation, VATS, and sublobar resection. Multivariate analysis showed that patients treated with VATS had a decreased risk of postoperative complications (odds ratio, 12.8; 95% confidence interval, 1.29-127.9; P=0.03).

Conclusions

Surgical resection for hemoptysis in patients with benign lung diseases is the mainstay of effective treatment with acceptable morbidity and mortality rates. If applicable, we recommend elective (planned) sublobar resection using VATS in order to improve postoperative outcomes.

A Stepwise Embolization Strategy for a Bronchial Arterial Aneurysm: Proximal Coil and Distal Glue with the Optional Use of a Microballoon Occlusion System

PURPOSE

This study aimed to demonstrate a transcatheter embolization strategy for bronchial artery aneurysms (BAAs) using coils for the proximal lesion and glue (n-butyl-2-cyanoacrylate [NBCA]) embolization for the distal lesion with or without the use of a microballoon occlusion catheter.

MATERIALS AND METHODS

Five patients with BAAs presenting with hemoptysis were enrolled in this study. A bronchial angiogram indicated a mediastinal BAA near the orifice, accompanied by dilated distal branches with or without intrapulmonary BAA. A stepwise procedure was performed. First, the intrapulmonary branches were embolized with glue, with or without the use of a microballoon catheter depending upon the anatomical and local flow hemodynamic conditions. Second, the mediastinal BAA was tightly packed with detachable coils.

RESULTS

Glue embolization of intrapulmonary abnormal branches successfully controlled hemoptysis in all patients; microballoon catheters were used in five of the 10 arteries. The volume embolization ratio of coils within the mediastinal BAA ranged from 28 to 59%, and neither coil compaction nor signs of recanalization were observed during follow-up.

CONCLUSION

The stepwise embolization procedure with the sequential use of glue (with or without a microballoon occlusion system) and detachable coils may represent a possible endovascular strategy for the treatment of complex BAAs.

LEVEL OF EVIDENCE IV

Level 4: Case Series.

Embolization through the thyrocervical trunk: vascular anatomy, variants, and a case series

Background and purpose

The thyrocervical trunk (TCT) is the second ascending branch of the subclavian artery. It is considered a ‘border territory’ between interventional vascular radiology and interventional neuroradiology because it gives rise to branches both cervical and to the upper limbs. We describe the TCT branches anatomy, the most frequent variants, and expose eight endovascular procedures performed through the thyrocervical trunk.

Methods

A retrospective review of all the interventional radiology procedures carried out through the TCT in our tertiary care center from August 2014 to January 2017 is presented.

Results

A total of eight endovascular procedures through the TCT including six preoperative embolizations: three paragangliomas, a cervical vertebral metastasis, a cervical vertebral aneurysmal bone cyst, and a very rare case of nerve root extradural cervical hemangioblastoma, as well as two emergency embolizations: a patient with a cervical traumatic active bleeding hematoma and a recurrent hemoptysis in a single ventricle patient.

Conclusions

A correct knowledge of the vascular anatomy, anatomical variants, and anastomosis (especially with the anterior spinal artery) of the TCT is essential for a safe embolization, both preoperatively and on an emergency basis. In cases of recurrent hemoptysis and severe lower-neck injuries, the TCT should always be reviewed.

Massive Hemoptysis with a Fungus Ball-like Shadow in an Old Tuberculosis Cavity That Was Shown to Be a Clot by Bronchoscopy

Development of aspergilloma is common in cases with a fungus ball-like shadow in cavities due to old tuberculosis. Some reports have shown that blood clots tend to appear as a fungus ball-like shadow. A 71-year-old man with a history of pulmonary tuberculosis presented with a fungus ball-like shadow in an old cavity and hemoptysis. There was no evidence of aspergillus infection on various examinations. We confirmed a blood clot and aneurysm of an artery under direct vision by bronchoscopy. A lateral thoracic artery aneurysm was detected by angiography. Transcatheter arterial embolization was performed. After treatment, the artery aneurysm disappeared.

Long-term outcomes and prognostic factors in patients with mild hemoptysis

OBJECTIVE

The aim of this retrospective study was to observe the long-term outcomes of conservative treatment and bronchial artery embolization (BAE) in patients with mild hemoptysis and to analyze the risk factors associated with hemoptysis recurrence.

