Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

Feasibility and outcomes of bronchial artery embolization in patients with non-massive hemoptysis

Purpose

To evaluate the safety, efficacy, and long-term outcome of bronchial artery embolization (BAE) in the treatment of non-massive hemoptysis and the prognostic factors associated with recurrent bleeding.

Materials and methods

From March 2005 to September 2014, BAE was performed in 233 patients with non-massive hemoptysis. All patients had a history of persistent or recurrent hemoptysis despite conservative medical treatment. We assessed the technical and clinical success, recurrence, prognostic factors related to recurrent bleeding, recurrence-free survival rate, additional treatment, and major complications in all the patients.

Results

Technical success was achieved in 224 patients (96.1%), and clinical success was obtained in 219 (94.0%) of the 233 patients. In addition, 64 patients (27.5%) presented hemoptysis recurrence with median time of 197 days after embolization. Tuberculosis sequelae and presence of aberrant bronchial artery or non-bronchial systemic collaterals were significantly related to recurrent bleeding (p < 0.05). The use of Histoacryl-based embolic materials significantly reduced the recurrent bleeding rate (p < 0.05). Patient who had a tuberculosis sequelae showed a significantly lower recurrence-free survival rate (p = 0.013). Presence of aberrant bronchial artery or non-bronchial systemic collaterals showed a statistically significant correlation with recurrence-free survival rate (p = 0.021). No patients had major complications during follow-up.

Conclusions

BAE is a safe and effective treatment to manage non-massive hemoptysis. The procedure may offer a better long-term control of recurrent hemoptysis and quality of life than conservative therapy alone.

Bronchial Artery Embolization in Life-Threatening Hemoptysis: Outcome and Predictive Factors

Purpose:

To determine the outcome and predictive factors of clinical success of bronchial artery embolization in life-threatening hemoptysis.

Material and Methods:

We reviewed all bronchial artery embolization procedures performed for life-threatening hemoptysis between January 2008 and December 2018. The outcomes and predictive factors of clinical success following embolization were evaluated.

Results:

One hundred and eighty-four bronchial artery embolization procedures performed in 145 patients were eligible for the study. The technical and clinical success rates of the procedures were 170/184 (92.4%) and 129/184 (70.1%), respectively. The unstable hemodynamics and prothrombin time/international normalized ratio >1.5 was associated with lower clinical success rate, while embolization of more than one vessel was associated with higher clinical success rate.

Conclusion:

Bronchial artery embolization is a safe and effective procedure for controlling bleeding in life-threatening hemoptysis. However, low clinical success rate was noted in patients with unstable hemodynamics and coagulopathy, while multiple vessel embolization was associated with higher clinical success.

Bronchial artery embolization. What further we can offer?

Introduction

Massive hemoptysis is the most feared of all respiratory emergencies, with many underlying causes. In 90% of cases, the source of hemoptysis is the bronchial circulation. Despite high recurrence rates, bronchial artery embolization (BAE) remains the first-line treatment in management of hemoptysis.

Aim

To establish pre-procedure and procedural protocols for BAE.

Material and methods

The study included a total of 50 patients referred to the Department of Radiology for complaints of hemoptysis. Pre-procedure computed tomography (CT) angiography for determination of responsible circulation was performed as a regular protocol except in cases presenting with life-threatening hemoptysis. Polyvinyl alcohol (PVA size, 300–500 μm and 500–700 μm) particles combined with gel foam embolization was performed. Successful catheterization and embolization of the targeted vessel was considered technical success and the cessation of hemoptysis to minimal levels was labeled clinical success.

Results

Thirty-two (64%) male and 18 (36%) female subjects comprised the study group. Forty (80%) patients had moderate to severe hemoptysis. Tuberculosis (80%) was the most common etiology. Five patients had severe AV shunting and were embolized with decremental particle size (500–700 μm followed by 300–500 μm) to occlude the bed and then embolize the artery. Technical success was achieved in all the patients, but clinical success was achieved in 40 (80%) patients.

Conclusions

Bronchial artery embolization is a minimally invasive procedure recognized for primary management of hemoptysis. Preprocedure evaluation with CT angiography can add incremental value in management. Usage of decremental particle size is helpful to embolize large AV shunts.

Value of multidetector computed tomography angiography before bronchial artery embolization in hemoptysis management and early recurrence prediction: a prospective study

Background

Multidetector computed tomography (MDCT) angiography is a useful examination to detect the source of the bleeding in patients with hemoptysis. The aim of the study was to prospectively evaluate the role and clinical efficacy of MDCT angiography before bronchial artery embolization (BAE) for the management of hemoptysis, and to investigate the predictors of early recurrence.

Methods

It is a double-center study which included 57 hemoptysis patients undergoing MDCT angiography prior to BAE from August 2019 to July 2020. A prospective analysis of culprit arteries detected by MDCT angiography allowed an evaluation of the role of this technique. A follow-up was done to assess the efficacy of BAE with preprocedural MDCT angiography and to explore the risk factors of early recurrent hemoptysis.

Results

The accuracy of MDCT angiography in the identification of culprit arteries was as high as 97.5%. The average number of total culprit arteries per patient was 2.75 ± 1.73. Among which, the average numbers of culprit ectopic bronchial arteries (BAs) and non-bronchial systemic arteries (NBSAs) per patient were 0.21 ± 0.41 and 1.04 ± 1.57, respectively. The immediate clinical success rate, total hemoptysis recurrence rate, and early hemoptysis recurrence rate of BAE following MDCT angiography were 94.7, 18.5, 16.7%, respectively. Aspergilloma (HR = 6.63, 95% CI: 1.31–33.60, p = 0.022) was associated with an increase in the risk of early recurrence.

