Superselective bronchial artery embolization for hemoptysis with a coaxial microcatheter system

Efficacy and safety of CalliSpheres drug-eluting beads for bronchial arterial chemoembolization for refractory non-small-cell lung cancer and its impact on quality of life: A multicenter prospective study

Objective

This study aimed to prospectively observe the efficacy and safety of CalliSpheres drug-eluting beads bronchial arterial chemoembolization (DEB-BACE) for refractory non-small-cell lung cancer (NSCLC).

Methods

The interventional therapy plan was as follows: 300-500 μm CalliSpheres drug-loaded microspheres were loaded with epirubicin, and then slow embolization of tumor supplying artery was performed after microcatheter superselection. Chest enhanced computed tomography and related hematological examination were reviewed after 2 months of DEB-BACE, and the tumor response after the first interventional therapy was evaluated using modified response evaluation criteria in solid tumors. The overall survival (OS) of patients was determined, and the quality of life and the incidence rate of adverse reactions were observed.

Results

From January 2019 to January 2021, 43 patients with refractory NSCLC were enrolled. The patients were followed up until June 2022. All 43 patients underwent DEB-BACE 1.79 ± 0.69 times on average. The 3-, 6-, 12-, and 24-month survival rates were 100%, 86.0%, 41.9%, and 11.8%, respectively. The median OS was 11.5 months. After the first interventional treatment, cough and wheezing significantly improved in 31 patients, hemoptysis was effectively controlled in 12 patients, and superior vena cava compression disappeared in 2 patients after 2 times of treatment. The general health status of the patients after treatment significantly improved compared with that before treatment, including the improvement in physical and emotional functions. Fatigue, nausea and vomiting, dyspnea, and insomnia improved significantly after treatment. No serious adverse events, such as spinal cord injury and cerebral embolism, were observed during the perioperative period. The main adverse reaction after DEB-BACE was chest pain (13/43, grade 1) followed by fever (10/43, grade 1-2), which was significantly relieved within 3-5 days after symptomatic treatment. Other adverse reactions included irritating cough, nausea and vomiting, and bone marrow suppression, and the incidence was less than 20%.

Conclusions

DEB-BACE was effective and safe in treating refractory NSCLC, which could significantly improve patients' quality of life and was worthy of clinical promotion and application.

Use of the triple coaxial (triaxial) microcatheter system in superselective arterial embolisation for complex interventional cases: an initial experience with the system

LEARNING OBJECTIVE

To share our experience in utilising the triple coaxial (triaxial) system in superselective cannulation of arteries for complex embolisation procedures.

BACKGROUND

Percutaneous transcatheter selective embolisation is widely performed for a myriad of oncologic (e.g., trans-arterial chemo- or radio-embolisation) and non-oncologic (e.g., for embolisation of bleeding and benign conditions such as uterine fibroid and benign prostate hyperplasia) purposes. The cornerstone of such embolisation procedures is to achieve superselective cannulation of the arterial supply to the tumour/organ, preventing the complication of non-target embolisation. However, a multitude of factors, such as complex vascular anatomy, can pose challenges to achieving this goal.

CLINICAL FINDINGS/PROCEDURAL DETAILS

The triaxial system utilises two smaller microcatheters telescoped through each other over a microwire. We have adopted the triaxial system for specific cases due to its perceived superior torquability and trackability compared to the conventional coaxial system, in which superselective cannulation is anticipated to be challenging. The triaxial system is also favourable in situations where the inner microcatheter needs to be "sacrificed" after administering the embolics (e.g., after administering radioisotopes in radioembolisation, N-butyl cyanoacrylate [NBCA] glue or ethylene-vinyl alcohol copolymer [EvOH] Onyx). Through a case series with procedural details such as fluoroscopic time, contrast administered, etc., we hope to illustrate the utility and efficacy of the triaxial system as well as present pitfalls in its usage.

CONCLUSION

The triaxial system appears to be a valuable system for certain complex embolisation procedures and could be better suited than the conventional coaxial systems in these specific circumstances.

Bronchial Artery Embolization

Massive hemoptysis is a highly morbid medical condition with up to 75% mortality with conservative treatment. Bronchial artery embolization has emerged as the common treatment for both acute massive hemoptysis and chronic hemoptysis. This article will review the clinical presentation, bronchial artery anatomy, embolization procedure, complications, and expected outcomes.

Role of Interventional Radiology in the Management of Non-aortic Thoracic Trauma

Trauma remains a leading cause of death for all age groups, and nearly two-thirds of these individuals suffer thoracic trauma. Due to the various types of injuries, including vascular and nonvascular, interventional radiology plays a major role in the acute and chronic management of the thoracic trauma patient. Interventional radiologists are critical members in the multidisciplinary team focusing on treatment of the patient with thoracic injury. Through case presentations, this article will review the role of interventional radiology in the management of trauma patients suffering thoracic injuries.

Clinical characteristics and postoperative outcomes of systemic artery-to-pulmonary vessel fistula in hemoptysis patients

OBJECTIVES

To investigate the clinical characteristics and outcomes on the success of bronchial arterial embolization (BAE) in patients with and without systemic artery-to-pulmonary vessel fistula (SA-PF) and to evaluate the feasibility of CTA in the assessment of SA-PF.

METHODS

We retrospectively enrolled 420 consecutive patients that underwent BAE for hemoptysis control in our hospital from September 2011 to May 2019. The clinical characteristics, preprocedural CTA findings, BAE procedural findings, and follow-up outcomes were collected. Patients were divided into two groups according to DSA findings: patients with SA-PF and those without.