METHODS

Patients with mild hemoptysis from January 2005 to January 2016 were enrolled in this study. The patients' medical records, including smoking history, etiologic diseases, bronchoscopic findings, mortality, BAE information, and follow-up data of recurrent hemoptysis, were reviewed and analyzed.

RESULTS

A total of 288 patients with mild hemoptysis were included in this study. Of them, 71 patients (24.7%) underwent BAE and 217 patients (75.3%) were treated conservatively. The clinical success rate of BAE was 98.6%, with a low minor complication rate of 5.6%. Bronchoscopy before treatments was performed in 237 patients (82.3%). Fifty-five patients (19.1%) experienced recurrent hemoptysis during a median follow-up period of 2.4years (interquartile range: 1.0-4.4years). Patients who showed active bleeding or blood clots on bronchoscopy had a significantly lower recurrence-free survival rate than patients with no bronchoscopic evidence of bleeding or blood clots (p=0.012). The risk factors affecting recurrence were heavy smoking (p=0.002, hazard ratio [HR]: 3.57), aspergillosis (p=0.035, HR: 6.01), and bronchoscopic findings of active bleeding (p=0.016, HR: 3.29) or blood clots (p=0.012, HR: 2.77).

CONCLUSIONS

The recurrence rate of hemoptysis was not negligible in patients with mild hemoptysis. BAE can be considered in patients with a high risk of recurrence.

Bronchial artery embolization in treatment of hemoptysis: Treatment efficacy and complications at a tertiary care chest centre

Background

Hemoptysis is one of the most alarming condition to both the patients suffering from it and the treating physicians. It is caused due to varied etiologies. One of the emergent and at times life-saving treatment option is by minimally invasive interventional radiological technique of Bronchial Atery Embolization (BAE). The authors aimed to carry out a retrospective analysis of short term efficacy and safety of all patients treated by this technique at a tertiary care thoracic centre.

Methods

A total of 52 patients were included in the study who had a median follow up of 35 days. All these patients were referred for hemoptysis, intractable hemoptysis not controlled by conservative management or massive hemoptysis. An analysis of the underlying etiology, immediate and short term outcomes and complications was made.

Results

The study showed Tuberculosis and its sequel (bronchiectasis and chronic fibrotic changes) as the commonest etiology (65%). The BAE showed high short term efficacy (92%) in stopping the hemoptysis with a relatively low complication rate especially of major complications such as spinal cord ischemia (1.9%). The study strengthens the limited Indian data available on the subject and based on its outcome, BAE should be tried in all patients presenting with uncontrollable or massive hemoptysis not getting relief by conservative management alone.

Conclusion

BAE is a very effective procedure with very less complications for management of massive or uncontrollable hemoptysis.

Bronchial artery embolization: first-line option for managing massive hemoptysis

Background Today, treatment for hemoptysis is not limited to surgery, and among the various options, bronchial artery embolization is regarded as an effective approach. Methods In this retrospective study, 179 of 389 patients with massive hemoptysis were treated with bronchial artery embolization, without taking into account the underlying pathological lesions responsible (bronchiectasis in 41, aspergilloma in 29, lung cancer in 25, old tuberculosis in 23, pyothorax in 19, others in 23). Results Bronchial artery embolization failed in 12 cases. In the 167 successful cases, surgery was required in 16 and bronchial occlusion was performed in 4; 3 patients died due to recurrent massive hemoptysis. After bronchial artery embolization, thoracic surgery for reasons other than hemostasis was carried out in 15 patients. Bronchial artery embolization was performed in 31 patients with hemoptysis who had a history of chest surgery. Four patients underwent bronchial occlusion, and immediate hemostasis was achieved in all of them. Conclusions For treatment of hemoptysis, bronchial artery embolization is a safe and minimally invasive technique that can be performed repeatedly, and provides not only short-term but also prolonged effectiveness; thus it can be used as a first-line treatment irrespective of the underlying pathological lesion. Bronchial occlusion may be useful for emergency hemostasis, but it warrants careful follow-up with consideration of additional elective treatment such as bronchial artery embolization.

