Multi-detector row CT of hemoptysis

Predictive Factors for Recurrent Hemoptysis after Bronchial Artery Embolization in Patients with Lung Cancer

PURPOSE

To identify clinical, radiological, and angiographic characteristics associated with recurrent hemoptysis after bronchial artery embolization (BAE) in patients with lung cancer and severe hemoptysis admitted to the intensive care unit (ICU).

MATERIALS AND METHODS

A total of 144 consecutive patients with lung cancer who underwent BAE for life-threatening hemoptysis admitted in the ICU between 2014 and 2022 were retrospectively included. Demographics, laboratory values, clinical course, and radiological/angiographic features were compared between those with and without recurrent hemoptysis within 1 month after embolization.

RESULTS

Of the 144 patients (mean age, 60.2 years [SD ± 10.9]; females, 15.3%), 34.7% (50/144) experienced clinically relevant recurrent hemoptysis within 1 month; among them, 29 of 50 (58.0%) cases necessitated a second embolization. Massive hemoptysis was observed in 54.2%, with 16.7% receiving the vasopressin analog terlipressin. The mean volume of hemoptysis and simplified acute physiology score II (SAPS II) were 235 mL (SD ± 214.3) and 31.2 (SD ± 18.6), respectively. Computed tomography (CT) angiography revealed pulmonary artery (PA) injury (11.5%) and necrosis/cavitation (25.8%), and PA embolization was performed in 15.3% of cases. Technical success rate was 92%. SAPS II (P = .01), massive hemoptysis (P < .001), terlipressin use (P = .01), necrosis/cavitation (P = .01), and PA injury on CT angiography (P < .001) were associated with recurrent hemoptysis. Independent predictors on multivariate analysis were massive hemoptysis (P = .016) and PA injury on CT angiography (P = .001).

CONCLUSIONS

In patients with lung cancer and life-threatening hemoptysis treated by BAE, massive hemoptysis and PA injury identified on CT angiography are independent predictors of recurrent hemoptysis.

Serial assessment of computed tomography angiography for pulmonary and systemic arteries using a reduced contrast agent dose for the diagnosis of systemic artery-to-pulmonary artery shunts

PURPOSE

To evaluate the diagnostic performance and feasibility of a modified computed tomography (CT) scan protocol, we performed a serial assessment of the computed tomography angiography for pulmonary artery (CTA-P) and systemic artery (CTA-S) (CTA-PS) using a reduced contrast agent dose to diagnose systemic artery-to-pulmonary artery shunts (SPSs).

MATERIALS AND METHODS

Twenty-five patients who underwent multiphase contrast-enhanced chest CT and conventional chest angiography were included. Three image sets (CTA-P, CTA-S, and CTA-PS) were evaluated by two board-certified radiologists. The visualization of the CT image findings associated with SPSs, such as filling defects and enhancement in the pulmonary arteries, was evaluated using a 5-point scale.

RESULTS

The diagnostic performance (sensitivity, specificity, and accuracy) of CT imaging findings associated with SPSs in CTA-P and CTA-PS were as follows: CTA-P, 57.1%, 87.5%, and 62.0%; CTA-PS, 81.0%, 100.0%, and 84.0%. CT findings associated with SPSs in CTA-P were significantly sensitive to the CTA-PS protocol. There were no significant differences between the CTA-S and CTA-PS protocols. The area under the curve (AUC) of the CT imaging findings associated with SPSs in the CTA-P and CTA-PS groups was 0.835 and 0.911, respectively (P = 0.191). The AUC of the CT imaging findings associated with SPSs in CTA-S and CTA-PS were 0.891 and 0.926, respectively (P = 0.373).

CONCLUSION

CTA-PS using a reduced contrast agent dose protocol could improve the overall diagnostic confidence of SPSs, owing to better visualization of CT imaging findings associated with SPSs compared to individual assessments of CTA-P or CTA-S. Therefore, CTA-PS can be used as an alternative preembolization evaluation modality to conventional angiography in patients with hemoptysis suspected of having SPSs.

