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

[Severe hemoptysis in the onco-hematology patient]

In France, even though it occurs only exceptionally in cases of hemopathy, severe hemoptysis in cancer is the leading cause of hemoptysis. Without adequate treatment, in-hospital mortality exceeds 60%, even reaching 100% at 6 months. The management of severe hemoptysis should be discussed with the oncologist. Aside from situations of threatening hemoptysis, in which bronchoscopy should be performed immediately, CT angiography is an essential means of localizing the bleeding and determining the causes and the vascular mechanisms involved. In more than 90% of cases, hemoptysis is linked to systemic bronchial or non-bronchial hypervascularization, whereas in fewer than 5%, it is associated with pulmonary arterial origin or, exceptionally, with damage to the alveolar-capillary barrier. The most severely ill patients must be treated in intensive care in centers equipped with interventional radiology, thoracic surgery and, ideally, with interventional bronchoscopy. Interventional radiology is the first-line symptomatic treatment. In over 80% of cases, bronchial arteriography with embolization allows immediate control. Emergency surgery should be avoided, as it is associated with significant mortality. Appropriate and adequate care reduces hospital mortality to 30%, enabling patients to benefit from the most recent, survival-prolonging treatments.

Revisiting Spinal Cord Infarction after Bronchial Artery Embolization

It is unusual to write a letter to the editor of the Journal of Vascular and Interventional Radiology about an article published in a different journal. Unfortunately, this important article has gone relatively unnoticed in the interventional radiology community. The author's hope is that this letter draws attention to this rare, severe complication related to BAE. Superselective coil embolization for BAE should be revisited and studied to demonstrate its true effectiveness and complication rate. Ultimately, patients and their physicians must decide whether they want to incur a higher risk of paraplegia versus a potentially higher risk of recurrence and death.

Society of Chest Imaging and Interventions Consensus Guidelines for the Interventional Radiology Management of Hemoptysis

The recommendations from the Society of Chest Imaging and Interventions expert group comprehensively cover all the aspects of management of hemoptysis, highlighting the role of diagnostic and interventional radiology. The diversity existing in etiopathology, imaging findings, and management of hemoptysis has been addressed. The management algorithm recommends the options for effective treatment while minimizing the chances of recurrence, based on the best evidence available and opinion from the experts.

A 65-Year-Old Man With Massive Hemoptysis

CASE PRESENTATION

A 65-year-old man experienced a cough and mild hemoptysis suddenly one morning. He was prescribed tranexamic acid and carbazochrome salicylate by the local clinic at the first visit, and his hemoptysis stopped. However, 2 days later, he experienced recurrent hemoptysis that was prolonged intermittently. He had slight dyspnea and chest discomfort, but no other symptoms, such as sputum, fever, or chest pain. He was referred to our hospital for further assessment of hemoptysis. He had experienced mild hemoptysis of unknown causes 8 years earlier without recurrence until this episode. He had bronchial asthma that was treated with an inhaled corticosteroid and hypertension and hyperuricemia that were untreated with medication. He had no known allergies or family history of lung disease. He did not smoke. The patient denied alcohol consumption, any recent travel, or exposure to TB.

Prevalence of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization

OBJECTIVES

To identify the prevalence of non-bronchial systemic culprit arteries and their relationship to bleeding lobes in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization (BAE).

METHODS

Data of 83 consecutive patients with bronchiectasis and chronic pulmonary infection (non-tuberculous mycobacteriosis, aspergillosis, and tuberculosis) who underwent de novo BAE between January 2019 and December 2020 were retrospectively reviewed. The prevalence of culprit arteries was investigated.

RESULTS

Fifty-five patients (66%) had 172 non-bronchial systemic culprit arteries. The bleeding lobes were the right upper, right middle, right lower, left upper, and left lower lobes in 14 (17%), 20 (24%), 7 (8%), 31 (37%), and 11 (13%) patients, respectively. The internal thoracic (49%; n = 41), intercostal (28%; n = 23), and inferior phrenic (28%; n = 23) arteries were the top three non-bronchial systemic culprit arteries, which were involved in all five types of bleeding lobes. The costocervical trunk and thoracoacromial and lateral thoracic arteries were predominant in patients with upper lobe bleeding. Ligament arteries were predominant in patients with left lower lobe bleeding.

CONCLUSIONS

These findings will better ensure the identification of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection. All systemic arteries, especially those which are adjacent to the lung lesions, should be evaluated carefully using MDCT; the internal thoracic, intercostal, and inferior phrenic arteries should be proactively assessed using angiography.

KEY POINTS

• Non-bronchial systemic culprit arteries were identified in 66% of patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization. • The internal thoracic (49%), intercostal (28%), and inferior phrenic (28%) arteries were the top three arteries, which were involved in all five types of bleeding lobes. • The costocervical trunk and thoracoacromial and lateral thoracic arteries were prominent in patients with upper lobe bleeding, and the ligament artery was prominent in patients with left lower lobe bleeding.