Diffuse Alveolar Hemorrhage in Autoimmune Diseases

PURPOSE OF REVIEW

The present paper establishes a narrative and analytical review of diffuse alveolar hemorrhage (DAH) in ANCA-associated vasculitis, systemic lupus erythematosus, and antiphospholipid syndrome.

RECENT FINDINGS

Recent studies found a frequent association between DAH and infections and systemic lupus erythematosus and its associated factors. Biological therapies like rituximab have demonstrated benefit mainly in patients with ANCA-associated vasculitis. Main clinical manifestations of diffuse alveolar hemorrhage in these three diseases include dyspnea, pulmonary infiltrates, cough, and hypoxemia. The presence of hemorrhagic bronchoalveolar lavage, hemosiderin containing macrophages, or an increase of carbon monoxide diffusing capacity have been described in some series as helpful findings for the diagnosis. Hemoptysis has been seen mainly in systemic lupus erythematosus. The cornerstone of therapy includes glucocorticoids and cyclophosphamide, and recent findings in ANCA-associated vasculitis suggest the similar benefit of rituximab. Future evaluations and systematic reviews will help to define the real benefit for therapies that appeared to be controversial at the moment.

Transcatheter Arterial Chemoembolization with Spherical Embolic Agent in Patients with Pulmonary or Mediastinal Metastases from Breast Cancer

PURPOSE

To evaluate safety and feasibility of transcatheter arterial chemoembolization with superabsorbent polymer microspheres (SAP-MS) for patients with pulmonary or mediastinal metastasis from breast cancer.

METHODS

Between November 2002 and January 2015, 14 patients with 29 unresectable pulmonary or mediastinal breast cancer metastases underwent transcatheter arterial chemoembolization using SAP-MS (50-100 μm) after injection of a combination of 2-4 types of anticancer drugs (eg, cisplatin [30 mg] + fluorouracil [500 mg], or epirubicin [40 mg] + mitomycin C [4 mg] + fluorouracil [500 mg]). As a primary endpoint, local tumor response and adverse events were evaluated 1 month after the first transcatheter arterial chemoembolization, according to Response Evaluation Criteria In Solid Tumors Version 1.1 and Common Terminology Criteria for Adverse Events Version 4 criteria. Transcatheter arterial chemoembolization was repeated as needed. Overall survival was analyzed as a secondary endpoint.

RESULTS

Response rate was 28.6% (partial response, 4 patients; stable disease, 10 patients). Median progression rate was -12.7%. No cases of hematologic toxicity of grade 3 or higher were observed. A grade 3 maculopapular rash was observed in 1 patient. After the first transcatheter arterial chemoembolization sessions, 63 additional transcatheter arterial chemoembolization sessions were performed (average, 5.5 sessions per patient; range, 2-10 sessions). The median overall survival time after the first session was 29 months, and the 5-year survival rate was 49.5%.

CONCLUSIONS

Transcatheter arterial chemoembolization with SAP-MS is a well-tolerated and feasible palliative treatment option for patients with pulmonary or mediastinal metastasis from breast cancer.

Consensus Document of the Italian Association of Hospital Cardiologists (ANMCO), Italian Society of Pediatric Cardiology (SICP), and Italian Society of Gynaecologists and Obstetrics (SIGO): pregnancy and congenital heart diseases

The success of cardiac surgery over the past 50 years has increased numbers and median age of survivors with congenital heart disease (CHD). Adults now represent two-thirds of patients with CHD; in the USA alone the number is estimated to exceed 1 million. In this population, many affected women reach reproductive age and wish to have children. While in many CHD patients pregnancy can be accomplished successfully, some special situations with complex anatomy, iatrogenic or residual pathology are associated with an increased risk of severe maternal and fetal complications. Pre-conception counselling allows women to come to truly informed choices. Risk stratification tools can also help high-risk women to eventually renounce to pregnancy and to adopt safe contraception options. Once pregnant, women identified as intermediate or high risk should receive multidisciplinary care involving a cardiologist, an obstetrician and an anesthesiologist with specific expertise in managing this peculiar medical challenge. This document is intended to provide cardiologists working in hospitals where an Obstetrics and Gynecology Department is available with a streamlined and practical tool, useful for them to select the best management strategies to deal with a woman affected by CHD who desires to plan pregnancy or is already pregnant.