Successful Endovascular Management of Recurrent Hemoptysis due to Multiple Rasmussen Aneurysms in a Case of Pulmonary Tuberculosis: A Rare Case Scenario

Background

Hemoptysis is defined as coughing out of blood. Pulmonary tuberculosis is the most common cause of hemoptysis in tuberculosis-endemic countries like India. Rasmussen aneurysm is a pseudoaneurysm arising from the pulmonary artery adjacent to or within a tuberculous cavity. Chest radiographs, chest computed tomography angiography (CTA), and digital subtraction angiography (DSA) are the imaging tools for evaluating a case of hemoptysis.

Case

A 32-year-old man with a history of pulmonary tuberculosis presented with complaints of recurrent hemoptysis. On imaging evaluation, multiple pulmonary artery pseudoaneurysms were seen in the left lung. The patient was shifted to the DSA lab and the pseudoaneurysms were subsequently treated by endovascular coil embolization. Hemoptysis resolved following the procedure and the patient was again started on anti-tubercular therapy.

Conclusion

Endovascular coiling is minimally invasive, safe, and effective management of multiple Rasmussen aneurysms for preventing possible torrential blood loss and unfortunate death.

"Triple-low" radiation dose bronchial artery CT angiography before bronchial artery embolisation: a feasibility study

AIM

To explore the feasibility of a "triple-low" dose (low tube voltage, low tube current, and low contrast agent volume) bronchial artery computed tomography (CT) angiography (CTA) to replace routine dose bronchial artery CTA before bronchial artery embolisation (BAE).

MATERIALS AND METHODS

CTA was obtained from 60 patients with body mass index (BMI) < 30 kg/m2 using a 256 multi-section iCT system, and they were divided into two groups: (1) group A: 100 kVp, 100 mAs, 50 ml contrast medium (CM); (2) group B: 120 kVp, automatic tube current modulation (ACTM), 80 ml CM. CT attenuation of the thoracic aorta, image noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated, and subjective image quality scores and traceability scores assessed. The effective radiation dose was calculated.

RESULTS

The radiation dose was reduced by 79.7% in group A compared to group B (p<0.05). The CT attenuation of the thoracic aorta was increased by approximately 13% in group A compared to group B (p<0.05). Higher image noise, lower SNR, and CNR were obtained in group A compared to group B (all p<0.05). Both subjective image quality scores and traceability scores did not differ between groups A and B (both p>0.05).

CONCLUSION

It is feasible to use the "triple-low" dose CTA protocol for patients with a body mass index (BMI) < 30 kg/m2. The radiation dose was reduced by 79.7%, and the dose of contrast medium was reduced by 37.5% to ensure the diagnostic value.

Pulmonary Artery Embolization in the Management of Hemoptysis Related to Lung Tumors

(1) Background: Bronchial artery embolization has been shown to be effective in the management of neoplastic hemoptysis. However, knowledge of pulmonary artery embolization is lacking. The aim of this study was to evaluate the safety and efficacy of pulmonary artery embolization in patients presenting with hemoptysis related to lung tumors. (2) Methods: This retrospective study reviewed all consecutive patients with cancer and at least one episode of hemoptysis that required pulmonary artery embolization from December 2008 to December 2020. The endpoints of the study were technical success, clinical success, recurrence of hemoptysis and complications. (3) Results: A total of 92 patients were treated with pulmonary artery embolization (63.1 years ± 9.9; 70 men). Most patients had stage III or IV advanced disease. Pulmonary artery embolization was technically successful in 82 (89%) patients and clinically successful in 77 (84%) patients. Recurrence occurred in 49% of patients. Infectious complications occurred in 15 patients (16%). The 30-day mortality rate was 31%. At 3 years, the survival rate was 3.6%. Tumor size, tumor cavitation and necrosis and pulmonary artery pseudoaneurysm were significantly associated with recurrence and higher mortality. (4) Conclusions: Pulmonary artery embolization is an effective treatment to initially control hemoptysis in patients with lung carcinoma, but the recurrence rate remains high and overall survival remains poor.

Hemoptysis in Cancer Patients

Hemoptysis in cancer patients can occur for various reasons, including infections, tumors, blood vessel abnormalities and inflammatory conditions. The degree of hemoptysis is commonly classified according to the quantity of blood expelled. However, volume-based definitions may not accurately reflect the clinical impact of bleeding. This review explores a more comprehensive approach to evaluating hemoptysis by considering its risk factors, epidemiology and clinical consequences. In particular, this review provides insight into the risk factors, identifies mortality rates associated with hemoptysis in cancer patients and highlights the need for developing a mortality prediction score specific for cancer patients. The use of hemoptysis-related variables may help stratify patients into risk categories; optimize the control of bleeding with critical care; implement the use of tracheobronchial or vascular interventions; and aid in treatment planning. Effective management of hemoptysis in cancer patients must address the underlying cause while also providing supportive care to improve patients' quality of life.