RESULTS

A total of 184 (43.7%) patients presented with SA-PF. Pneumonia was less likely to be the concomitant condition in patients with SA-PF (p < 0.001). The mean number of culprit arteries per patient was significantly higher in patients with SA-PF compared to that in patients without SA-PF (p = 0.017). The SA-PF patients saw a greater probability of recurrence (HR: 2.782, 95% CI: 1.617-4.784, p < 0.001). SA-pulmonary venous fistula (SA-PVF) favored lower hemoptysis recurrence rate (HR: 0.199, 95%CI: 0.052-0.765, p = 0.019). SA-pulmonary artery fistula (SA-PAF) can be detected by optimized CTA protocol with a detection rate of 65.3% (49/75).

CONCLUSIONS

The presence of SA-PF is an independent risk factor predicting early recurrence of hemoptysis after BAE. SA-PVF seems to be a protective factor for longer hemoptysis control compared to SA-PAF. Optimized preprocedural CTA is a reliable examination to identify SA-PAF.

KEY POINTS

• The appearance of SA-PF is associated with a greater probability of early recurrent hemoptysis after bronchial artery embolization. • The presence of SA-PVF seems to be a protective factor for longer hemoptysis control after BAE compared to SA-PAF. • Optimized CTA protocol seems to be a promising auxiliary examination to detect SA-PAF.

Single-Center Experiences of Preoperative Juvenile Nasal Angiofibroma Embolization With Gelfoam, Reducing Financial Burden on Patients in Developing Country

Introduction

Juvenile nasal angiofibroma (JNA) is a highly vascular tumor of the nasopharynx. Endovascular embolization followed by surgery is the treatment of choice. This study aimed to determine that single catheter technique with Gelfoam is an effective and safe technique for embolization to reduce the financial burden on patients in a developing country.

Materials and methods

We retrospectively reviewed the imaging, surgical, and histopathological records of 108 patients who underwent preoperative endovascular tumor embolization followed by surgical resection between March 2017 and March 2021.

Results

After embolization no major complication was observed in any patient. Complete devascularization of tumor was done in 87.8%. Intraoperative blood loss resulting in transfusion was almost the same as with other embolization techniques.

Conclusion

Single catheter with Gelfoam is a cost-effective and safe technique for JNA embolization.

Endovascular treatment of chronic hemoptysis in patients with pulmonary tuberculosis

BACKGROUND

We aimed to demonstrate the safety and efficacy of bronchial artery embolization (BAE) in patients with pulmonary tuberculosis in the planned management of "mild" hemoptysis. This treatment, already widely documented and used as a life-saving therapy in an emergency regimen, if properly planned in poorly controlled patients through medical therapy alone, can provide a valid opportunity by reducing the frequency and extent of non-fatal bleeding, but which still worsen the quality of life of these already significantly traumatized patients.

METHODS

All procedures were conducted through a right common femoral access with a 5 Fr catheter and a 2.7 Fr super-selective catheter coaxial technique of the branches of the bronchial arteries with suspected bleeding sources. Embolizations were performed with 500-700 micron Terumo PVA plastic microparticles. We decided to adopt the following inclusion criteria for the selection of patients to be enrolled: documented diagnosis of pulmonary TB, the presence of at least one bleeding episode that required at least two blood transfusions, evaluation with bronchoscopic examination to ascertain the bronchial origin of bleeding and the affected lobar site, execution of an angio-ct radiological study for the evaluation of the bronchial systemic anatomy as well as the patency of the pulmonary arterial circulation, general hemodynamic compensation and an age of enrollment between 25 and 65 years.

RESULTS

All selective embolization interventions demonstrated a technical success of 100% of the total number of patients. 11 out of 12 patients did not show any signs of relapse or complications related to the interventional procedure at a first check-up carried out at 48 hours, instead a fatal massive hemoptysis occurred in only one patient. At the next three-month follow-up, no relapses were documented in all selected patients. Only one patient required a second embolization four months after the first procedure.

CONCLUSIONS

Radiological-interventional approach in the elective regimen of super-selective embolization of the bronchial arteries (BAE) in the management and control of "mild" hemoptysis in patients with pulmonary tuberculosis not controlled exclusively by medical therapy, according to a strategy systematic of planned intervention and respecting clear and standardized inclusion criteria, represented in our experience a safe and effective procedure, free from significant short and long term complications, especially in well selected patients, which, although not always allows a definitive and stable control of hemoptysis, can in any case significantly limit the risks, also allowing a better planning of the most appropriate therapeutic intervention strategy.

High false-negative rate of the anterior spinal artery by intercostobronchial trunk arteriography alone compared to CT during arteriography

OBJECTIVES

This study aimed to assess the frequencies of the anterior spinal arteries identified by CT during arteriography (CTA) and arteriography alone.

METHODS

This retrospective study included 137 vessels in 83 patients who performed both bronchial arteriography and CTA and categorized them into three groups based on the catheter tip locations: intercostobronchial trunk (ICBT), bronchial artery (BA), and intercostal artery (ICA). The frequencies of anterior spinal artery identified by CTA and arteriography alone were compared for each group.

RESULTS

ICBT, BA, and ICA groups were evaluated by CTA in 46, 79, and 12 vessels, respectively. By CTA evaluation, anterior spinal artery was identified in seven vessels (15.2%) in ICBT group, 0 in BA group and two (16.7%) in ICA group. The frequencies of anterior spinal artery were significantly higher (p < 0.05) in ICBT and ICA groups than in BA group. By arteriography evaluation alone, a faint anterior spinal artery was identified in two vessels (4.3%) in ICBT group, 0 in BA group, and 1 (8.3%) in ICA group.