Embolization of a Bronchial Artery Aneurysm in a Chronic Obstructive Pulmonary Disease (COPD) Patient with Non-Massive Hemoptysis

Background

Bronchial artery aneurysm (BAA) is a rare condition with a reported prevalence of less than 1% of all selective bronchial arterial angiograms. Despite its low incidence, BAA represents a potential cause of hemoptysis.

Case Report

We describe the case of a 63-year-old man suffering from chronic obstructive pulmonary disease (COPD), who presented with non-massive hemoptysis.

CT angiography revealed a single bronchial artery aneurysm of 9 mm in diameter, abutting the esophageal wall.

Other CT findings included hypertrophy of the bronchial arteries along the mediastinal course, diffuse thickening of the walls of numerous bronchial branches and a “ground glass” opacity in the anterior segment of the right upper pulmonary lobe suggestive of alveolar hemorrhage.

The final diagnosis was established based on selective angiography, which was followed by transcatheter arterial embolization (TAE) of the BAA and of the pathological bronchial circulation.

Follow-up CT scans revealed a total exclusion of the aneurysm from the systemic circulation, resolution of the parenchymal “ground glass” opacity and absence of further episodes of hemoptysis over a period of two years.

Conclusions

An incidental finding of a bronchial artery aneurysm necessitates prompt treatment.

CT angiography and TAE represent the methods of choice for an appropriate diagnosis and treatment, respectively.

In case of a BAA associated with chronic inflammatory diseases, such as COPD, in patients with hemoptysis, TAE of the BAA and of the pathological bronchial circulation, in association with the treatment of the underlying disease, represents a valid approach that can improve the pulmonary status and prevent further episodes of hemoptysis.

A side-hole catheter for catheterization of a difficult internal mammary artery

Background The internal mammary artery (IMA) can be a source of hemoptysis in patients with chronic lung disease. Intervention via the IMA can be a challenge due to anatomic variations and lead to excessive contrast use and radiation exposure. Purpose To evaluate safety and efficiency of a new side-hole catheter for the catheterization of the IMA in patients with hemoptysis. Material and Methods From January 2011 to August 2014, a total of 96 transarterial embolization procedures required exact evaluation of the IMA due to chronic lung disease involving the anterior thorax. In 17 cases (18%) of these 96 procedures, the conventional selective IMA angiography failed and instead a novel side-hole catheter as a modification of a cobra-type curved catheter was used. The side hole allowed passage of a micro-wire and catheter. Results Failed catheterizations were due to severe vascular tortuosity, acutely angulated subclavian artery, or abnormal takeoff of the IMA. The Cobra shaped catheter with the microcatheter through the side-hole catheter yielded a technical success rate of 100%. Longer time was required to catheterize the IMA with the Cobra shaped catheter than with the side-hole catheter (17 vs. 2 min, P < 0.05). There were no procedure-related complications. Conclusion Side-hole catheter technique is useful in patients whose internal mammary artery is difficult to access. Further design revisions are needed to improve the ease and speed of IMA catheterization and angiography.

Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study

OBJECTIVES

Evidence on the safety and long-term efficacy of super selective bronchial artery embolisation (ssBAE) using platinum coils in patients with haemoptysis is insufficient. The objective of the present study was to evaluate the safety and the 3-year postprocedure haemoptysis-free survival rate of de novo elective ssBAE using platinum coils rather than particles for the treatment of haemoptysis.

DESIGN

A single-centre retrospective observational study.

SETTING

Hemoptysis and Pulmonary Circulation Center in Japan.

PARTICIPANTS

A total of 489 consecutive patients with massive and non-massive haemoptysis who underwent de novo elective ssBAE without malignancy or haemodialysis.

INTERVENTIONS

ssBAE using platinum coils. All patients underwent CT angiography before the procedure for identifying haemoptysis-related arteries (HRAs) and for procedural planning.

PRIMARY AND SECONDARY OUTCOME MEASURES

The composite of the 3-year recurrence of haemoptysis and mortality from the day of the last ssBAE session. Each component of the primary end point and procedural success defined as successful embolisation of all target HRAs were also evaluated.