Effect of computed tomography angiography prior to bronchial embolization on radiation dose and recurrent hemoptysis

PURPOSE

To investigate whether pre-procedure Computed Tomography Angiography (CTA) improves radiation exposure, procedure complexity, and symptom recurrence after bronchial embolization for massive hemoptysis.

MATERIAL AND METHODS

A single-center retrospective review of bronchial artery embolization (BAE) for massive hemoptysis was performed for procedures between 2008 and 2019. Multi-variate analysis was performed to determine the significance of pre-procedure CTA and etiology of hemoptysis on patient radiation exposure (reference point air kerma, RPAK) and rate of recurrent hemoptysis.

RESULTS

There were 61 patients (mean age 52.5 years; SD = 19.2 years, and 57.3% male) and CTA was obtained for 42.6% (26/61). Number of vessels selected was a mean of 7.2 (SD = 3.4) in those without CTA and 7.4 (SD = 3.4) in those with CTA (p = 0.923). Mean procedure duration was 1.8 h (SD = 1.6 h) in those without CTA and 1.3 h (SD = 1.0 h) in those with CTA (p = 0.466). Mean fluoroscopy time and RPAK per procedure were 34.9 min (SD = 21.5 min) and 1091.7 mGy (SD = 1316.6 mGy) for those without a CTA and 30.7 min (SD = 30.7 min) and 771.5 mGy (SD = 590.0 mGy) for those with a CTA (p = 0.523, and p = 0.879, respectively). Mean total iodine given was 49.2 g (SD = 31.9 g) for those without a CTA and 70.6 g (SD = 24.9 g) for those with a CTA (p = 0.001). Ongoing hemoptysis at last clinical follow up was 13/35 (37.1%) in those without CTA and 9/26 (34.6%) in those with CTA (p = 0.794).

CONCLUSIONS

Pre-procedure CTA did not improve radiation effective dose and symptom recurrence after BAE and is associated with significant increases in total iodine dose.

Prevalence of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization

OBJECTIVES

To identify the prevalence of non-bronchial systemic culprit arteries and their relationship to bleeding lobes in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization (BAE).

METHODS

Data of 83 consecutive patients with bronchiectasis and chronic pulmonary infection (non-tuberculous mycobacteriosis, aspergillosis, and tuberculosis) who underwent de novo BAE between January 2019 and December 2020 were retrospectively reviewed. The prevalence of culprit arteries was investigated.

RESULTS

Fifty-five patients (66%) had 172 non-bronchial systemic culprit arteries. The bleeding lobes were the right upper, right middle, right lower, left upper, and left lower lobes in 14 (17%), 20 (24%), 7 (8%), 31 (37%), and 11 (13%) patients, respectively. The internal thoracic (49%; n = 41), intercostal (28%; n = 23), and inferior phrenic (28%; n = 23) arteries were the top three non-bronchial systemic culprit arteries, which were involved in all five types of bleeding lobes. The costocervical trunk and thoracoacromial and lateral thoracic arteries were predominant in patients with upper lobe bleeding. Ligament arteries were predominant in patients with left lower lobe bleeding.

CONCLUSIONS

These findings will better ensure the identification of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection. All systemic arteries, especially those which are adjacent to the lung lesions, should be evaluated carefully using MDCT; the internal thoracic, intercostal, and inferior phrenic arteries should be proactively assessed using angiography.

KEY POINTS

• Non-bronchial systemic culprit arteries were identified in 66% of patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization. • The internal thoracic (49%), intercostal (28%), and inferior phrenic (28%) arteries were the top three arteries, which were involved in all five types of bleeding lobes. • The costocervical trunk and thoracoacromial and lateral thoracic arteries were prominent in patients with upper lobe bleeding, and the ligament artery was prominent in patients with left lower lobe bleeding.

