Giant bronchoesophageal fistula: a rare complication of bronchial artery embolization

Case Report: Ectopic pulmonary embolism as a complication of bronchial artery embolization

Bronchial artery embolization (BAE) is currently the first-line treatment for massive hemoptysis. Previous studies have proven its safety and efficacy, with mild, transient, and reversible complications. This case described a patient with congenital multiple bronchopulmonary fistulas who underwent BAE due to massive hemoptysis. However, due to an overlooked and misdiagnosed atypical fistula, the patient experienced an ectopic pulmonary embolism and subsequently secondary pulmonary infarction. He eventually exhibited a full postoperative recovery following percutaneous catheter-directed embolectomy. This case revealed a type of occult fistula masked by multiple bronchial artery branches, which may be a potential risk factor for an ectopic pulmonary embolism during BAE. We propose that it is crucial to identify abnormal anastomosis, especially atypical fistula, and select appropriate embolization materials during BAE.

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.

Inhalable tranexamic acid for haemoptysis treatment

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.

Bronchial artery embolization for treatment of life-threatening hemoptysis

Massive hemoptysis is an emergent and life-threatening condition with a broad range of underlying causes. Fortunately, massive hemoptysis accounts for a minority of cases of hemoptysis, ~5%. Unlike hemorrhage in other areas of the body, the primary cause of death from pulmonary hemorrhage is most commonly asphyxiation rather than exsanguination. Given the limited capacity for the lung to preserve oxygen transfer in the setting of massive hemoptysis, a rapid and effective method for controlling hemorrhage is essential to minimize death in patients demonstrating respiratory compromise. Since its introduction in 1973, bronchial artery embolization has proven to be a safe and effective tool for the treatment of massive hemoptysis and is now considered the treatment of choice, with initial success rates ranging from 77 to 94%. The long-term control rate of hemoptysis ranges from 70 to 85% and is largely a function of the degree of inflammation and the natural progression of the underlying disease. This article reviews the current literature on bronchial artery embolization for the treatment of massive hemoptysis.

Long-term effect of bronchial artery embolization in Korean patients with haemoptysis

OBJECTIVE AND BACKGROUND

Bronchial artery embolization (BAE) has been regarded as a bridging therapy in the management of massive haemoptysis until a more definite therapy can be pursued. The long-term effectiveness of BAE and the factors associated with failure to control bleeding in an Asian setting of tuberculosis are unknown and were investigated.

METHODS

Over approximately 4 years, 139 patients received BAE to treat haemoptysis at a single centre, of these, 118 had been followed up for more than 1 year (median 23 months) and were retrospectively recruited into the study. Patients were divided into those who required readmission for treatment of recurrent haemoptysis after BAE (re-bleeding group), and those who did not (non-rebleeding group).

RESULTS

Of the 118 patients, 112 (95.8%) had haemoptysis of greater than 100 mL per day. The most common underlying cause of haemoptysis was pulmonary tuberculosis. Eight patients, four of whom had advanced lung cancer, died after BAE. There were 32 patients (27.1%) in the re-bleeding group. Aspergillosis was significantly associated with re-bleeding after BAE (P<0.05). There were no differences in gender, age, degree of haemoptysis, or APACHE II scores between the re-bleeding and non-rebleeding groups. Twelve patients in the re-bleeding group had a repeat BAE only, whereas seven underwent surgery after repeat BAE. Of the 118 patients who underwent initial BAE, one showed a transient spinal ischaemia.

CONCLUSIONS

BAE with appropriate medical treatment should be sufficient for most patients with massive haemoptysis. In patients with massive haemoptysis due to aspergilloma, however, elective surgery should be considered if bleeding is not controlled by repeated BAE.

Percutaneous embolotherapy for life-threatening hemoptysis

STUDY OBJECTIVES

The management of life-threatening hemoptysis frequently poses a therapeutic dilemma because such patients are often poor surgical risks. Less often, patients refuse surgical intervention. The value of percutaneous embolotherapy, a useful alternative in these situations, was assessed.

DESIGN, SETTING, PATIENTS, INTERVENTIONS

Sixteen consecutive patients who underwent percutaneous embolotherapy for life-threatening hemoptysis in a tertiary-care hospital were evaluated retrospectively. The bronchial arteries, as well as other intrathoracic arteries, were evaluated and selectively embolized if they were considered to supply the pathologic area from which the hemoptysis arose.

RESULTS

The most common cause for hemoptysis was posttuberculous bronchiectasis (n = 12) with or without mycetomas. Ten patients required blood transfusions before embolotherapy. Pleural disease was noted on the chest radiograph in 13 patients and was generally associated with the presence of nonbronchial systemic collateral vessels. In three patients, arteries other than the bronchial arteries were the only source of hemoptysis. Percutaneous embolotherapy was successful in controlling the hemoptysis in all patients. The only complication documented was a transient paraparesis in one patient. Six patients did not return for follow-up. Of the remaining 10 patients, 3 patients had minor episodes of hemoptysis that were treated conservatively with success. One patient had significant recurrent hemoptysis that was managed with radiotherapy. One patient subsequently underwent a lobectomy.

CONCLUSION

Percutaneous embolotherapy is a useful therapeutic modality in the management of life-threatening hemoptysis. The contribution of nonbronchial systemic collateral vessels, particularly where there is evidence of coexistent pleural disease, should always be suspected. In experienced hands, this is a safe and potentially life-saving procedure.

Treatment of recurrent severe hemoptysis in cystic fibrosis with tranexamic acid

Major hemoptysis is a potentially life-threatening complication of cystic fibrosis (CF) lung disease. Bronchial artery embolization (BAE) along with treatment of a CF pulmonary exacerbation has become the most widely used therapeutic approach for major hemoptysis in CF. However, BAE has been associated with severe complications, especially when bronchial artery to spinal artery anastomoses are present. This case study describes the successful treatment of major hemoptysis in CF with tranexamic acid, in an individual in whom 12 previous BAE procedures had been performed and further procedures were contraindicated secondary to bronchial artery to spinal artery collaterals. Recurrence of the hemoptysis occurred after attempts had been made to withdraw the tranexamic acid. Tranexamic acid was resumed with resolution of the hemoptysis, and the therapy has been used continuously for 13 months without any complications.

Benign tracheoesophageal fistula: results of surgical therapy

Acquired fistulas between the trachea and the esophagus (TEFs) are unusual, serious and still challenging clinical entities. Between 1980 and 1997, 31 patients with acquired benign TEF were evaluated and treated in our department. The definitive treatment was undertaken when patients were weaned from the ventilator. Dissection of the fistula and closure of the tracheal and esophageal defect was performed in 26 patients. Esophagogastroplasty plus closure of the tracheal defect and omental interposition was performed in two patients. Tracheal resection and reconstruction plus of the sternocleidomastoid muscle interposition was carried out in one patient with circumferential tracheal damage. In two patients, no surgical treatment was carried out. One patient died after surgical treatment. In 23 patients, long-term follow-up was excellent, with normal post-operative function of both the esophagus and the airway. Two failures of treatment occurred which required definitive tracheostomy plus T-tube. Management of TEFs can be safely carried out after weaning patients from the ventilator.

Esophageal perforation after sequential double-lung transplantation

The authors report a case of esophageal perforation after sequential double-lung transplantation for bronchiectasis. This complication was probably related to the devascularization of the esophageal wall during pneumonectomy.