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Roussel A, Sage E, Roux A, Guth A, Mellot F, Gravel G. Bronchial artery embolization for hemoptysis in adult patients with cystic fibrosis: a single-center retrospective study. Acta Radiol 2023; 64:1381-1389. [PMID: 36802809 DOI: 10.1177/02841851221126833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Hemoptysis is a severe complication of cystic fibrosis (CF) for which bronchial artery embolization (BAE) is an efficient primary therapeutic option. However, recurrence is more frequent than for other etiologies of hemoptysis. PURPOSE To assess the safety and efficacy of BAE in patients with CF and hemoptysis and predictive factors for recurrent hemoptysis. MATERIAL AND METHODS This retrospective study reviewed all adult patients with CF treated by BAE for hemoptysis in our center from 2004 to 2021. The primary endpoint was the recurrence of hemoptysis after bronchial artery embolization. Secondary endpoints were overall survival and complications. We introduced the vascular burden (VB) defined as the sum of all bronchial artery diameters measured on pre-procedural enhanced computed tomography (CT) scans. RESULTS A total of 48 BAE were performed in 31 patients. A total of 19 recurrences occurred with a median recurrence-free survival of 3.9 years. In univariate analyzes, percentage of unembolized VB (%UVB) (hazard ratio [HR] = 1.034, 95% confidence interval [CI=1.016-1.052; P < 0.001) and %UVB vascularizing the suspected bleeding lung (%UVB-lat) (HR = 1.024, 95% CI=1.012-1.037; P < 0.001) were associated with recurrence. In multivariate analyzes, only %UVB-lat remained significantly associated with recurrence (HR = 1.020, 95% CI=1.002-1.038; P = 0.030). One patient died during follow-up. No complication of grade 3 or higher was reported according to the CIRSE classification system for complications. CONCLUSION When possible, unilateral BAE seems sufficient in patients with CF with hemoptysis even in such a diffuse disease involving both lungs. The efficiency of BAE could be improved by thoroughly targeting all arteries vascularizing the bleeding lung.
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Affiliation(s)
- Alexandre Roussel
- Department of Diagnostic and Interventional Radiology, Foch Hospital, Suresnes, France
| | - Edouard Sage
- Department of Thoracic Surgery, Foch Hospital, Suresnes, France
| | - Antoine Roux
- Department of Pneumology, Foch Hospital, Suresnes, France
| | - Axel Guth
- Department of Diagnostic and Interventional Radiology, Foch Hospital, Suresnes, France
| | - François Mellot
- Department of Diagnostic and Interventional Radiology, Foch Hospital, Suresnes, France
| | - Guillaume Gravel
- Department of Diagnostic and Interventional Radiology, Foch Hospital, Suresnes, France
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Role of Bronchial Artery Embolization as Early Treatment Option in Stable Cystic Fibrosis Patients with Sub-Massive Hemoptysis: Personal Experience and Literature Review. J Clin Med 2022; 11:jcm11216432. [PMID: 36362659 PMCID: PMC9657817 DOI: 10.3390/jcm11216432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/19/2022] [Accepted: 10/27/2022] [Indexed: 11/22/2022] Open
Abstract
(1) Background: We describe our experience with cystic fibrosis (CF) patients treated with bronchial artery embolization (BAE) for sub-massive hemoptysis to understand if early treatment of sub-massive hemoptysis can reduce the volume of any subsequent bleedings. (2) Materials: We performed a retrospective study including CF patients who underwent angiographic procedures for BAE following sub-massive hemoptysis, from March 2016 to December 2021. All patients underwent an initial chest angio-CT study. BAE was realized with microspheres or coils. (3) Results: Thirteen patients were included, subjected to at least one BAE after sub-massive hemoptysis, for a total of 19 procedures. Technical success was 94.7%; in a single case, the catheterization of the bronchial arterial feeder was not achievable and the procedure was repeated. Primary clinical success was 92.3%; secondary clinical success was 69.2%. Relative clinical success was 85%. A higher incidence of recurrent hemoptysis following treatment with coils was observed (100% of cases) compared to treatment with microspheres (54.5% of cases) χ2 = 5.43 (p < 0.05). (4) Conclusions: BAE is a safe and effective method for the treatment of hemoptysis in CF patients; it should be practiced not only after massive or recurrent hemoptysis but also in patients with sub-massive bleeding to improve their life expectancy and quality of life.