CIRSE Standards of Practice on Bronchial Artery Embolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing bronchial artery embolisation to effectively treat haemoptysis. It has been developed by an expert writing group established by the CIRSE Standards of Practice Committee.

Bronchial artery aneurysm: Prevalence, clinical characteristics, and long-term prognosis following bronchial artery embolization

PURPOSE

To investigate the prevalence, clinical characteristics, and long-term prognosis of bronchial artery aneurysm (BAA) following bronchial artery embolization (BAE).

MATERIALS AND METHODS

The medical records of consecutive patients who underwent bronchial artery angiography between August 2013 to December 2019 were reviewed retrospectively. Patients who were diagnosed with BAA during this period were enrolled in this study. The prevalence, patients' characteristics, symptoms, comorbidities, angiographic findings, and long-term prognosis following BAE were investigated.

RESULTS

BAA was observed in 20 out of 508 patients who underwent bronchial artery angiography (3.9%). The patients' median age was 69 years (range 44-91). The main causes of BAA were cryptogenic, bronchiectasis/cystic fibrosis, and pulmonary aspergillosis. The median diameter of the ruptured BAAs was significantly smaller than that of the unruptured BAAs [5.4 mm (4.8-7.3 mm) versus 9.0 mm (7.2-13.9 mm), p = 0.009]. All patients were successfully treated with BAE without major adverse events. The median follow-up period after BAE was 970 (quartiles: 561-1796) days. The BAA-related survival rate was 100% at 2 and 3 years after BAE, and the overall survival rate after BAE was 89.2% (95% CI: 89.0-89.3) at 2 years and 74.3% (95% CI, 74.0-74.5) at 3 years. BAA related adverse events and mortality did not occur during the follow up period.

CONCLUSION

BAA was observed in 3.9 % (20/508) of patients who underwent bronchial artery angiography. All patients with BAA were successfully treated by BAE. BAA rupture and consequent mortality did not occur during follow up period.

Long-term prognostic outcomes in patients with haemoptysis

Background

Haemoptysis is a challenging symptom that can be associated with potentially life-threatening medical conditions. Follow-up is key in these patients to promptly detect new or misdiagnosed pathologic findings. Few prospective studies have evaluated long-term prognostic outcomes in patients with haemoptysis. Furthermore, the role played by antiplatelet and anticoagulant drugs on mortality and recurrence rates is unclear. The aim of this study was to assess mortality after 18 months of follow-up. Furthermore, the incidence of recurrence and the risk factors for recurrence and death were evaluated (including the role played by anticoagulant and antiplatelet drugs).

Methods

Observational, prospective, multicentre, Italian study.

Results

451/606 (74.4%) recruited patients with haemoptysis completed the 18 months follow-up. 22/604 (3.6%) diagnoses changed from baseline to the end of the follow-up. 83/604 (13.7%) patients died. In 52/83 (62.7%) patients, death was the outcome of the disease which caused haemoptysis at baseline. Only the diagnosis of lung neoplasm was associated with death (OR (95%CI): 38.2 (4.2–347.5); p-value: 0.0001). 166 recurrences were recorded in 103/604 (17%) patients. The diagnosis of bronchiectasis was significantly associated with the occurrence of a recurrence (OR (95% CI): 2.6 (1.5–4.3)); p-value < 0.0001). Anticoagulant, antiaggregant, and anticoagulant plus antiaggregant drugs were not associated with an increased risk of death and recurrence.

Conclusions

Our study showed a low mortality rate in patients with haemoptysis followed-up for 18 months. Pulmonary malignancy was the main aetiology and the main predictor of death, whereas bronchiectasis was the most frequent diagnosis associated with recurrence. Antiplatelet and/or anticoagulant therapy did not change the risk of death or recurrence. Follow-up is recommended in patients initially diagnosed with lower airways infections and idiopathic bleeding.

Trial registration: NCT02045394

Combined therapy with bronchial artery embolization and tranexamic acid for hemoptysis

BACKGROUND

While most previous studies have viewed tranexamic acid as a bridging or temporary therapy, our preliminary study offers insights into the combined therapy of antifibrinolytic agent with endovascular treatment for hemoptysis.

PURPOSE

To investigate the feasibility and safety of combined therapy, to analyze factors affecting the outcomes of combined therapy, and to compare the effectiveness of combined therapy between groups with different etiologies.

MATERIAL AND METHODS

Between January 2011 and December 2014, 64 patients (33 men, mean age 64.6 years) underwent combined therapy for hemoptysis. The median follow-up time was 14.7 months (range 174-2435 days). Patients were divided into a tuberculosis group (Group_TB, n=37) and a non-tuberculosis group (Group_non-TB, n=27).