CONCLUSIONS

Anterior spinal artery branched only from the ICBT or ICA and not from the BA in both arteriography and CTA assessments. There was high false-negative rate (71%) of the anterior spinal artery by ICBT arteriography alone assessment compared to CTA assessment. This result explains one of the reasons that spinal ischemia occurs in arteriography-negative spinal artery cases.

ADVANCES IN KNOWLEDGE

False-negative rate of anterior spinal artery was 71% (5/7) by intercostobronchial trunk arteriography alone assessment.

Randomised trial of first-line bronchial artery embolisation for non-severe haemoptysis of mild abundance

Background

Whereas first-line bronchial artery embolisation (BAE) is considered standard of care for the management of severe haemoptysis, it is unknown whether this approach is warranted for non-severe haemoptysis.

Research question

To assess the efficacy on bleeding control and the safety of first-line BAE in non-severe haemoptysis of mild abundance.

Study design and methods

This multicentre, randomised controlled open-label trial enrolled adult patients without major comorbid condition and having mild haemoptysis (onset <72 hours, 100–200 mL estimated bleeding amount), related to a systemic arterial mechanism. Patients were randomly assigned (1:1) to BAE associated with medical therapy or to medical therapy alone.

Results

Bleeding recurrence at day 30 after randomisation (primary outcome) occurred in 4 (11.8%) of 34 patients in the BAE strategy and 17 (44.7%) of 38 patients in the medical strategy (difference −33%; 95% CI −13.8% to −52.1%, p=0.002). The 90-day bleeding recurrence-free survival rates were 91.2% (95% CI 75.1% to 97.1%) and 60.2% (95% CI 42.9% to 73.8%), respectively (HR=0.19, 95% CI 0.05 to 0.67, p=0.01). No death occurred during follow-up and no bleeding recurrence needed surgery.

Four adverse events (one major with systemic emboli) occurred during hospitalisation, all in the BAE strategy (11.8% vs 0%; difference 11.8%, 95% CI 0.9 to 22.6, p=0.045); all eventually resolved.

Conclusion

In non-severe haemoptysis of mild abundance, BAE associated with medical therapy had a superior efficacy for preventing bleeding recurrences at 30 and 90 days, as compared with medical therapy alone. However, it was associated with a higher rate of adverse events.

Trial registration number

NCT01278199

Preemptive non-selective bronchial artery angioembolization to reduce recurrence rate of hemoptysis

Background

Massive hemoptysis which is presented in advanced lung diseases is a life-threatening condition. Bronchial artery embolization as a minimally invasive procedure is the treatment of choice either in first or recurrent hemoptysis. This study aimed to assess the early and late efficacy of bronchial angioembolization (BAE) without microcatheter.

Methods

In this prospective cohort study, all patients with hemoptysis who had undergone BAE from August 2018 to March 2019 were included. Angiographic patterns including bleeding sources, number of involved vessels, the underlying etiology, and recurrence rate were evaluated in a one-year follow up.

Results

153 patients were included with mean age of 55 ±16 years. 68% of them were male and 58% had life-threatening massive hemoptysis. Three distinct angiographic patterns were recognized. The culprit bleeding vessel was bronchial in 126 (92%), intercostal in 4 (3%), and both vessels in 7 (5%) of cases (p<0.05). One vessel involvement was seen in 56 patients; however it was observed in 69% of non-cystic fibrosis lobar bronchiectasis patients. In 1, 3 and 12 months follow up, recurrent hemoptysis was reported in 15 (11%), 4 (2.5%), and 24 (15.5%), respectively. In 52% of cases, no abnormal vessels were observed during aorta injection, but culprit bronchial or intercostal arteries were found in selective investigational angiography.

Conclusion

BAE was successful in the control of hemoptysis and resulted in a low rate of recurrence in different types of lung diseases. This could be due to the embolization of all pathological arteries found during angiography which might have prevented recurrent bleeding.

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.

Detection of arteriography-negative anterior spinal artery branching via intercostobronchial trunk confirmed by CT during intercostobronchial trunk arteriography: A case report

Spinal cord ischemia is an important complication of bronchial artery embolization for hemoptysis. It has been reported even though a spinal artery was not visualized on arteriography. We could show a 67-year-old man with repeated hemoptysis. His hemoptysis gradually worsened and diagnosed with severe hemoptysis, and transarterial embolization was planned to stop the hemoptysis. An anterior spinal artery arising from intercostobronchial trunk confirmed by computed tomography during arteriography even though it was not visualized on arteriography. Great care should be taken with transarterial embolization via intercostobronchial trunk, potentially branching the spinal artery, even though it was not visualized on arteriography alone.

Spinal Arterial Blood Supply Does Not Arise from the Bronchial Arteries: A Detailed Analysis of Angiographic Studies Performed for Hemoptysis

PURPOSE

To determine the angiographic prevalence of spinal arteries originating directly from the bronchial arteries in the setting of embolization for hemoptysis.

MATERIALS AND METHODS

Over a 14-year interval, 205 patients underwent angiography for hemoptysis. Twenty-five patients were excluded because their bronchial arteries were not visualized. The remaining 180 patients underwent a total of 254 angiographic procedures (range, 1-8 per patient). Images were reviewed jointly by 2 interventional radiologists with formal fellowship training in both peripheral and neurological interventional radiology. All catheterized arteries were evaluated for arterial contribution to the spinal cord. For patients with multiple studies, each unique artery was reported only once. Embolization was performed during at least 1 procedure in 158 patients (88%). Electronic record review was used to assess neurological sequelae after the procedure.