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3
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Dohna M, Renz DM, Stehling F, Dohna-Schwake C, Sutharsan S, Neurohr C, Wirtz H, Eickmeier O, Grosse-Onnebrink J, Sauerbrey A, Soditt V, Poplawska K, Wacker F, Montag MJ. Coil embolisation for massive haemoptysis in cystic fibrosis. BMJ Open Respir Res 2021; 8:8/1/e000985. [PMID: 34385150 PMCID: PMC8362706 DOI: 10.1136/bmjresp-2021-000985] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Accepted: 07/26/2021] [Indexed: 12/01/2022] Open
Abstract
Introduction Massive haemoptysis is a life-threatening event in advanced cystic fibrosis (CF) lung disease with bronchial artery embolisation (BAE) as standard of care treatment. The aim of our study was to scrutinise short-term and long-term outcomes of patients with CF and haemoptysis after BAE using coils. Methods We carried out a retrospective cohort study of 34 adult patients treated for massive haemoptysis with super selective bronchial artery coil embolisation (ssBACE) between January 2008 and February 2015. Embolisation protocol was restricted to the culprit vessel(s) and three lobes maximum. Demographic data, functional end-expiratory volume in 1 s in % predicted (FEV1% pred.) and body mass index before and after ssBACE, sputum colonisation, procedural data, time to transplant and time to death were documented. Results Patients treated with ssBACE showed significant improvement of FEV1% pred. after embolisation (p=0.004) with 72.8% alive 5 years post-ssBACE. Mean age of the patients was 29.9 years (±7.7). Mean FEV1% pred. was 45.7% (±20.1). Median survival to follow-up was 75 months (0–125). Severe complication rate was 0%, recanalisation rate 8.8% and 5-year-reintervention rate 58.8%. Chronic infection with Pseudomonas aeruginosa was found in 79.4%, Staphylococcus areus in 50% and Aspergillus fumigatus in 47.1%. Discussion ssBACE is a safe and effective treatment for massive haemoptysis in patients with CF with good results for controlling haemostasis and excellent short-term and long-term survival, especially in severely affected patients with FEV<40% pred. We think the data of our study support the use of coils and a protocol of careful and prudent embolisation.
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Affiliation(s)
- Martha Dohna
- Pediatric Radiology, Hannover Medical School, Hannover, Germany
| | | | - Florian Stehling
- Department of Pediatric Pulmonology and Sleep Medicine, University Hospital Essen, Essen, Germany
| | | | | | - Claus Neurohr
- Robert-Bosch-Krankenhaus Klinik Schillerhohe, Gerlingen, Germany
| | - Hubert Wirtz
- Department of Respiratory Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Olaf Eickmeier
- Department of Pneumology, Hospital of the Goethe University Frankfurt, Frankfurt am Main, Germany
| | | | | | - Volker Soditt
- Pediatrics, Stadtisches Klinikum Solingen, Solingen, Germany
| | - Krystyna Poplawska
- Pediatrics, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
| | - Frank Wacker
- Radiology, Hannover Medical School, Hannover, Germany
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4
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Haghi M, van den Oetelaar W, Moir LM, Zhu B, Phillips G, Crapper J, Young PM, Traini D. Inhalable tranexamic acid for haemoptysis treatment. Eur J Pharm Biopharm 2015; 93:311-9. [PMID: 25936858 DOI: 10.1016/j.ejpb.2015.04.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 04/21/2015] [Accepted: 04/23/2015] [Indexed: 10/25/2022]
Abstract
PURPOSE An inhalable dry powder formulation of tranexamic acid (TA) was developed and tested in a novel high-dose Orbital® multi-breath inhaler. The formulation was specifically intended for the treatment of pulmonary haemorrhage and wound healing associated with haemoptysis. METHODS Inhalable TA particles were prepared by spray drying and the powder characterised using laser diffraction, electron microscopy, thermal analysis, moisture sorption and X-ray powder diffraction. The aerosol performance was evaluated using cascade impaction and inline laser diffraction and interaction with epithelia cells and wound healing capacity investigated using Calu-3 air interface model. RESULTS The spray dried TA particles were crystalline and spherical with a D0.5 of 3.35 μm. The powders were stable and had limited moisture sorption (0.307%w/w at 90%RH). The Orbital device delivered ca. 38 mg powder per 'inhalation' at 60 l · min(-1) across four sequential shots with an overall fine particle fraction (⩽ 6.4 μm) of 59.3 ± 3.5% based on the emitted mass of ca. 150 mg. The TA particles were well tolerated by Calu-3 bronchial epithelia cells across a wide range of doses (from 1 nM to 10nM) and no increase in inflammatory mediators was observed after deposition of the particles (a decrease in IL-1β, IL-8 and INFγ was observed). Time lapse microscopy of a damaged confluent epithelia indicated that wound closure was significantly greater in TA treated cells compared to control. CONCLUSION A stable, high performance aerosol of TA has been developed in a multi-breath DPI device that can be used for the treatment of pulmonary lesions and haemoptysis.
