Occlusive endobronchial stent placement as a novel management approach to massive hemoptysis from lung cancer

A case of massive hemoptysis caused by lung cancer saved by V-V ECMO and hemostasis achieved by radiotherapy

Massive hemoptysis is one of the fatal complications of lung cancer. There is no established standard treatment method for it, and it often causes sudden suffocation, and some cases may be difficult to save. A 63-year-old man was admitted to the hospital with dyspnea, and developed massive hemoptysis from lung cancer shortly after admission. The tumor had obstructed the right main bronchus and had invaded the right pulmonary artery. Surgery and interventional radiology were judged impossible. The patient was successfully saved by the introduction of Veno-Venous Extra Corporeal Membrane Oxygenation (V-V ECMO), and hemostasis was obtained by radiotherapy. Two months after completion of radiotherapy, he was weaned off the ventilator and discharged on his own. He died of increased peritoneal dissemination and other complications 1 year and 1 month later, but no recurrence of hemoptysis was noted until his death. We experienced a case of massive hemoptysis in which V-V ECMO and radiation therapy succeeded in saving life and stopping bleeding. The use of V-V ECMO by emergency care teams and multimodality therapy, including radiotherapy, were effective for massive hemoptysis from lung cancer.

Novel use of metallic stent to control post-debulking bleeding in a patient with central airway obstruction

Bronchoscopy-related bleeding is often encountered and is usually self-limiting or controllable by conservative measures. However, major bleeds can be life threatening for the patient as well as challenging for the physician to manage. There are several methods to achieve adequate haemostasis should a significant airway bleed occur. In this context, we describe a patient who had a post-bronchoscopic debulking bleed which persisted despite use of all available measures, and we deployed a self-expanding metallic stent in an attempt to control it. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its usage in management of intractable haemoptysis exist in the literature.

Aetiology, diagnosis and treatment of moderate-to-severe haemoptysis in a North American academic centre

Significant haemoptysis is a frightening event for patients and clinicians alike. There is a paucity of contemporary literature on the subject.

A retrospective analysis of hospitalisations for haemoptysis of more than 50 mL·day⁻¹ in a tertiary referral centre during a 5-year period was performed. Patient's characteristics, haemoptysis aetiology, management and outcome were individually recorded. The aim of this study was to detail the causes of moderate (50–200 mL·day⁻¹) to severe (>200 mL·day⁻¹) haemoptysis along with the diagnostic measures and treatment options used in their management in a 21st century, tertiary-care North American centre.

A total of 165 hospitalisations for moderate-to-severe haemoptysis were included in the analysis. Lung cancer (30.3%) and bronchiectasis (27.9%) proved to be most frequent aetiologies. Computed tomography (CT) imaging and bronchoscopy were complementary in identifying the source of bleeding. Bronchial artery embolisation (BAE) was the most common treatment approach (61.8%) and resulted in initial bleeding control in 73.5% of cases. In-hospital mortality was 13.9%, varying from 3.3% in the moderate group to 24.7% in the severe group. Despite being the favoured approach in patients with more severe bleeding, initial BAE therapy was associated with a trend towards lower mortality compared to initial non-BAE therapy.

In summary, lung cancer and bronchiectasis were the main causes of moderate-to-severe haemoptysis in our population, CT and bronchoscopy are complementary in identifying the source of bleeding, bleeding volume is associated with outcomes and BAE is a key management tool.

In a contemporary North American population, lung cancer and bronchiectasis proved to be the leading causes of moderate-to-severe haemoptysis while CT and bronchoscopy appeared complementary in localising the source of bleedinghttps://bit.ly/2BFLvOT

Modified silicone stent for difficult-to-treat massive hemoptysis: a pilot study of 14 cases

Background

Massive hemoptysis is a life-threatening event with limited therapeutic options. Bronchoscopic placement of stents may offer an alternative option for massive hemoptysis. However, traditional silicone stents have not been customized, making it difficult to tailor to individual patient’s needs for achieving optimal hemostasis. To investigate the efficacy and safety of the modified silicone stent in patients with difficult-to-treat massive hemoptysis.

Method

Between May 2016 and November 2018, we enrolled 14 patients who underwent bronchoscopic placement of the modified silicone stent, which was fabricated manually based on the Y-shaped silicone stent by tailoring and suturing on site. We recorded the technical success, clinical success, and complications. Patients were followed up for recording the recurrence of massive hemoptysis and complications.

Results

Placement of the modified silicone stent was successful in all 14 patients with a mean duration of 69.6 minutes (technical success rate: 100%). After stenting, no further massive hemorrhage episodes recurred in 12 patients (clinical success rate: 85.7%). Two cases suffered from recurrent hemoptysis in 4 and 6 days after stenting, respectively. The main complications were sputum plugging, granuloma proliferation and pulmonary infection such as pneumonia. There were no adverse events of stent migration and suture dehiscence. After a median follow-up of 5.8 (range, 0.3–21.3) months, three patients withdrew and seven patients succumbed. Only one patient died of uncontrolled pneumonia which was possibly related to stent placement.