RESULTS

One or 2 bronchial arteries originating from the aorta were identified in 57 patients (32%) on the right and in 75 patients (42%) on the left. Conjoined bronchial arteries were found in 76 patients (42%). Spinal arterial supply was absent in all. A total of 102 patients (57%) had at least 1 right and 11 patients (6%) at least 1 left intercostobronchial artery. Spinal arterial supply from the intercostal portion of an intercostobronchial artery was found in 6 patients (5 right, 1 left). Medical record review revealed no postprocedure symptoms referable to spinal cord injury in any patient.

CONCLUSIONS

Spinal arterial supply does not originate directly from the bronchial artery but can originate from the intercostal portion of an intercostobronchial artery.

Bronchial arterial embolization using a gelatin sponge for hemoptysis from pulmonary aspergilloma: comparison with other pulmonary diseases

PURPOSE

To evaluate the clinical outcomes of bronchial artery embolization (BAE) using a gelatin sponge for hemoptysis from pulmonary aspergilloma and compare them with treatment outcomes for hemoptysis from other diseases.

METHODS

Fifty-two patients underwent BAE using a gelatin sponge. The etiology of hemoptysis was pulmonary aspergilloma in 8 (PA group) and other diseases in 44 (control group). The technical success rate, clinical success rate, hemoptysis-free rate, and complication rate were compared between the PA group and control group. Technical success was defined as the complete cessation of the targeted feeding artery as confirmed by digital subtraction angiography, and clinical success as the cessation of hemoptysis within 24 h of BAE. Recurrent hemoptysis was defined as a single or multiple episodes of hemoptysis causing > 30 ml of bleeding per day.

RESULTS

Technical and clinical success rates were 100% in both groups. Hemoptysis-free rates were 85% at 6 months and 72% at 12-60 months in the control group, and 38% at 6-12 months and 25% thereafter in the PA group (P = 0.0009). No complications were observed following BAE in any case in the two groups.

CONCLUSION

BAE using a gelatin sponge may not be effective for hemoptysis from pulmonary aspergilloma.

Exacerbation of chronic pulmonary aspergillosis was associated with a high rebleeding rate after bronchial artery embolization

BACKGROUND

Hemoptysis is a common symptom associated with chronic pulmonary aspergillosis (CPA). While surgery is the primary choice to manage hemoptysis, it is often avoided because patients with CPA are more likely to have complications such as respiratory insufficiency and low pulmonary function. Bronchial artery embolization (BAE) may be considered one of the treatments of massive and persistent hemoptysis for such patients.

METHODS

We retrospectively reviewed medical records of 41 patients, admitted to National Hospital Organization Tokyo National Hospital, Tokyo, Japan with hemoptysis arising from CPA between January 2011 to December 2016, who were considered inoperable and had undergone BAE.

RESULTS

Out of the 41 cases analyzed in this study, 21 (51.2%) developed rebleeding after BAE within the mean follow-up duration of 24 months. The non-rebleeding rate of patients after BAE was 92.7% within a month and 65.8% within a year. Patients who developed rebleeding had significantly more non-bronchial systemic arteries responsible for the bleeding compared with patients who did not develop rebleeding (mean of 2.55 vs. 4.86, respectively, P = 0.011). Patients with stable or improved radiological findings demonstrated significantly lower rebleeding rates than those with radiological deterioration (P < 0.001). The non-rebleeding patients had significantly better survival than those with rebleeding (79.7% vs. 39.9% over 5 years, P = 0.046).

CONCLUSIONS

Bronchial artery embolization was effective in controlling hemoptysis in patients with CPA, especially those who could not undergo surgical resection. However, disease control of CPA was important to prevent rebleeding over the long term and to improve survival after BAE.

An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ^©RSNA, 2018.

An applied anatomical study of bronchial artery

The aim of this study was to reveal the external features of the bronchial artery (BA) system, so as to provide morphological basis for clinic. The BAs in 48 adult cadavers were dissected and analyzed. The number of BAs in 48 cases was 118. The incidence of BA arising from thoracic aorta, right posterior intercostal artery, and right subclavian artery was 69.49, 27.12, and 3.39%, respectively. The origin of BAs in individual specimen might be single, two, or all of them, respectively. According to the different origin and/or origins of BAs, it could be divided into five categories. As for the course of BAs, in this study, all the left BAs arising from thoracic aorta passed forward around the left side of esophagus and then entered left pulmonary hilum; most (n = 15) of the right BAs arising from thoracic aorta passed forward around the left side of esophagus and then entered right pulmonary hilum; a few (n = 8) of the right BAs arising from thoracic passed forward the right side of esophagus and bronchus and then entered right pulmonary hilum. Besides, in our group, the special courses were that right intercostal-bronchial trunk (RICBT) arising from thoracic aorta passed between vertebra and esophagus and gave off BA which curved forward around the right side of esophagus and then entered right pulmonary hilum, common bronchial trunk (CBT) arising from thoracic aorta passed forward around the left side of esophagus laying anterior to bronchus or posterior to bronchus, then dividing into a left and a right BAs entering right and left pulmonary hilum, respectively. In 4 cadavers, the RICBT gave off the radiculomedullary artery and BA in turn, so radiculomedullary artery has the same origin with BA. Of all BAs, the mean diameter of right posterior intercostal artery, CBT, left BA, and right BA was 2.17 ± 0.84, 1.79 ± 0.57, 1.44 ± 0.50, and 1.39 ± 0.38 mm, respectively. The information gained from this study will be of value in clinic application.

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.

Transarterial chemoembolization for management of hemoptysis: initial experience in advanced primary lung cancer patients

PURPOSE

To evaluate the hemostatic effects of transarterial infusion chemotherapy in addition to embolization (chemoembolization) for advanced primary lung cancer with tumor-related hemoptysis.

