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

Development of a model to predict recurrence after bronchial artery embolization for non-cancer related hemoptysis

Background

Relapse after effective bronchial arterial embolization (BAE) for controlling hemoptysis is not uncommon. Studies reported diverse predictors of recurrence. However, a model to assess the probability of recurrence in non-cancer related hemoptysis patients after BAE has not been reported. This study was to develop a model to predict recurrence after BAE for non-cancer related hemoptysis.

Methods

The study cohort included 487 patients who underwent BAE for non-cancer-related hemoptysis between January 2015 and December 2019. We derived the model’s variables from univariate and multivariate Cox regression analyses. The model presented as a nomogram scaled by the proportional regression coefficient of each predictor. Model performance was assessed with respect to discrimination and calibration.

Results

One-month and 1-, 2-, 3- and 5-year recurrence-free rates were 94.5%, 88.0%, 81.4%, 76.2% and 73.8%, respectively. Risk factors for recurrence were underlying lung diseases and the presence of systemic arterial-pulmonary circulation shunts. This risk prediction model with two risk factors provided good discrimination (area under curve, 0.69; 95% confidence interval, 0.62–0.76), and lower prediction error (integrated Brier score, 0.143).

Conclusion

The proposed model based on routinely available clinical and imaging features demonstrates good performance for predicting recurrence of non-cancer-related hemoptysis after BAE. The model may assist clinicians in identifying higher-risk patients to improve the long-term efficacy of BAE.

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.

Recurrent massive hemoptysis in a patient with cystic fibrosis: balloon assisted Onyx embolization after bronchial artery coil recanalization

Background

Although not standard of care, Cystic Fibrosis patients with recurrent hemoptysis occasionally have coil embolization of bronchial arteries. In the event of recanalization of these arteries in this specific subset of patients, the presence of indwelling coils makes the prospect of conventional particle embolization more difficult, preventing both adequate catheterization of the coiled segment and reflux of the particles.

Case presentation

In this report, we describe a case of bronchial artery embolization of a complex Cystic Fibrosis patient with massive hemoptysis from recanalized coiled bronchial arteries utilizing a Scepter Balloon Catheter® (Microvention Terumo, USA) in administration of the liquid embolic agent Onyx® (Medtronic, USA).

Conclusions

The Scepter occlusion balloon catheter allowed for careful placement of the tip within the interstices of the pre-existing coils, allowing for Onyx injection directly into the coil mass without reflux, reconfirming the benefits of Onyx embolization in bronchial artery embolization and providing evidence that the Scepter occlusion balloon catheter should be added to the armamentarium of devices used in complex bronchial artery embolization for Cystic Fibrosis patients with massive hemoptysis.

Evaluation of the bronchial arteries: normal findings, hypertrophy and embolization in patients with hemoptysis

The enlargement of the bronchial arteries occurs in a multitude of congenital and acquired diseases and is responsible for the majority of cases of hemoptysis. In this review, we provide a simplified imaging approach to the evaluation of the bronchial arteries. We highlight the anatomy and function of the bronchial arteries, typical imaging findings, how to recognize bronchial artery dilatation, and its underlying causes. Contrast-enhanced computer tomography plays a major role in diagnosing bronchial artery enlargement and also improves treatment planning. Bronchial artery embolization has proven to be effective in controlling the potential hazardous hemoptysis.

Management of hemoptysis in patients with lung cancer

Hemoptysis related to malignancy is common and accounts for nearly a quarter of all cases of hemoptysis in the US, and approximately 20% of patients with lung cancer will experience some degree of hemoptysis during their disease course. Both minor and massive hemoptysis come with diagnostic and treatment challenges and are associated with increased mortality. We will discuss the definition and epidemiology of hemoptysis related to malignancy, outline our approach to the initial evaluation and diagnostic workup, and extensively review the management of minor and massive hemoptysis. Specific emphasis will be on relevant signs and symptoms, imaging, and the role of bronchoscopy, and the differences in approach for minor hemoptysis compared to massive hemoptysis. While the role of surgical management is very limited in this patient population, the role of endobronchial and endovascular management will be discussed in detail.

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.