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Affiliation(s)
- Mehra Haghi
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia
| | - Wilco van den Oetelaar
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia; Avans University of Applied Sciences, Hogeschoollaan 1, 4818 CR Breda, The Netherlands
| | - Lyn M Moir
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia
| | - Bing Zhu
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia
| | - Gary Phillips
- Pharmaxis Ltd, 20 Rodborough Rd, Frenchs Forest, NSW 2086, Australia
| | - John Crapper
- Pharmaxis Ltd, 20 Rodborough Rd, Frenchs Forest, NSW 2086, Australia
| | - Paul M Young
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia
| | - Daniela Traini
- Respiratory Technology, Woolcock Institute of Medical Research and Discipline of Pharmacology, Sydney Medical School, The University of Sydney, NSW 2037, Australia.
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Abstract
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.
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Affiliation(s)
- K Hurt
- Department of Respiratory Medicine, Kings College Hospital, Denmark Hill, London, SE5 9RS.
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6
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Cystic fibrosis and the thoracic surgeon. Eur J Cardiothorac Surg 2010; 39:716-25. [PMID: 20822917 DOI: 10.1016/j.ejcts.2010.07.024] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Revised: 07/19/2010] [Accepted: 07/21/2010] [Indexed: 11/21/2022] Open
Abstract
Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.
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Anomalous origin of bronchial arteries in patients with cystic fibrosis: therapeutic implications for embolisation. MINIM INVASIV THER 2009; 10:249-53. [PMID: 16754024 DOI: 10.1080/136457001753334305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Bronchial artery embolisation (BAE) is an accepted method of controlling haemoptysis in patients with cystic fibrosis. However, anomalous origin of the bronchial arteries, documented in anatomical and angiographic studies, makes the procedure more difficult and increases the number of recurrences. Clinical records and films from three patients affected by cystic fibrosis with haemoptysis, in which the origin of the bleeding vessels was considered anomalous, out of a total of seven patients who underwent BAE, were reviewed. In two patients the source of bleeding was identified from, respectively, the left and the right internal mammary artery and in one from the left thyrocervical trunk. All the vessels considered to be the possible source of haemoptysis were embolised; immediate control of haemoptysis after embolisation was achieved in all patients, but minor haemoptysis recurred in two patients who were conservatively treated. In haemoptysis in patients with cystic fibrosis the possibility of anomalous origin of the bronchial arteries should be considered. This frequency may be higher than in other pulmonary diseases that cause haemoptysis, so a search for anomalous bronchial arteries is mandatory to achieve accurate embolisation and reduce the rate of recurrence.
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8
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Abstract
Cystic fibrosis (CF) has a variety of pulmonary manifestations that include pneumonia, pulmonary abscess, bronchiectasis, hemoptysis, and pneumothorax. Although newer therapies have greatly improved survival of patients with CF, surgical interventions for definitive treatment of these sequelae are often required. Several reports have illustrated that, with the current advances in the perioperative treatment and care of CF patients, surgical interventions for these pulmonary manifestations may be performed safely, resulting in a greatly improved quality of life. Also, although improvements in lung transplantation offer new hope for definitive treatment of those patients with cystic fibrosis, special considerations regarding other surgical issues, such as the prevalence of gastroesophageal reflux, need to be addressed.