RESULTS

The median patient age was 69 years, and 46.4% were men. The total number of target vessels was 4 (quartile 2-7), and the procedural success rate was 93.4%. There were 8 (1.6%) major complications: 1 aortic dissection, 2 symptomatic cerebellar infarctions and 5 mediastinal haematoma cases. The haemoptysis-free survival rates were estimated by the Kaplan-Meier analysis at 86.9% (95% CI 83.7% to 90.2%) at 1 year, 79.4% (74.8% to 84.3%) at 2 years and 57.6% (45.1% to 73.4%) at 3 years. Although not statistically significant by the adjusted analysis of variance with multiple imputation of missing variables, cryptogenic haemoptysis tended to show the most favourable outcome and non-tuberculous mycobacterium showed the worst outcome (adjusted p=0.250).

CONCLUSIONS

We demonstrated the safety and long-term efficacy of elective ssBAE using platinum coils and established that it can be a valuable therapeutic option for treating patients with haemoptysis.

Bronchial Artery Aneurysm with Associated Bronchial Artery to Pulmonary Artery Fistula: Treatment by Embolization

Bronchial artery aneurysm (BAA) is a rare vascular phenomenon. This review highlights a case of a BAA that was complicated by the presence of a bronchial artery to pulmonary artery (BA-PA) fistula, consequently presenting a unique challenge to management. BAAs have a strongly reported risk of rupture resulting in life-threatening hemoptysis. Embolization has thus become routine for the management such severe cases. The management of incidentally found anomalies is less obvious, but prophylactic embolization is a generally accepted practice. In this report, we review some of the risks and benefits associated with BAA embolization with specific consideration of the challenges in cases of co-existing BA-PA fistula.

Imaging in noncardiovascular thoracic emergencies: a pictorial review

Cardiovascular and noncardiovascular conditions are commonly encountered in the emergency department. While the majority of patients have underlying cardiovascular aetiologies, such as acute myocardial infarction, congestive heart failure, aortic dissection and pulmonary embolism, a small subset of patients have underlying noncardiovascular conditions, although they present with similar symptoms of chest pain, dyspnoea, cough, haemoptysis and haematemesis. This article aims to describe the imaging findings in common noncardiovascular conditions of the chest that are frequently encountered in the emergency department, with a review of the existing literature.

Massive Hemoptysis due to Right Inferior Phrenic Artery-to-Right Pulmonary Artery Fistula in the Right Middle Lobe of the Lung

Massive hemoptysis is a medical emergency and needs immediate treatment. It occurs in a wide variety of pulmonary diseases and typically originates from the bronchial arteries. We herein report a very rare case of a patient bleeding from a right phrenic artery-to-pulmonary artery fistula accompanied with focal bronchiectasis in the right middle lobe of the lung. In this case, multi-detector computed tomography was useful for clarifying the etiology and the abnormal anastomosis and facilitated effective angiographic embolization.

Bronchial artery embolization for the treatment of haemoptysis in pulmonary hypertension

PURPOSE

To test the efficacy of bronchial artery embolization (BAE) to treat haemoptysis in pulmonary hypertension (PH).

METHODS

33 patients were treated by BAE for haemoptysis associated with PH (PH group = 21) or non-associated with PH (control group = 12). The details of procedure, outcome, and rate of relapse were compared between the two groups. Within the PH group, the comparison was operated between subjects with congenital heart disease-associated pulmonary artery hypertension (CHD-APAH subgroup = 12) and non-CHD (non-CHD-APAH subgroup = 9).

RESULTS

The rate of relapse at 30 and 90-days was similar between the PH group and control group. BAE in the PH group was more challenging (median 2 arteries embolized per procedure) compared to the control group (median 1 artery embolized per procedure; p = 0.001). Bleeding arteries were more heterogeneous in the PH group, while a single right bronchial artery was the only clinical finding in 66.7% of controls (p = 0.001). Within the PH group, the CHD subgroup showed higher survival rate compared to the non-CHD-APAH group (p = 0.007).

CONCLUSION

BAE is effective and safe for the treatment of haemoptysis in PH, yet more challenging than other conditions. In PH-associated haemoptysis, BAE provides higher survival rate for subjects with PH associated with CHD.