MATERIALS AND METHODS

Ten consecutive patients with stage IIIB/IV or recurrent primary lung cancer (squamous cell carcinoma in six, adenocarcinoma in four) who underwent chemoembolization for control of hemoptysis were enrolled. At enrollment, five patients were considered refractory and five had contraindications to standard therapies. The amount of hemoptysis was massive in two patients, moderate in seven, and slight in one. Transarterial infusion chemotherapy via feeding arteries using cisplatin (25 mg/m²) and 5-fluorouracil (300 mg/m²) was repeated every 3-4 weeks for three cycles. HepaSphere (100-150 µm) or gelatin sponge particles were selected as embolic materials depending on the presence of pulmonary shunts and were added for embolization just after drug infusion.

RESULTS

Hemoptysis improved in all patients (resolution in nine, significant decrease in one). The median hemostasis time was 11.9 months (range 2.7-25.9 months). The target pulmonary lesions shrank in seven patients, and pulmonary atelectasis disappeared in three of five patients.

CONCLUSIONS

Chemoembolization may be a palliative option with favorable hemostasis time for advanced primary lung cancer with hemoptysis.

Fabricated bronchial artery embolization for hemoptysis using a coil

Background

Bronchial artery embolization is considered a conservative form of therapy for hemoptysis. This study aimed to examine the short- and long-term effects of bronchial artery embolization, as well as the performance of the coils used in our hospital.

Methods

We reviewed the background, symptoms, findings, and prognosis of 27 cases of bronchial artery embolization for hemoptysis between April 2003 and October 2011. For embolization materials, short coils combined with a long interlocking detachable coil were mainly used from March 2008.

Results

Aspergillosis and chronic empyema comprised the majority of cases. In terms of short-term results, there were 25 successful cases of bronchial artery embolization and 2 unsuccessful cases. Regarding the long-term outcome of the successful cases, during an average observation period of 17 months, one patient required repeat bronchial artery embolization, and one was admitted to another hospital with recurrent hemoptysis.

Conclusions

Bronchial artery embolization for hemoptysis was preformed in a safe and minimally invasive manner with positive results over both the short- and long-term, thus underscoring its utility as a form of treatment. Furthermore, by combining the use of long and short coils, we were able to reduce the number of coils necessary for the procedure, and thus reduce the time and cost involved.

Diagnosis and management of hemoptysis

Hemoptysis is the expectoration of blood that originates from the lower respiratory tract. It is usually a self-limiting event but in fewer than 5% of cases it may be massive, representing a life-threatening condition that warrants urgent investigations and treatment. This article aims to provide a comprehensive literature review on hemoptysis, analyzing its causes and pathophysiologic mechanisms, and providing details about anatomy and imaging of systemic bronchial and nonbronchial arteries responsible for hemoptysis. Strengths and limits of chest radiography, bronchoscopy, multidetector computed tomography (MDCT), MDCT angiography and digital subtraction angiography to assess the cause and lead the treatment of hemoptysis were reported, with particular emphasis on MDCT angiography. Treatment options for recurrent or massive hemoptysis were summarized, highlighting the predominant role of bronchial artery embolization. Finally, a guide was proposed for managing massive and nonmassive hemoptysis, according to the most recent medical literature.

Outcomes of bronchial artery embolization for life-threatening hemoptysis secondary to tuberculosis

OBJECTIVE

To appraise the immediate and long-term outcomes of bronchial arterial embolization for life-threatening hemoptysis secondary to tuberculosis.

METHODS

112 patients with life-threatening hemoptysis due to tuberculosis underwent bronchial artery embolization from January 2004 to February 2014. Life-threatening hemoptysis was defined as expectoration of at least 400 ml of blood in 24 hour. The median follow-up is 20 months, ranging from 2 to 52 months.

RESULTS

The hemoptysis control rate was 86.6% at 14 days, 84.8% at 30 days, 78.6% at 240 days, 75.9% at 360 days, respectively. None of these characteristics, including gender, age and tuberculosis status, was significantly associated with immediate control of bleeding. Patients with active tuberculosis had a significantly longer recurrence-free duration than did patients with inactive tuberculosis (P = 0.040), which was further confirmed by Cox regression hazards model (P = 0.046). There was no spinal cord complication or mortality related to bronchial artery embolization. The most common complication was transient chest pain.

CONCLUSION

Bronchial arterial embolization is an effective and safe technique in the management of life-threatening hemoptysis secondary to tuberculosis. Active tuberculosis may be associated with a lower rate of recurrence of hemoptysis.

Multidetector computed tomography in life-threatening hemoptysis

Life-threatening hemoptysis is a severe condition that requires rapid diagnosis and treatment. One of the treatments of choice is embolization. The initial assessment aims to locate the origin and cause of bleeding. The technological advance of the development of multidetector computed tomography (MDCT) has changed the management of patients with life-threatening hemoptysis. MDCT angiography makes it possible to evaluate the cause of bleeding and locate the vessels involved both rapidly and noninvasively; it is particularly useful for detecting ectopic bronchial arteries, nonbronchial systemic arteries, and pulmonary pseudoaneurysms. Performing MDCT angiography systematically before embolization enables better treatment planning. In this article, we review the pathophysiology and causes of life-threatening hemoptysis (including cryptogenic hemoptysis) and the MDCT angiography technique, and we review how to systematically evaluate the images (lung parenchyma, airways, and vascular structures).

Bronchial artery embolization

Hemoptysis represents a significant clinical entity with high morbidity and potential mortality. Most hemorrhages from a bronchial source arise in the setting of chronic inflammatory diseases. Medical management (in terms of resuscitation and bronchoscopic interventions) and surgery have severe limitations in these patient populations. Embolization procedures represent the first-line treatment for hemoptysis arising from a bronchial arterial source. This article discusses anatomical and technical considerations, as well as outcomes and complications, in the setting of bronchial arterial embolization in the treatment of hemoptysis.