Conclusions

MDCT angiography should be performed before BAE for the management of hemoptysis. Aspergilloma was an independent predictor for early recurrence.

Angiographic Findings and Outcomes of Bronchial Artery Embolization in Patients with Pulmonary Tuberculosis

Objective

We aimed to evaluate the angiographic findings and outcomes of bronchial artery embolization in tuberculosis patients and to compare them with those of non-tuberculosis patients.

Materials and Methods

Patients who underwent bronchial artery embolization in a single interventional radiology department with hemoptysis were reviewed. A total of 89 patients (66 males and 23 females; mean age 52.71±15.37) were incorporated in the study. The patients were divided into two groups: tuberculosis group (n=36) and non-tuberculosis group (16 malignancy, 22 bronchiectasis, 6 pulmonary infection, 5 chronic obstructive pulmonary disease, 4 idiopathic; n=53). Angiography and embolization procedure were performed by interventional radiologists with 5, 10, and 20 years of experience. Angiographic findings were classified as tortuosity, hypertrophy, hypervascularity, aneurysm, bronchopulmonary shunt, extravasation, and normal bronchial artery. Chi-square test was used to compare angiographic findings between tuberculosis and non-tuberculosis patient groups.

Results

Bronchopulmonary shunt was found to be significantly higher in the tuberculosis group as compared to that in the non-tuberculosis group (p=0.002). Neither of the groups showed a statistically significant difference with respect to recurrence (p=0.436).

Conclusion

Bronchial artery embolization is a useful and effective treatment method of hemoptysis in tuberculosis. Evaluation of bronchopulmonary shunts in patients with tuberculosis is critical for the reduction of catastrophic complications.

Bronchial artery embolization in hemoptysis: a systematic review

We systematically reviewed the role of bronchial artery embolization (BAE) in hemoptysis. Literature search was done for studies on BAE published between 1976 and 2016. Twenty-two studies published in English, with sample size of at least 50 patients, reporting indications, technique, efficacy, and follow-up were included in the final analysis. Common indications for BAE included tuberculosis (TB), post-tubercular sequelae, bronchiectasis, and aspergillomas. Most common embolizing agent used was polyvinyl alcohol (size, 300-600 μm) with increasing use of glue in recent years. Overall immediate clinical success rate of BAE, defined as complete cessation of hemoptysis, varied from 70%-99%. However, recurrence rate remains high, ranging from 10%-57%, due to incomplete initial embolization, recanalization of previously embolized arteries, and recruitment of new collaterals. Presence of nonbronchial systemic collaterals, bronchopulmonary shunting, aspergillomas, reactivation TB, and multidrug resistant TB were associated with significantly higher recurrence rates (P < 0.05). Rate of major complications remained negligible and stable over time with median incidence of 0.1% (0%-6.6%). Despite high hemoptysis recurrence rates, BAE continues to be the first-line, minimally invasive treatment of hemoptysis in emergency settings, surgically unfit patients, or in patients with diffuse or bilateral lung disease.

Approach to Hemoptysis in the Modern Era

Hemoptysis is a frequent manifestation of a wide variety of diseases, with mild to life-threatening presentations. The diagnostic workup and the management of severe hemoptysis are often challenging. Advances in endoscopic techniques have led to different new therapeutic approaches. Cold saline, vasoconstrictive and antifibrinolytic agents, oxidized regenerated cellulose, biocompatible glue, laser photocoagulation, argon plasma coagulation, and endobronchial stents and valves are amongst the tools available to the bronchoscopist. In this article, we review the evidence regarding the definition, etiology, diagnostic modalities, and treatment of severe hemoptysis in the modern era with emphasis on bronchoscopic techniques.

The Management of Chronic Pulmonary Aspergillosis: The UK National Aspergillosis Centre Approach

Purpose of Review

Chronic pulmonary aspergillosis (CPA) is a serious long-term fungal disease of the lung with a worldwide prevalence. Treatment of CPA is not straightforward given the often-multiple associated co-morbidities, complex clinical picture, drug interactions, toxicities and intolerances.

Recent Findings

First line treatment is oral itraconazole or voriconazole. In the event of intolerance or toxicity, patients may be swapped from itraconazole to voriconazole or vice versa. In the event of resistance or further intolerance, third line treatment with posaconazole could be initiated. In those with pan-azole resistance, short-term courses of intravenous liposomal amphotericin B or micafungin are fourth line therapy, keeping in mind the nephrotoxic effects of amphotericin B.

Summary

The available evidence for current treatments in CPA is limited and based mostly on retrospective cohort studies. There is a real need to raise awareness of this devastating disease to enable early treatment as well as prospective drug trials and studies to identify potential patient factors that correlate with progression, severity and overall outcomes in order to target future therapies.

Typical carcinoid involving the main carina managed with arterial embolisation, endobronchial resection and ablation, ultimately followed by carinal resection

Bronchial carcinoids are uncommon pulmonary tumours, and the gold standard management is surgical resection. Their management is often complicated by their proximal location and propensity to bleed when manipulated. A 22-year-old man was found to have typical carcinoid tumour involving the carina and surgical resection was considered not feasible. We report our experience with a multimodality approach involving arterial embolisation, with subsequent endobronchial resection and ablation. Residual disease was found and managed with definitive carinal resection.