RESULTS

Embolotherapy was technically successful in 62/64 (96.9%) cases. The immediate clinical success rate was 96.8% (60/62). The short-term and long-term recurrence rates were 12.9% (n=8) and 19.4% (n=12), respectively. The one-, two-, and four-year recurrence-free survival rates were 61%, 49%, and 32%, respectively. There was no significant survival difference between the two groups. Suboptimal embolization was a significant risk factor for immediate clinical failure (odds ratio 29.624, P = 0.023). Optimal embolization (hazard ratio [HR] 0.199, P = 0.023) and older age (HR 0.956, P = 0.013) were significantly associated with lower recurrence risk.

CONCLUSION

Combined therapy is an effective and safe treatment modality for hemoptysis of various etiologies, with potential benefits for short-term recurrence vis-a-vis current literature evidence. Suboptimal embolization was the most important modifiable risk factor for treatment failure and recurrence after combined therapy.

Intraoperative bronchial blood flow evaluation using indocyanine green fluorescence for bronchoplasty: A case report

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Indocyanine green fluorescence (ICG-FL) detects blood flow of the bronchial artery.

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ICG-FL is effective for blood flow evaluation after bronchial artery embolization.

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Bronchial blood flow evaluation may reduce the risk of anastomotic leakage.

Introduction and importance

Blood flow evaluation of bronchial arteries using indocyanine green fluorescence (ICG-FL) is rarely reported during pulmonary resection. We present the case of a patient with bronchiectasis and a history of bronchial artery embolization (BAE) for hemoptysis. Bronchial artery blood flow was evaluated using ICG-FL during lobectomy with bronchoplasty.

Case presentation

A 63-year-old woman presented with right middle lobe bronchiectasis (due to nontuberculous mycobacteriosis) and repeated hemoptysis, which had previously been corrected each time with hemostasis by BAE. Bronchoscopy revealed a swollen blood vessel proximal to the right middle lobe bronchus that was suspected of being the origin of bleeding. Right middle lobectomy with bronchoplasty was performed to prevent hemoptysis. ICG-FL was used to detect the patency of the right bronchial arteries, and the arteries surrounding the right middle lobe bronchus were ligated. The proximal side of the right middle lobe bronchus was cut in a deep wedge shape, and the bronchus was anastomosed. ICG-FL revealed that the blood supply was maintained at the bronchial anastomosis. No bronchial anastomotic leakage was observed after the surgery.

Clinical discussion

The key to successful bronchoplasty is the maintenance of blood flow. Bronchial artery blood flow theoretically decreases after BAE. In this case, ICG-FL was able to detect bronchial artery patency before cutting the bronchus as well as the maintenance of blood flow at the bronchial anastomosis after bronchoplasty.

Conclusion

Intraoperative blood flow evaluation of the bronchus using ICG-FL may reduce the risk of bronchial anastomotic leakage caused by ischemia after bronchoplasty.

Spinal Cord Infarction after Bronchial Artery Embolization for Hemoptysis: A Nationwide Observational Study in Japan

Background The most serious complication of bronchial artery embolization (BAE) for hemoptysis is spinal cord infarction. However, because it is rare, previous reports from single institutions have been insufficient to determine the actual prevalence of spinal cord infarction after BAE. Purpose To investigate the actual prevalence of spinal cord infarction as a complication of BAE using a nationally representative inpatient database. Materials and Methods This retrospective study was performed using data from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2018. The authors identified patients who were diagnosed with hemoptysis and underwent BAE during hospitalization. The overall prevalence of spinal cord infarction after BAE was determined. The authors also compared the prevalence of spinal cord infarction using the Fisher exact test according to the embolic agent used for BAE: coils, gelatin sponge (GS) particles, and N-butyl-2-cyanoacrylate (NBCA). Results During the study period, 8563 patients (mean age ± standard deviation, 68 years ± 13; 5103 men) met the inclusion criteria. Among these 8563 patients, 1577 (18%), 6561 (77%), and 425 (5%) underwent BAE with coils, GS particles, and NBCA, respectively. The overall prevalence of spinal cord infarction as a complication of BAE was 0.19% (16 of 8563 patients). The prevalence of spinal cord infarction after BAE with coils, GS particles, and NBCA was 0.06% (one of 1577 patients), 0.18% (12 of 6561 patients), and 0.71% (three of 425 patients), respectively (P = .04). Conclusion With use of a nationwide real-world inpatient database, the results of this study demonstrated that the actual prevalence of spinal cord infarction as a complication of bronchial artery embolization (BAE) for hemoptysis was 0.19%. Patients who underwent BAE with coils had a lower prevalence of spinal cord infarction than patients who underwent BAE with gelatin sponge particles or N-butyl-2-cyanoacrylate. © RSNA, 2021.