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Affiliation(s)
- Alex G Cuenca
- Department of Surgery, University of Florida, Gainesville, Florida, 32610-0286, USA
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Vidal V, Therasse E, Berthiaume Y, Bommart S, Giroux MF, Oliva VL, Abrahamowicz M, du Berger R, Jeanneret A, Soulez G. Bronchial Artery Embolization in Adults with Cystic Fibrosis: Impact on the Clinical Course and Survival. J Vasc Interv Radiol 2006; 17:953-8. [PMID: 16778227 DOI: 10.1097/01.rvi.0000222822.82659.50] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Although bronchial artery embolization (BAE) is effective in the acute control of recurrent or major hemoptysis in adults with cystic fibrosis, outcomes after embolization are not well known. The objective of this retrospective study was to evaluate respiratory function, survival, and hemoptysis-free survival in adult patients with cystic fibrosis treated for hemoptysis with BAE. MATERIALS AND METHODS Of 297 patients with cystic fibrosis hospitalized from 1990 to 2004, 30 patients (mean age, 26.7+/-9.2 years) presented with major or persistent hemoptysis that required 42 BAE sessions. These patients were compared with a control group of 27 patients without hemoptysis requiring embolization who were matched for age, sex, and forced expiratory volume in 1 second (FEV1). RESULTS Hemoptysis stopped within 24 hours after BAE in 96.6% of patients (n=29), and there were no major complications. The change in the slope of FEV1 after the BAE or matching date was significantly worse in the embolization group (P=.0007). At last follow-up, nine and one patients, respectively, had undergone lung transplantation in the BAE and control groups (P=.002). The 5-year survival rates without lung transplantation were 31% and 84%, respectively, in the BAE and control groups (hazard ratio, 5.95; P=.002). Sixty-two percent of patients were free of hemoptysis 5 years after BAE. The number of collateral arteries was the only factor associated with the risk of death or recurrent hemoptysis (P=.001). CONCLUSIONS Despite the effectiveness of embolization in controlling recurrent or major hemoptysis, adults with cystic fibrosis who have undergone BAE for hemoptysis are at much higher risk of respiratory function aggravation, death, and the need for lung transplantation than those who have not undergone BAE for hemoptysis. They are more likely to die or to undergo lung transplantation than to present with recurrent major hemoptysis.
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Affiliation(s)
- Vincent Vidal
- Department of Radiology, Hôpital Timone, Marseille, France, and Department of Radiology, Centre Hospitalier de l'Université de Montréal, Quebec, Canada
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10
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Barben JU, Ditchfield M, Carlin JB, Robertson CF, Robinson PJ, Olinsky A. Major haemoptysis in children with cystic fibrosis: a 20-year retrospective study. J Cyst Fibros 2004; 2:105-11. [PMID: 15463858 DOI: 10.1016/s1569-1993(03)00066-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2003] [Accepted: 03/14/2003] [Indexed: 11/30/2022]
Abstract
BACKGROUND Major haemoptysis occurs in approximately 1% of children with cystic fibrosis (CF). This report describes management and follow-up of these children at a tertiary centre in Australia. METHODS Retrospective review of medical records from 1980-1999. RESULTS Fifty-one children (45% female) had major haemoptysis (102 episodes). Mean age at first episode was 15 years (range 7-19) and mean FEV(1) was 56% predicted (range 14-98). Massive life-threatening haemoptysis was not confined to those with severe lung disease (FEV1 < 50% predicted). Bronchial artery embolisation (BAE) was more likely to be the initial treatment for those with massive haemoptysis and chronic recurrent bleeding tended to be treated conservatively (P = 0.01). Overall, 52 BAE were performed in 28 children with an immediate success rate of 98%; 13 children (46%) had repeated BAE. Four patients died as a direct result of severe haemoptysis. Mean follow-up was 54 months (range 0.5-183). Median survival time (Kaplan-Meier estimate) after first haemoptysis was 70 months, with a significantly longer survival for male patients independent of age (RR 3.8; 95% CI 1.7-8.8; P = 0.001). Median survival time following initial treatment with BAE was longer (103 months) compared to conservative treatment (52 months, P = 0.09). CONCLUSIONS Massive haemoptysis was unrelated to the severity of lung disease and was more likely to be treated with embolisation. BAE was highly effective, however, 46% of the children required re-embolisation at some time, which is similar to the recurrence risk for major hemoptysis treated conservatively on longer term follow-up.