Conclusions

The modified silicone stent is an effective and safe gate-keeping therapeutic option for difficult-to-treat massive hemoptysis.

Pulmonary Artery Stent Graft Repair of Bronchovascular Fistula

Endobronchial stenting is a well-established palliative approach in lung cancer patients with airway obstruction secondary to tumor burden. However endobronchial stenting can be complicated by stent erosion into adjacent vessels. Although most cases of endobronchial stent-related hemoptysis can be treated by stent revision and/or surgical resection, here we present a case managed by endovascular pulmonary arterial stent placement as a last resort option in the management of an iatrogenic bronchovascular fistula in a nonsurgical candidate.

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.

Combined Management of a Bronchial Artery Fistula After Lung Transplantation

A 46-year-old female patient exhibited massive endobronchial bleeding after dilation of a left bronchial anastomotic stenosis after lung transplantation, consistent with a bronchopulmonary artery fistula (BPAF). The BPAF was treated with a bronchial covered self-expandable metallic stent and percutaneous transcatheter pulmonary artery stent placement. BPAF is rare and leads to death in most cases because of massive hemoptysis. We describe a case of successful combined management of BPAF using both bronchial and pulmonary stent placement.

Massive haemoptysis from right middle lobe bronchus managed by customized silicon stents

Massive haemoptysis is life-threatening. Management options include pharmacological treatment, bronchial artery embolization, surgical resection, and bronchoscopic interventions. As an alternative treatment method of controlling haemoptysis, endobronchial stent insertion has been performed in several pulmonary carcinoma patients. We presented an 89-year-old bronchiectasis patient who developed massive haemoptysis from the right middle lobe bronchus. Haemoptysis was not controlled by both pharmacological treatment and bronchial artery embolization. Two customized silicone stents with the one in the right middle lobe bronchus and another in the right intermediate bronchus were used to manage haemoptysis. One month after stents implantation, the stent inside the right intermediate bronchus was removed, another stent was left in the right middle lobe bronchus to continue occluding the bleeding passageway. Haemoptysis did not occur after silicon stents deployment. This may be the first case of receiving straight silicon stent implantation to manage massive haemoptysis from the right middle lobe bronchus.

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 near-fatal hemoptysis with left secondary carinal y stent

Massive hemoptysis can be a life threatening condition and needs urgent treatment in lung cancer. In the fiberoptic bronchoscopy of a fifty-two-year-old who was admitted with hemoptysis, left upper lobe upper division orifice was seen totally obstructed with a submucosal infiltration. One hour after the mucosal biopsies, massive hemoptysis occurred. Urgent rigid bronchoscopy was performed. The left main bronchus was occluded by sterile gauze. After cleaning of the coagulum patient was intubated and charged to intensive care unit. The next day, rigid bronchoscopy was repeated and the bleeding was observed to continue from the left upper lobe. Removing the gauze, 14 × 10 × 10 mm silicon Y stent was inserted in the left main bronchus after adjustments were made. Bleeding was stopped after insertion of the stent and patient could be extubated. In this case a successful control of hemoptysis was sustained after insertion of a customized silicon stent was presented.

Endobronchial valves in the management of recurrent haemoptysis

Minimally invasive treatment modalities for life-threatening haemoptysis in patients unresponsive to medical interventions and/or in patients deemed functionally inoperable are limited. We describe the implantation of endobronchial valves in a patient with recurrent haemoptysis, which presents both a novel indication for the use of these devices and a novel intervention for haemoptysis. Our patient is a 30-year-old male who developed bilateral upper lobe aspergillomata following previous pulmonary tuberculosis. The patient had a history of multiple hospitalisations for life-threating haemoptysis despite repeated bronchial artery embolisations. He was deemed to be inoperable given the bilateral nature of his disease and very poor pulmonary reserves. We proceeded to identify the segments involved with the aid of computed tomography reconstruction and implanted 3 endobronchial valves. Our patient remained haemoptysis free for 6 months and experienced no stent-related complications. Moreover, he was subsequently employed as a manual labourer and showed significant improvements in his functional capacity. Endobronchial valves may therefore represent a viable medium-term treatment option as a blockade device in patients unresponsive to medical interventions and/or in patients deemed functionally inoperable. Prospective studies are indicated to better delineate the role of endobronchial valves in this setting.