A systematic approach to the management of massive hemoptysis

Massive hemoptysis is regarded as a potentially lethal condition that requires immediate attention, and prompt action. Although minor hemoptysis is frequently encountered by most clinicians, massive hemoptysis in far less frequent and most physicians are not prepared to manage this time-sensitive clinical presentation in a systematic and timely fashion. Critical initial steps in management need to be implemented in an expedited fashion, such that patients may have a chance at a more definitive treatment. In this article, we review the definition, vascular anatomy, etiology, diagnostic evaluation, epidemiology and prognostic markers of massive hemoptysis. A systematic approach to management, stabilization and treatment options is followed. An algorithm is proposed for the management of massive hemoptysis and the importance of a multidisciplinary approach is emphasized.

[The features of diagnosis and treatment of traumatic and non-traumatic pulmonary bleeding]

AIM

To analyze an efficacy of differentiated approach for pulmonary bleeding of different etiology and severity.

MATERIAL AND METHODS

The study included 134 cases of pulmonary bleeding for the period 2006-2015 including 53 patients with traumatic and 81 with non-traumatic etiology. Men/women ratio was 2.7:1, mean age was 43 years. Comparative retrospective analysis of X-ray and CT data in diagnosis of bleeding source was performed. Bronchoscopy was used to confirm these data. There were 43 endovascular examinations including 40 cases of bronchial arteriography (BAG).

RESULTS AND DISCUSSION

X-ray and CT-signs of bleeding source were detected more often in case of traumatic pulmonary bleeding (62.3% and 93%) compared with non-traumatic (27.2 and 54%; p<0.05). Bronchoscopy revealed ongoing pulmonary bleeding in 40 (30%) patients, completed - in 94 (70%) patients. Indirect angiographic signs were the most frequent for pulmonary bleeding origin: hypervascularization (32.6%), bronchial-pulmonary shunts (23.2%) and bronchial artery dilatation (20.9%). 17 patients with ongoing bleeding underwent bronchial obstruction with adequate hemostasis in all cases. Endovascular interventions included bronchial arteries embolization (EBA) (33), occlusion of intercostal arteries (3) and segmental branches of low-lobar pulmonary artery (1), aortic stenting (1). Early efficacy of EBA was 97% with 2 month recurrence of pulmonary bleeding near 12.5%. Ongoing traumatic pulmonary bleeding was an indication for emergency thoracotomy in 18.9% compared with 12.3% for non-traumatic bleeding when surgery was made after endoscopic and endovascular hemostasis.

CONCLUSION

Differentiated approach depending on etiology and severity of pulmonary bleeding improves outcomes and reduces the number of operations for ongoing severe bleeding.

A retrospective analysis of 334 cases of hemoptysis treated by bronchial artery embolization

OBJECTIVES

To analyze the safety and efficacy of bronchial artery embolization (BAE) in the management of hemoptysis.

METHODS

We conducted a retrospective study of 334 patients who had undergone BAE for hemoptysis from January 2007 to July 2013. Our study included 255 (76.3%) males and 79 (23.7%) females with an age range from five to 81 years old. All relevant arteries were evaluated but only those arteries that showed hypertrophy and significant blush were targeted. Polyvinyl alcohol (PVA) was used in all patients and gel foam was used in combination with PVA where there was significant shunting.

RESULTS

Mild hemoptysis was seen in 70 patients, moderate in 195 patients, and severe in 69 patients. On imaging, right side disease was seen in 101 patients, left side involvement in 59 patients, and bilateral involvement in 174 patients. Post-tubercular changes were the predominant pathology seen in 248 patients. Among 334 patients (386 procedures), 42 patients underwent the procedure twice and five patients underwent the procedure thrice. A total of 485 arteries were attempted of which 440 arteries were successfully embolized. Right intercosto-bronchial was the most common culprit artery present in 157 patients, followed by common bronchial (n=97), left bronchial (n=55), and right bronchial (n=45). We embolized a maximum of four arteries in one session. Immediate complications such as dissection and rupture occurred in only nine sessions (2.3%). Twenty-five procedures (6.5%) were repeated within two months, which were due to technical or clinical failure and 27 procedures (7%) were repeated after two months.

CONCLUSIONS

BAE is a safe and effective procedure with a negligible complication rate. Our approach of targeting hypertrophied arteries was effective.