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Affiliation(s)
- Juerg U Barben
- Department of Respiratory Medicine, Royal Children's Hospital, Parkville, Melbourne, Victoria 3052, Australia
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Furnari ML, Salerno S, Rabiolo A, Caravello V, Pardo F. Bronchial to subclavian shunt in a CF patient. A potential pitfall for embolization. J Cyst Fibros 2003; 2:217-9. [PMID: 15463877 DOI: 10.1016/s1569-1993(03)00095-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2003] [Accepted: 07/04/2003] [Indexed: 11/18/2022]
Abstract
Bronchial artery embolization is a well accepted and widely used technique in the management of massive haemoptysis in cystic fibrosis (CF). It can be a complex procedure requiring a deep knowledge of the bronchial artery anatomy including the possible bronchial anastomoses. We report a case of complex vascular anatomy of the left bronchial artery with multiple anastomoses with the ipsilateral subclavian artery as cause of non-attempted embolization.
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Affiliation(s)
- M L Furnari
- Cystic Fibrosis Regional Center, Children Hospital 'Di Cristina' ARNAS, Palermo, Italy
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12
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Barben J, Robertson D, Olinsky A, Ditchfield M. Bronchial artery embolization for hemoptysis in young patients with cystic fibrosis. Radiology 2002; 224:124-30. [PMID: 12091671 DOI: 10.1148/radiol.2241010654] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To review the authors' 15-year experience with bronchial artery embolization (BAE) for treatment of hemoptysis in young patients with cystic fibrosis. MATERIALS AND METHODS By searching the 1985-1999 radiology database, the authors identified 23 young patients who had been referred to the radiology department for angiography. Twenty of these patients underwent BAE. The 23 medical records were retrospectively reviewed with regard to embolization agents used, embolization success rates, number of repeat embolizations, survival times, and causes of death. RESULTS BAE was performed on 38 occasions in 20 patients. The mean age of patients at first BAE was 15 years (age range, 7-19 years). The majority (n = 34 [89%]) of BAEs were performed by using polyvinyl alcohol. The immediate success rate after BAE (ie, no recurrent bleeding within 24 hours) was 95% (36 of 38 BAEs). Eleven (55%) patients required more than one BAE, and the median time between first and second embolizations was 4 months (range, 5 days to 61 months). Three patients died as a consequence of severe hemoptysis during induction of anesthesia with intermittent positive pressure ventilation in preparation for BAE. The median survival duration after the first BAE (Kaplan-Meier estimate) was 84 months (average follow-up, 61 months; range, 5 days to 169 months). CONCLUSION BAE had a high success rate for short-term control of bleeding; however, more than half the patients required repeat embolization during the long-term follow-up.
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Affiliation(s)
- Juerg Barben
- Department of Respiratory Medicine, Royal Children's Hospital, Flemington Rd, Parkville 3052, Victoria, Australia
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13
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Máiz L, Girón R, Martínez MT, Prados C, Escobar H, Garzón G, Sánchez J, Mingo A, Blázquez J. [Life-threatening hemoptysis in cystic fibrosis: clinical characteristics and management in 36 episodes]. Med Clin (Barc) 2002; 118:299-301. [PMID: 11888498 DOI: 10.1016/s0025-7753(02)72365-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND Our goal was to evaluate the clinical characteristics and management of life-threatening hemoptysis in patients with cystic fibrosis (CF). PATIENTS AND METHOD We included adult CF patients followed up at the Cystic Fibrosis Units of the Autonomous Community of Madrid who had life-threatening hemoptysis from June 1990 to December 1999. RESULTS Twelve CF patients (4 females) developed 36 episodes of life-threatening hemoptysis (30 massive and 6 recurrent). Lung disease was moderate to severe. Sputum cultures revealed Pseudomonas aeruginosa in 10 patients. Thirteen episodes (36%) resolved upon antibiotic treatment and 3 (8%) after antibiotic therapy and bronchoscopy. Bronchial artery embolization (BAE) was performed in 20 of 36 events. Immediate technique success was achieved in 80% episodes (16 of 20) after one session, 85% (17/20) after two sessions, and 95% (19/20) after three sessions. No major complications associated with the procedure were seen. The overall recurrence rate per episode was 69% (24 of 35 episodes in 6 patients) with a mean time of recurrence of 13 months. There were no massive hemoptysis-associated deaths during the follow-up. CONCLUSIONS Life-threatening hemoptysis is a frequent complication in CF patients who have moderate or severe lung disease. When conservative therapeutic measures (including antibiotics) fail to control it, BAE should be performed. When performed by expert professionals, BAE is effective and safe to immediate control of life-threatening hemoptysis in patients with CF.