The impact of bronchial artery embolisation on the quality of life of patients with haemoptysis: a prospective observational study

Objectives

Patients with haemoptysis often experience daily physical and mental impairment. Bronchial artery embolisation is among the first-line treatment options used worldwide; however, no evidence exists regarding the health-related quality of life (HRQoL) after bronchial artery embolisation. Therefore, this study aimed to evaluate the effects of bronchial artery embolisation on the HRQoL of patients with haemoptysis.

Methods

We prospectively enrolled 61 consecutive patients who visited our hospital from July 2017 to August 2018 and received bronchial artery embolisation for haemoptysis. The primary outcome was the HRQoL evaluated using the Short Form Health Survey, which contains physical and mental components, before and after bronchial artery embolisation. The secondary outcomes were procedural success, complications, and recurrence-free survival rate at 6 months.

Results

The mean age of the patients was 69 years (range, 31–87 years). The procedural success rate was 98%. No major complications occurred. The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8% (95% confidence interval, 91.1–92.5%). Compared with the pre-treatment scores, the physical and mental scores were significantly improved at 6 months after bronchial artery embolisation (p < 0.05).

Conclusion

Bronchial artery embolisation improved the HRQoL of patients with haemoptysis.

Key Points

• Bronchial artery embolisation improved the HRQoL of patients with haemoptysis.

• Vessel dilation on computed tomography and systemic artery-pulmonary artery direct shunting on angiography were the most common abnormalities.

• The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8%.

Effectiveness of bronchial arterial embolization using N-butyl-2-cyanoacrylate for local control of pulmonary hilar or mediastinal tumors that are refractory to chemotherapy

PURPOSE

To investigate local control and survival after bronchial artery embolization (BAE) using N-butyl-2-cyanoacrylate (NBCA) for pulmonary hilar or mediastinal tumors that are refractory to chemotherapy or chemoradiotherapy.

METHOD

This is a single center retrospective study involving 42 patients treated between 2015 and 2018 for pulmonary hilar or mediastinal tumors (primary tumors in 5 and metastatic ones in 37). Tumor histology was sarcoma in 22 and carcinoma in 20 patients. All patients had shown tumor progression regardless of previous chemotherapy (n = 37) or chemoradiotherapy (n = 5). Thirty-seven patients (88 %) had respiratory symptoms, such as cough, dyspnea, and hemoptysis. BAE was performed using NBCA to shrink tumors for extending life expectancy. Target tumors were followed with computed tomography at 1,3, and 6 months after BAE. Endpoints included the best tumor response within 6 months as well as overall survivals in patients with and without tumor responses.

RESULTS

Best local responses within 6 months were complete response (CR) in 1 patient, partial response (PR) in 16, stable disease (SD) in 24, and progressive disease (PD) in 1; the CR/PR rate was 40 % (17/42). Median follow-up period was 13 months (range:1-43). Overall survival in patients with CR/PR was significantly better than in those with SD/PD (p = 0.006); with 3-year survival rates of 45 % (8/17) and 0% (0/25), respectively.

CONCLUSIONS

BAE using NBCA has potential promise for shrinking hilar and/or mediastinal tumors that are refractory to chemotherapy or chemoradiotherapy, and may also improve overall survival in patients who respond.

How to avoid describing your radiological research study incorrectly

Abstract

This review identifies and examines terms used to describe a radiological research “study” or “trial”. A taxonomy of clinical research descriptions is explained with reference to medical imaging examples. Because many descriptive terms have precise methodological implications, it is important that these terms are understood by readers and used correctly by researchers, so that the reader is not misled.

Key Points

• Multiple different terms are being used to describe radiological research “studies” and “trials”, and many of these terms have precise methodological implications.

• Radiological researchers sometimes use titles that describe their research incorrectly. This can mislead the reader as to what was actually done.

• It is important that readers and researchers understand the correct taxonomy of clinical research and that researchers adopt the correct description for their work.

Erratic coil migration in the bronchus after bronchial artery embolization

Herein, we report two cases of erratic coil migration from the bronchial artery to the bronchus after bronchial artery embolization (BAE). Neither patient exhibited haemoptysis recurrence, but chest radiographs revealed that part of the coil had disappeared. In Case 1, the patient coughed up the coil 4.5 years after BAE. We performed repeat BAE to minimize the possibility of haemoptysis considering bronchoscopic and angiographic findings. In Case 2, the patient had severe dry cough 2 years after BAE. Chest radiography showed migrated coils in the trachea; bronchoscopy revealed a migrated fragment of the coil protruding from the elevated mucosa. We used a loop cutter to split the coil and then removed it using forceps. Coil migration to the bronchus is an infrequent late-stage complication of super-selective bronchial artery coil embolization, and only one other case has been reported. Accordingly, we propose treatment strategies and speculate on the mechanism of fistula formation.