Outcomes of Esophageal Arterial Embolization for Treatment of Hemoptysis

PURPOSE

To investigate safety and efficacy of esophageal arterial embolization (EAE) in addition to bronchial arterial embolization (BAE) for treatment of hemoptysis as well as the importance and characteristics of esophageal arteries in patients with hemoptysis.

MATERIALS AND METHODS

Between January 2013 and December 2014, 20 patients (13 men and 7 women, mean age 58.4 y) underwent EAE in addition to BAE for hemoptysis. Retrospective review of patient records was performed to evaluate major causes of hemoptysis, treatment indications based on CT findings, esophageal angiography findings, and outcomes after embolization including clinical success rate and complications.

RESULTS

Hemoptysis was caused by bronchiectasis (12 patients), tuberculosis (7 patients), and lobectomy (1 patient). CT showed lower lobe lung lesions in all (100%) patients. The esophageal arteries originated from the aorta between the carina and diaphragm (18 patients) or from the inferior phrenic arteries (2 patients) and were tortuous with longitudinal off-midline courses. Communications between the esophageal and the bronchial or inferior phrenic arteries were present in 12 patients. One patient who was treated using N-butyl cyanoacrylate developed dysphagia that resolved with medical treatment. Repeat BAE was performed in 2 patients 5 days and 20 days later, and the clinical success rate was 90% (18/20).

CONCLUSIONS

EAE in addition to BAE is safe in the treatment of hemoptysis and should be considered for lower lobe lesions.

Localization of bleeding sites in patients with hemoptysis based on their chest computed tomography findings: a retrospective cohort study

Background

The aim of this study was to propose a localization strategy for bleeding sites in hemoptysis patients using their chest computed tomography (CT) findings.

Methods

Between January 2005 and July 2009, the chest CT findings of 161 hemoptysis patients were retrospectively reviewed. Following chest CT, the lobe with the most prominent ground glass attenuation (GGA) or specific lesions with the potential to cause pulmonary hemorrhage were analysed to develop a localization strategy for bleeding sites. Fibre optic bronchoscopy (FOB) findings of active bleeding were used as the standard reference for the bleeding sites.

Results

The concordance rate between the most prominent GGA and FOB findings was higher than that between specific lesions and FOB findings (Kappa value [k] = 0.751 vs. 0.448, p < 0.001). Among the specific lesions, there were high concordance rates between lung cancer and FOB findings (3/3, 100%) and fungus balls and FOB findings (8/9, 89%). The agreement of localization of the bleeding site between FOB findings and the localization strategy based on chest CT findings including the most prominent GGA, lung cancer and fungus balls, showed almost perfect (k = 0.904).

Conclusions

The localization of bleeding sites in hemoptysis patients could be determined by chest CT findings such as the most prominent GGA, malignancy and fungus ball.

The Role of Interventional Oncology in the Management of Lung Cancer

Interventional radiological procedures for diagnosis and treatment of lung cancer have become increasingly important. Imaging-guided percutaneous biopsy has become the modality of choice for diagnosing lung cancer, and in the era of target therapies, it is an useful tool to define earlier patient-specific tumor phenotypes. In functionally inoperable patients, especially the ablative procedures are potentially curative alternatives to surgery. In addition to thermally ablative treatment, selective chemoembolization by a vascular access allows localized therapy. These treatments are considered for patients in a reduced general condition which does not allow systemic chemotherapy. The present article reviews the role of interventional oncology in the management of primary lung cancer, focusing on the state of the art for each procedure.

Unilateral Emphysema in Infancy, a Rare Presentation of Aberrant Bronchial Artery: Case Report and Review of Literature

Aberrant bronchial arteries are rarely seen and may originate from various vascular structures. Hemoptysis is the most common clinical presentation of cases with anomalous bronchial artery. We report a case of a 1-month-old infant presented with respiratory distress and left lung emphysema. Radiologic investigations and bronchoscopy revealed that the cause is an aberrant left bronchial artery compressing the left main bronchus. Surgical division of the aberrant vessel was performed with gradual improvement of the emphysema and respiratory distress. Unilateral emphysema due to vascular compression was previously reported. However, to the best of our knowledge, this is the first reported case of aberrant bronchial artery presenting with external compression of a main bronchus and unilateral emphysema. Also, this is the youngest reported case with an aberrant bronchial artery.