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Affiliation(s)
- Luis Máiz
- Servicio de Neumología, Unidad de Fibrosis Quística, Hospital Ramón y Cajal, Spain.
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14
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Antonelli M, Midulla F, Tancredi G, Salvatori FM, Bonci E, Cimino G, Flaishman I. Bronchial artery embolization for the management of nonmassive hemoptysis in cystic fibrosis. Chest 2002; 121:796-801. [PMID: 11888962 DOI: 10.1378/chest.121.3.796] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Hemoptysis is a common complication in patients with cystic fibrosis (CF). Current approaches to patients with hemoptysis include conservative medical therapy, bronchial artery embolization (BAE), and surgery. We investigated the effectiveness of early BAE on the outcome in patients with minor bleeding. DESIGN, PATIENTS, AND INTERVENTIONS We reviewed the clinical records from the Cystic Fibrosis Service for eight consecutive patients treated with medical therapy who had undergone early BAE and eight matched patients treated with conservative medical therapy alone. MEASUREMENTS We assessed the mean number of bleeding episodes, pulmonary exacerbations, lung function (FEV(1)), Shwachman score, and Nottingham Health Profile (NHP) scores, the year before BAE and for the 3 ensuing years. RESULTS During a 3-year follow-up, patients who underwent embolization had significantly fewer bleeding episodes (p < 0.001) and pulmonary exacerbations (p < 0.006). Lung function declined significantly in both groups (p < 0.001). The modified Shwachman score declined significantly during the follow-up only in patients who did not undergo embolization (p < 0.001). Patients treated by early embolization had significantly better NHP scores, indicating a better quality of life (p < 0.05). None of the patients who underwent BAE had adverse reactions. CONCLUSIONS Early BAE in patients with CF who have nonmassive hemoptysis is an effective, safe therapeutic approach offering better long-term control of recurrent bleeding and quality of life than medical therapy alone.
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Affiliation(s)
- Mariano Antonelli
- Department of Pediatrics, University of Rome La Sapienza, Rome, Italy.
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15
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John P. Thoracic interventional radiology in children. Paediatr Respir Rev 2001; 2:131-44. [PMID: 12531060 DOI: 10.1053/prrv.2000.0121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Significant technological advancements have been achieved in radiology with the introduction of a branch speciality known as interventional radiology. Radiology has moved into the therapeutic arena, performing minimally invasive diagnostic and therapeutic procedures. The interventional radiologist can treat certain vascular and non-vascular conditions with "keyhole" or perhaps more correctly "pinhole" techniques using catheter-based technology directed under image guidance with X-ray (including computed tomography), ultrasound and magnetic resonance imaging. Interventional radiology can provide new treatment options for children not possible a few years ago.
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Affiliation(s)
- P John
- Birmingham Children's Hospital NHS Trust, UK.
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16
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Kaukuntla HK, Amer KM, Honeybourne D, Stableforth DE, Khalil-Marzouk JF. Extrapleural bronchial artery ligation for life-threatening hemoptysis in cystic fibrosis--a case report. Angiology 2000; 51:787-92. [PMID: 10999621 DOI: 10.1177/000331970005100912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Hemoptyses are common in cystic fibrosis (CF) patients. They range from massive life-threatening (> 240 mL/24 hours) to recurrent minor streaking. Limited pulmonary reserve, potential concurrent chest infection, and the progressive nature of CF pose a high risk to this subgroup. Conservative management and selective bronchial artery embolization (BAE) control most acute episodes, but the recurrence rate is high. The possible need for lung transplantation in future makes an extrapleural approach for bronchial artery ligation desirable. The aim of this study was to assess the role of extrapleural bronchial artery ligation in the treatment of recurrent hemoptysis in CF patients. This is a retrospective analysis of four patients between 1986 and 1999 treated by extrapleural thoracotomy and ligation of bronchial arteries. Indications, surgical experience, and outcome are presented. Three patients underwent unilateral, and one patient bilateral extrapleural thoracotomy (in two separate sessions) for bronchial artery ligation. There were three men and one woman, with a mean age of 26.6 years (range 19-32 years). Indications were failure to stabilize the bronchial arterial catheter for BAE (three cases), recurrence after BAE previously controlled bleeding (one case), and communication with the right costocervical trunk signifying risk to the spinal circulation (one case). The mean follow-up was 68 months (range 3-144 months). There was one death in this series, a patient who was asphyxiated with hemoptysis, requiring ventilation preoperatively. He underwent successful extrapleural thoracotomy for bronchial artery ligation, with no further bleeding but succumbed to severe chest infection and multiorgan failure a few days later. Two patients had recurrent bleeding 12 and 36 months after surgery. Selective bronchial angiography proved the contralateral bronchial arteries to be the culprit. Extrapleural bronchial artery ligation is an effective method of controlling hemoptysis in CF, when BAE has failed. This approach minimizes pleural adhesions and is, therefore, desirable in the future consideration for lung transplantation. In this experience, muscle-sparing thoracotomy and postoperative epidural analgesia significantly improved the postoperative recovery.