Temporary endobronchial embolization with silicone spigots for moderate hemoptysis: a retrospective study

BACKGROUND

The management of airway bleeding is generally performed in an emergency to prevent hypoxemia and lung flooding. When the bleeding arises from peripheral lesions that are not visible endoscopically, bronchoscopic options have limited curative intents. Endobronchial embolization using silicone spigots (EESS) is a novel approach.

OBJECTIVES

We analyzed the efficacy and safety of EESS in a retrospective study.

METHODS

We retrospectively reviewed charts of patients referred to our center for moderate hemoptysis (MH) who underwent EESS. Successful management is defined as immediate bleeding cessation.

RESULTS

From December 2008 to January 2012, 9 patients were treated with EESS in our endoscopy unit. The MH originated from the left upper lobe in 4 cases, the right upper lobe in 3 cases and the right middle lobe and left lower lobe in 1 case each. Thirteen spigots were inserted. The success rate was 78%. Of the 9 patients, 7 were referred to interventional radiology for bronchial artery embolization, with a success rate of 86%, and 2 were referred for thoracic surgery. One patient had EESS as definitive treatment; the silicone spigots were bronchoscopically removed after a median of 4 days in 6 of the remaining 8 patients. Only 2 patients had hemoptysis recurrence after a median follow-up of 107 days (ranging from 13 to 1,017 days). None of the patients died from hemoptysis.

CONCLUSION

EESS is an original, temporary technique that requires only a flexible bronchoscope and biopsy forceps for placement and removal. EESS ensures airway protection while waiting for definitive management.

[Management of massive hemoptysis]

Massive hemoptyses are serious clinical conditions that can quickly jeopardize the vital prognosis. The major risk is asphyxiation, due to the bleeding into the tracheobronchial tree. The clinician should provide in parallel support for diagnosis and treatment, locating the bleeding but also finding its cause. Such patients should be cared for by a multidisciplinary team, having quick access to an important technical support. The association fiberoptic bronchoscopy-chest CT scan seems to be the most effective to locate and identify the cause of the bleeding. The development of bronchial artery embolization has revolutionized the management of these patients, replacing surgery in many of its indications. The latter still keeps a place in the management of these patients. Indeed, it is the main etiological treatment, preventing the vast majority of recidivism. It is absolutely indicated in the treatment of bleeding from the pulmonary vessels, and in case of failure of other techniques. It should be performed whenever possible away from the episode of hemoptysis, in order to minimize the operative risk.

Advanced malignant lung disease: what the specialist can offer

Lung cancer is not only the most commonly diagnosed cancer worldwide, but it is still the leading cause for cancer-related death. The 5-year survival for lung cancer in Europe and in the USA is totally 16%. Therefore, a palliative therapy regimen is required to control the disease and reduce symptoms with the objective of enhancing quality of life of lung cancer patients. In addition to chemotherapy that is still one of the most important pillars in the treatment of advanced lung cancer, further interventional strategies can be offered to improve a patient's quality of life. A locoregional tumour progression is frequently associated with malignant pleural effusion or pericardial effusion, central airway obstruction, tracheo-oesophageal fistula, severe haemoptysis or superior vena cava (SVC) syndrome threatening life and necessitating urgent palliation. Recurrent pleural effusion causing dyspnoea can be managed by pleurodesis, serial thoracocentesis or insertion of an indwelling catheter. Symptomatic malignant pericardial effusion often requires an urgent pericardiocentesis. Furthermore, surgical procedures, instillation of sclerosing agents or local chemotherapy should be considered in refractory pericardial effusion. The therapy regimen of central airway stenosis includes mechanical and thermic endoscopic procedures providing rapid relief of symptoms. To prevent recurrence of airway obstruction, the insertion of a stent or palliative brachytherapy provide re-establishment of the patency of obstructed airways. Haemoptysis can be managed by bronchoscopic interventions as well as by arterial embolization or palliative thoracic radiotherapy. The therapy of SVC syndrome is dependent of histology. In small-cell lung cancer, chemotherapy is recommended. In non-small-cell lung cancer, stent insertion and/or radiotherapy are the therapeutic pillars.

Endobronchial stent insertion to manage hemoptysis caused by lung cancer

Hemoptysis in patients with lung cancer is not uncommon and sometimes have dangerous consequences. Hemoptysis has been managed with various treatment options other than surgery and medicine, such as endobronchial tamponade, transcatheter arterial embolization and radiation therapy. However, these methods can sometimes be used only temporarily or are not suitable for a patient's condition. We present a case in which uncontrollable hemoptysis caused by central lung cancer was successfully treated by inserting a covered self-expanding bronchial stent. The patient could be extubated and was able to undergo further palliative therapy. No recurrent episodes of hemoptysis occurred for the following three months. As our case, airway stenting is a considerable option for the tamponade of a bleeding lesion that cannot be successfully managed with other treatment methods and could be used to preserve airway patency in a select group of patients.