Preprocedural Planning with Prospectively Triggered Multidetector Row CT Angiography Prior to Bronchial Artery Embolization in Cystic Fibrosis Patients with Massive Hemoptysis

[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.

Management of life-threatening hemoptysis in the ICU

Life-threatening hemoptysis is commonly encountered in the ICU and its management can be challenging even for experienced clinicians. Depending on the etiology and severity, one can tailor the treatment modality and therapeutic intervention(s). The grading of severity of hemoptysis varies greatly in the literature; however, unlike hemorrhage in other scenarios, small amounts of blood can significantly impair oxygenation and ventilation leading to cardiovascular collapse. Importantly, the initial evaluation and management should focus on airway and hemodynamic stabilization along with maintenance of oxygenation and ventilation. In this review, we discuss commonly encountered etiologies, vascular anatomy, diagnostic evaluation, and therapeutic interventions. We examine the evolving trends in etiologies of life-threating hemoptysis over the years. The role of flexible and rigid bronchoscopy as both a diagnostic and therapeutic modality is explored, as well as the use and indications of several bronchoscopic techniques, such as topical hemostatic agents, endobronchial tamponade, and tranexamic acid (TXA). In addition, we assess the use of multi-row detector computed tomography as the initial rapid diagnostic method of choice and its use in planning for definitive treatment. The efficacy and long-term results of bronchial artery embolization (BAE) are evaluated, as well as indications for surgical intervention. Furthermore, the importance of a multidisciplinary approach is emphasized. The necessary interplay between intensivists, consultative services, and radiologists is described in detail and an algorithmic management strategy incorporating the above is outlined. Given the complexity in management of life-threatening hemoptysis, this paper aims to summarize the available diagnostic and therapeutic methods and provide a standardized approach for the management of patients with this often difficult to treat condition.

Transarterial management of advance lung cancer

Previous reports on transarterial treatment for lung cancer were reviewed. The bronchial arterial infusion therapy has a long history since 1964. Better local control with less doses of anti-neoplastic agents was warranted by trying transarterial administration to lung and mediastinal tumors. It is reported that both primary and metastatic tumors are fed by bronchial or other systemic arteries. The bronchial arterial embolization for hemoptysis has been introduced for clinical practice since 1973. Hemoptysis by not only benign but also malignant diseases has been well controlled by embolization. In recent decades, the technical elements for transarterial treatments have markedly improved. They make it possible to carry out precise procedures of selective catheter insertion to the tumor relating arteries. Current concepts of transarterial treatment, technical aspects and treatment outcomes are summarized. Tentative result from chemo-embolization for advanced lung cancer using recent catheter techniques was also described. It provides favorable local control and survival merits. It is considered that a population of lung cancer patients can benefit from transarterial management using small doses of anti-neoplastic agents, with less complications and less medical costs.

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.

Management of severe hemoptysis

INTRODUCTION

Though rare, severe hemoptysis (SH) is associated with a mortality rate exceeding 50% when not managed properly. Areas covered: This paper reviews the recent epidemiological data regarding SH, the role of multidetector computed tomography angiography (MDCTA), and fiberoptic bronchoscopy (FOB) in its management, as well as the value of current treatments. Expert commentary: MDCTA is becoming an essential modality, since it allows determining the location, etiology, and mechanism of the bleeding. FOB can be delayed, except when local control of bleeding is required. Emergency treatment relies on interventional radiology. Both bronchial and non-bronchial arteries should be explored during bronchial arteriography. Surgery must be considered in all operable patients if the cause of hemoptysis persists.

Electrocardiography-Gated Computed Tomography of the Bronchial Arteries With Iterative Image Reconstruction: Clinical Evaluation and Image Quality

BACKGROUND

The aim of this study was to apply electrocardiography (ECG)-gated prospective-triggered multidetector row computed tomography angiography with iterative model reconstruction (IMR) to optimize imaging of the bronchial arteries in patients with the chief complaint of hemoptysis.

METHODS

This was a prospective observational study. Between August 2015 and June 2016, we enrolled 31 consecutive patients with the chief complaint of hemoptysis who were scheduled to undergo computed tomography of the bronchial artery. Patients were randomly divided into 3 groups: group A, with filtered back-projection reconstruction; group B, with iDose reconstruction; and group C, with ECG-gated prospective-triggered multidetector row computed tomography angiography with IMR. Image quality, visibility, and traceability were compared.

RESULTS

Image quality, including signal-to-noise and contrast-to-noise ratios, visibility, and traceability, was best in group C.

CONCLUSIONS

With the help of IMR and ECG-synchronized prospective-triggered technology, the bronchial artery anatomy can be accurately depicted in patients with massive hemoptysis.

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

INTRODUCTION

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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