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Affiliation(s)
- H K Kaukuntla
- Department of Thoracic Surgery, Birmingham Heartlands Hospital, UK
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Chapman SA, Holmes MD, Taylor DJ. Unilateral diaphragmatic paralysis following bronchial artery embolization for hemoptysis. Chest 2000; 118:269-70. [PMID: 10893396 DOI: 10.1378/chest.118.1.269] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Bronchial artery embolization is an effective treatment for patients with hemoptysis. Serious complications are rare, but may occur if the arterial supply to other structures is compromised. We present a case of unilateral diaphragmatic paralysis following bronchial artery embolization in a patient with cystic fibrosis. We believe that the diaphragmatic paralysis was due to the inadvertent obstruction of the left pericardiacophrenic artery during the embolization procedure, with compromise of the phrenic nerve blood supply. This resulted in a significant loss of lung function in our patient, who did not recover despite the subsequent return of diaphragmatic function.
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Affiliation(s)
- S A Chapman
- Royal Adelaide Hospital Chest Clinic, Adelaide, Australia.
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18
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Brinson GM, Noone PG, Mauro MA, Knowles MR, Yankaskas JR, Sandhu JS, Jaques PF. Bronchial artery embolization for the treatment of hemoptysis in patients with cystic fibrosis. Am J Respir Crit Care Med 1998; 157:1951-8. [PMID: 9620932 DOI: 10.1164/ajrccm.157.6.9708067] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Hemoptysis is common in patients with cystic fibrosis (CF). Bleeding may vary in severity, ranging from minor blood-streaking of sputum to expectoration of significant quantities of blood. Major hemoptysis, defined as bleeding greater than 240 ml/24 h, represents a medical emergency. Bronchial artery embolization (BAE) is one of the treatment options for hemoptysis. We reviewed the 10-yr experience at the University of North Carolina Hospitals in the treatment of hemoptysis by BAE. Eighteen patients with CF were hospitalized on 29 occasions and underwent 36 BAE procedures for the control of hemoptysis. Most patients (n = 11) had very severe lung disease (FEV1 < 35%) with a high incidence (n = 9, 50%) of multi-drug-resistant bacteria. Fifteen patients (n = 33 procedures) were followed for a mean of approximately 22 mo after BAE. The overall efficacy of BAE for initial control of hemoptysis was 75% (n = 22) after one session, 89% (n = 26) after two sessions, and 93% (n = 27) after three sessions. The overall recurrence rate per episode was 46% (12/26 presentations in four patients) with a mean time for recurrence of approximately 12 mo. There was a high incidence (75%) of bleeding from nonbronchial systemic collateral vessels among patients (n = 7) who had undergone a previous BAE. There were two deaths associated with massive hemoptysis despite BAE. Three patients had transient neurologic deficits during BAE. We concluded that BAE is a relatively safe and effective means of treating significant hemoptysis in patients with CF.
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Affiliation(s)
- G M Brinson
- Division of Pulmonary and Critical Care Medicine and the UNC-CF Center, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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19
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Affiliation(s)
- L J States
- Department of Radiology, Childrens' Hospital of Philadelphia, PA 19104, USA
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20
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Chang AB, Ditchfield M, Robinson PJ, Robertson CF. Major hemoptysis in a child with cystic fibrosis from multiple aberrant bronchial arteries treated with tranexamic acid. Pediatr Pulmonol 1996; 22:416-20. [PMID: 9016477 DOI: 10.1002/(sici)1099-0496(199612)22:6<416::aid-ppul12>3.0.co;2-c] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- A B Chang
- Department of Thoracic Medicine, Royal Children's Hospital, Melbourne, Victoria, Australia
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