Bronchial and Nonbronchial Systemic Artery Embolization in Management of Hemoptysis: Experience with 348 Patients

Background. We aimed to report our experience with bronchial artery embolization (BAE) in the management of moderate recurrent and/or life-threatening hemoptysis. Methods. We evaluated the demographics, clinical presentation, radiographic studies, short- and long-term efficacy, and complications in patients Who underwent BAE, at a tertiary university hospital, from 2003 to 2012. Results. Three hundred forty-one patients underwent BAE for the management of moderate recurrent or life-threatening hemoptysis. Pulmonary TB and bronchiectasis were the most common etiologies for hemoptysis in our locality. The most common angiographic signs for hemoptysis were hypervascularity and systemic-pulmonary artery shunt. BAE was successful in controlling hemoptysis immediately in 95% of patients and at 1 month in 90% of patients. Recurrence of hemoptysis was observed in 9.6% of patients, and reembolization was indicated in 85% of those cases. Complications of BAE were self-limited acute and subacute complications, while chronic complications were not recorded during this study. Conclusions. TB and bronchiectasis are the commonest etiologies for moderate recurrent or life-threatening hemoptysis in our locality. Hypervascular lesions from the bronchial arteries and nonbronchial systemic arteries represented the major vascular abnormalities. Bronchial and nonbronchial systemic artery embolizations were effective to control both acute and chronic hemoptyses, with no serious complications.

Massive hemoptysis from pulmonary ligament artery supplying abnormal basal segments of the lower lobe

BACKGROUND

Non-bronchial systemic arteries can be a significant source of massive hemoptysis in patients with marked pleural involvement. However, in some cases without pleural involvement, the pulmonary ligament artery (PLA) can also enter the abnormal lung parenchyma and be responsible for hemoptysis.

PURPOSE

To discuss the factors influencing the development of a blood supply from the PLA in patients with hemoptysis.

MATERIAL AND METHODS

Seventy-five consecutive patients who underwent bronchial artery embolization (BAE) for massive hemoptysis were evaluated between January 2006 and December 2011 retrospectively. Selective arteriography showed an enlarged and tortuous PLA in five patients. CT was done to determine the site and extent of the underlying diseases before BAE in all patients. Angiographic and CT images were analyzed to determine if there was a relationship between PLA supply and location of the underlying disease or mediastinal pleural involvement.

RESULTS

The underlying lesions of six patients involved the basal segments of the lower lobe without marked mediastinal pleural thickening or adhesion, but diaphragmatic and lateral pleural thickening was observed in one case. Of these six patients, the PLA supplied blood to the lesions related to the hemoptysis in five patients. No patient with massive hemoptysis whose underlying lesions involved other segments of lung had a PLA supplying the lesions.

CONCLUSION

Even though pleural involvement is absent, underlying lesions involving the basal segments of the lower lobe could be a good indicator that the PLA is the cause of bleeding in patients with massive hemoptysis.

Preoperative embolization in surgical management of massive thoracic tumors

BACKGROUND

The surgical excision of a highly vascular giant tumor may be challenging. The aim of this study was to describe our experience with preoperative percutaneous embolization of massive vascular chest tumors before surgical excision.

METHODS

From 2009 to 2011, 8 cases of giant vascular thoracic tumor were treated at Assiut University Hospital, Assiut, Egypt, by preoperative embolization of the feeding arteries followed by successful excision after 48 h.

RESULTS

The median age of the 8 patients was 39 years. Embolization of their tumors resulted in a reduction of tumor size, and minimal blood loss was observed perioperatively. Perilesional edema and easy differentiation of ischemic tissue facilitated complete surgical removal of the tumors.

CONCLUSIONS

Preoperative embolization of giant vascular thoracic tumors is useful to decrease perioperative blood loss and facilitate total excision.

Coronary artery bypass grafting in a patient with unstable angina pectoris and bronchiectasis

Bronchiectasis is characterized by the abnormal and permanent dilatation of bronchi. Clinical manifestations of bronchiectasis include persistent or recurrent cough, purulent sputum, hemosputum, and hemoptysis. A 75-year-old man with bronchiectasis required coronary bypass grafting for unstable angina pectoris with severe stenosis of the left main trunk. Computed tomography showed fistulae between the dilated bronchial arteries and the left pulmonary artery. Cardiac catheter examination showed significant left-right shunt and left ventricular dilatation. To avoid perioperative massive hemoptysis, embolizations of 2 bronchial arteries and an inferior phrenic artery were performed preceding the coronary artery bypass grafting. Both transcatheter embolization and coronary artery bypass grafting were successfully performed without any complications. Herein, we illustrate a very rare case of bronchiectasis in a patient with unstable angina pectoris who underwent transcatheter embolization for a systemic-pulmonary shunt preceding coronary artery bypass grafting with cardiopulmonary bypass.

Endovascular treatment of haemoptysis: medium and long-term assessment

PURPOSE

To assess the short, medium and long-term results of bronchial artery embolisation (BAE) and identify the factors favouring the recurrence of haemoptysis.

PATIENTS AND METHODS

This is a retrospective study, between January 2001 and June 2010, comprising 53 consecutive patients with BAE. The mean age was 53.8 years. There were 15 women (28.30%) and 38 men (71.69%).

RESULTS

The aetiologies of haemoptysis were dominated by the residual signs of pulmonary tuberculosis: 18 cases (33.96%), bronchial dilations: 12 cases (22.64%) and aspergilloma: five cases (9.43%). The bronchial arteriography showed signs of bronchial hypervascularisation in 92.45% of the cases. Forty-six patients had a first embolisation (86.79%) with immediate efficacy in 84.90% of the cases (n=45). This efficacy was noted after more than 3 years in 60.08% of the cases. Short (< 30 days) and medium-term (> 30 days and < 3 years) recurrence of haemoptysis were noted in 17.39% and 8.69% of the cases respectively. A statistically significant correlation between aspergilloma and the immediate recurrence was found (P=0.013). The risk of medium and long-term recurrence (> 3 years) was correlated with age. The survival without recurrence was statistically higher when the age was less than 60 years (P=0.0041).

CONCLUSION

BAE is an effective treatment. Aspergilloma is a major risk factor in the recurrence of haemoptysis. Repeated embolisation may be proposed for these patients.

Bronchial artery embolization for hemoptysis

Bronchial artery angiography with embolization has become a mainstay in the treatment of hemoptysis. Major complications are rare and immediate clinical success defined as cessation of hemorrhage ranges in most series from 85% to 100%, although recurrence of hemorrhage ranges from 10% to 33%. Bronchial artery embolization offers a minimally invasive procedure for even the most compromised patient serving as first-line treatment for hemorrhage as well as providing a bridge to more definitive medical or surgical intervention focused upon the etiology of the hemorrhage. The aim of this article is to summarize the etiologies, pathophysiology, and the diagnostic and management strategies of hemoptysis as related to bronchial artery embolization. In addition, the techniques of arteriography and embolization as well as associated procedural outcomes and complications are delineated.

[Bronchial and nonbronchial systemic artery embolization in managing haemoptysis: 31 years of experience]

PURPOSE

The authors report on 31 years of experience with bronchial (BAE) and/or nonbronchial (NBAE) systemic artery embolisation for managing haemoptysis.

MATERIALS AND METHODS

A total of 534 patients who underwent bronchial artery angiography for haemoptysis between 1979 and 2010 were retrospectively evaluated. Of these patients, 477 (89%) had active bleeding and underwent BAE and/or NBAE (295 males and 182 females, aged between 12 and 71 years). Embolisation techniques, materials, major and minor complications and relapses were recorded.

RESULTS

Complete resolution of haemoptysis was achieved within 24 h in 458/477 (96%) cases and within 48 h in 2% of cases. The aetiology of haemoptysis was as follows: cystic fibrosis (23%), bronchiectasis (13%), tuberculosis sequelae (8%), chronic obstructive pulmonary disease (COPD) (6%) and no apparent cause (21%). Major complications were recorded in 3/477 (0.6%): stroke (n=1), transient ischaemic attack (TIA) (n=1) and transient quadriplegia (n=1). Minor complications were recorded in 143/477 (30%): chest pain 86/143 (60%) and dysphagia 29/143 (20%). During a mean follow-up period of 14 (8-36) months, haemoptysis recurrence was observed in 42/110 cases (38%) of cystic fibrosis and in 77/367 cases of other diseases (21%).

CONCLUSIONS

BAE and NBAE are effective and safe for acute treatment of haemoptysis, with low recurrence and complication rates. Interventional radiologist experience is crucial to the successful haemoptysis control and preventing complications.

Which Arteries Are Expendable? The Practice and Pitfalls of Embolization throughout the Body

This article outlines general concepts of, and strategies for, therapeutic embolization throughout the body, touching on all major arterial distributions. Clinical scenarios that allow or prevent safe embolization of vessels are presented. Specific agents are recommended where appropriate, as are alternate approaches when embolization is not an option. Pre-embolization precautions and adjunctive measures are described in high-risk areas.

Bronchial artery embolization for hemoptysis

Bronchial artery bleeding is the most common cause of life-threatening hemoptysis. The most common underlying etiologies include tuberculosis, bronchiectasis, aspergillosis, and cystic fibrosis. Bronchial artery embolization is an important treatment for significant hemoptysis, given its high early success rate and relatively low risk compared with alternative medical and surgical treatments. In this article, the relevant anatomy and pathophysiology leading to bronchial artery bleeding is discussed, including the roles of parenchymal lung diseases and of collateral and aberrant vessels. The indications for treatment, success rate, and complication rate for bronchial artery embolization are reviewed. Preprocedure clinical stabilization and evaluation, including the roles of radiographs, bronchoscopy, and computed tomography examination are evaluated. Details of technique, including the published variety of approaches, and an emphasis on avoidance of nontarget embolization of important mediastinal structures and of the anterior spinal artery are discussed.

Bronchial artery embolization

Massive hemoptysis is a frightening and potentially life-threatening clinical event. Patients with chronic inflammatory lung diseases such as bronchiectasis, sarcoidosis, tuberculosis, and cystic fibrosis develop markedly hypertrophied and fragile bronchial arteries that may lead to clinically significant hemoptysis. Surgical intervention is hazardous and often impossible in these patients with diffuse parenchymal lung disease. Superselective catheterization of the bronchial arteries feeding the affected areas followed by particulate embolization has proven to be an effective treatment for the control of bleeding. With modern microcatheters and guidewires, bronchial artery embolization is safe and well tolerated by patients. Because this treatment does not directly influence the primary underlying disease, recurrent episodes of bleeding are likely, which will require additional embolization procedures. In patients who have undergone prior bronchial artery embolization, the dominant feeding arterial supply often originates from nonbronchial systemic collateral vessels.

Complications of embolization

Embolization is a remarkably versatile procedure used in nearly all vascular and nonvascular systems to treat a wide range of pathology. The published literature is rich with studies demonstrating the enormous therapeutic potential offered by embolization procedures, and the possibilities continue to expand with the advent of new embolization agents and techniques. Unfortunately, with this variety and innovation comes a wide spectrum of potential complications, not always easy to classify and summarize, associated with embolization. This article reviews the procedures and associated complications of arterial and venous embolization procedures, organized by vascular distribution.

Hemoptysis--etiology, evaluation and treatment in a university hospital

OBJECTIVE

Evaluate patients admitted for hemoptysis, its etiology, use of diagnostic tests, treatment and outcome.

METHODS

A retrospective analysis was done, checking clinical files of patients admitted for hemoptysis, between 1st January 2004 and 31st December 2008.

RESULTS

Two hundred and thirty seven patients were included in this study, with a mean age of 57.9 years. In patients under 18 years, the most frequent diagnoses were Bronchiectasis and Congenital Cardiopathy. In adults, Pulmonary Tuberculosis Sequelae and Bronchiectasis were the dominant diagnoses (22.2 % and 15.8 %, respectively), followed by Lung Cancer. Active infection was responsible for bleeding in 51 patients, especially Pulmonary Tuberculosis, Pneumonia and Tracheobronchitis. The etiology of hemoptysis was not established in 6.3 %. All patients performed chest X-Ray. Chest CT was performed in 81.4 % of patients and Fiberoptic bronchoscopy in 52.7 %, the latter locating the source of bleeding in 38.4 % and establishing a final diagnosis in 17.6 %. In most patients, effective control of bleeding was achieved by medical treatment (90.7 %). During these 5 years, arterial embolization was performed in 11.8 % of patients. The main reason for embolization was recurrence prevention. There were 14 deaths (5.9 %), being identified as poor prognostic factors, hemodynamic instability and malignancy.

CONCLUSION

Hemoptysis is still a frequent symptom, being chronic infection sequelae and lung cancer their main causes. In this study, factors associated with a worse prognosis were hemodynamic instability and malignancy.

Nine-Year Single-Center Experience With Transcatheter Arterial Embolization for Hemoptysis: Medium-Term Outcomes

Purpose: To determine the medium-term efficacy of transcatheter arterial embolization (TAE) for hemoptysis. Materials and Methods: A total of 128 TAE were performed from April 1999 to April 2008 in 58 patients (30:28 F:M) with mean age of 49 (range:16-89). Major causes of hemoptysis included cystic fibrosis/bronchiectasis (24 of 58); lung metastasis (8 of 58); lung cancer (7 of 58); fungal infection (4 of 58). Follow-up was available in 57 of 58 for a median of 1.28 years. Primary and secondary efficacy of TAE for hemoptysis was calculated using Kaplan-Meier estimates. Results: Technical and clinical successes were estimated at 58 (100%) of 58 and 57 (98%) of 58, respectively. Recurrent hemoptysis occurred in 40% (23 of 58). In all, 34% (20 of 58) died during follow-up. Kaplan-Meier estimates for primary and secondary efficacy of TAE at 2, 4, 6, and 8 years were 0.82, 0.46, 0.17, and 0.09 (benign disease) and 0.30, 0, 0, and 0 (malignant disease), respectively. Conclusion: TAE is an effective treatment for hemoptysis in both short- and medium-terms, especially in benign lung disease.

[Severe haemoptysis: indications for triage and admission to hospital or intensive care unit]

Recognition of the criteria of severity and the early admission to a referral center play a critical role in the prognosis of severe haemoptysis. The therapeutic management should be undertaken urgently by providing general supportive care, i.e., optimization of oxygenation and haemodynamic stabilization to prevent recurrence of massive bleeding. Interventional radiology has dramatically improved the initial management of severe haemoptysis. Attempts to control haemoptysis by first-line non-surgical methods are necessary to optimize the operative conditions and improve morbidity and mortality. Surgical lung resection remains the treatment of choice in selected patients with localized lesions complicated by severe and/or recurrent episodes of haemoptysis (bronchiectasis) or lesions associated with a high risk of recurrence of bleeding (mycetoma). Haemoptysis related to pulmonary arterial involvement remains a surgical emergency.

Comparison of the effectiveness of embolic agents for bronchial artery embolization: gelfoam versus polyvinyl alcohol

Objective

The purpose of this study was to compare the results of different agents for bronchial artery embolization of hemoptysis.

Materials and Methods

From March 1992 to December 2006, a bronchial artery embolization was performed on 430 patients with hemoptysis. The patients were divided into three groups. Group 1 included 74 patients treated with a gelfoam particle (1×1×1 mm), while group 2 comprised of 205 patients treated with polyvinyl alcohol (PVA) at 355-500 µm, and group 3 included 151 patients treated with PVA at 500-710 µm. We categorized the results as technical and clinical successes, and also included the mid-term results. Retrospectively, the technical success was compared immediately after the procedure. The clinical success and mid-term results (percentage of patients who were free of hemoptysis) were compared at 1 and 12 months after the procedure, respectively.

Results

Neither the technical successes (group 1; 85%, 2; 85%, 3; 90%) nor the clinical successes (group 1; 72%, 2; 74%, 3; 71%) showed a significant difference among the 3 groups (p > 0.05). However, the mid-term results (group 1; 45%, 2; 63%, 3; 62%) and mid-term results excluding the recurrence from collateral vessels in each of the groups (group 1; 1 patient, 2; 4 patients, 3; 2 patients) showed that group 1 was lower than the other two groups (p < 0.05). No significant difference was discovered for the mid-term results between groups 2 and 3. Moreover, the same results not including incidences of recurrence from collateral vessels also showed no statistical significance between the two groups (p > 0.05).

Conclusion

Polyvinyl alcohol appears to be the more optimal modality compared to gelfoam particle for bronchial artery embolization in order to improve the mid-term results. The material size of PVA needs to be selected to match with the vascular diameter.