Coronary artery-bronchial artery fistula imaging characteristics and its correlation with pulmonary disease severity

Hemoptysis is a common clinical emergency, bronchial arterial embolization is considered to be an effective treatment. The presence of coronary artery-bronchial artery fistula (CBF) may lead to recurrence of hemoptysis after treatment. It is necessary to investigate the imaging characteristics of a CBF and its correlation with the severity of pulmonary disease. With the development of multi-detector computed tomography, our study used the 320-slice CT bronchial artery angiography technology to observe and visualize blood vessels. The image and clinical data of 2015 hemoptysis patients with 320-slice CT bronchial artery angiography were retrospectively reviewed from January 2015 to December 2019. The axial and three-dimensional CT images were analyzed. The incidence, anatomical characteristics of CBF and pulmonary disease severity score were evaluated. A total of 12 CBF vessels were detected in 11 patients. We found that the incidence of CBF in this group was 0.55% (11/2015). Mean CBF diameter was 1.9 mm (1.2-2.5 mm). The course of CBF usually was relatively fixed. The proportions of CBF originated from the left circumflex artery, right coronary artery, and left anterior descending artery were 75%, 16.7% and 8.3%, respectively. Preliminarily analysis of the correlation between the trend of CBF and the pulmonary diseases severity score showed that CBF was more likely to communicate with a bronchial artery on the side with a higher severity score. CBF may occur in patients with chronic pulmonary disease and hemoptysis, and its origin, course and trend are characteristic. Detailed and comprehensive computed tomography angiography image analysis is helpful to improve the clinical treatment of hemoptysis with CBF.

A novel angiographic classification of pseudoaneurysms of the pulmonary chronic inflammatory cavity based on selective angiograms and therapeutic implications

Background

Hemoptysis is a common clinical symptom. In the chronic tuberculosis cavity and chronic necrotizing pneumonia cavity, pseudoaneurysms (Pas) easily form and are prone to massive hemoptysis and repeated hemoptysis and can even endanger patient's life. However, it remains to be further analyzed whether Pas of the pulmonary chronic inflammatory cavity selectively affect the peripheral pulmonary branches. This study is based on selective angiography to classify peripheral pulmonary arterial Pas (PAPs) of the pulmonary chronic inflammatory cavity and to determine treatment options for PAPs, thereby guiding individualized clinical treatment.

Methods

Angiographic data of 392 noncancer patients undergoing hemoptysis were retrospectively analyzed. All of the patients underwent pulmonary and selective pulmonary angiography and bronchial and nonbronchial systemic collateral arterial angiography. A total of 9 patients had Pas of the pulmonary chronic inflammatory cavity, and a pseudoaneurysm systemic artery collateral (Pasac), inflow and outflow sections of the parent vessels, and direction of blood flow in the parent vessels were clearly observed with digital subtraction angiography (DSA) and/or C-arm cone-beam flat-panel detector computed tomography angiography (CBCTA). Patients with underlying disease had pulmonary tuberculosis (n=8) or lung abscess (n=1). The angiographic types of Pas were analyzed.

Results

Eight patients with chronic pulmonary tuberculosis and 1 patient with a necrotizing pneumonia cavity in the convalescent period were included in the study. Pas of the pulmonary chronic inflammatory cavity presented the following types: (I) pulmonary artery pseudoaneurysm (PAPa) (n=2 cases); (II) body arterial Pa (n=3 cases); and (III) systemic-pulmonary anastomosis Pa. Each type could be divided into two subtypes (n=4 cases). In nine cases, embolization and hemostasis were technically and clinically successful.

Conclusions

Pas of the pulmonary chronic inflammatory cavity are diverse (especially in cases of pulmonary tuberculosis). Angiographic typing plays a guiding role in the selection of an embolization strategy.

Role of computed tomography angiography in the evaluation of haemoptysis in children: Decoding the abnormal vessels

BACKGROUND & OBJECTIVES

Haemoptysis in children is potentially life-threatening. In most cases, the bleeding arises from the systemic circulation, and in 5-10 per cent of cases, it arises from the pulmonary circulation. The role of computed tomography angiography (CTA) in this setting is important. This study was undertaken (i) to study the role of single-phase split-bolus dual energy contrast-enhanced multidetector row CTA (DECTA) in the evaluation of haemoptysis in children; (ii) to analyze the patterns of abnormal vascular supply in the various aetiologies encountered.

METHODS

A retrospective study of 86 patients who underwent split bolus DECTA for the evaluation of haemoptysis was performed. Final diagnoses were categorized as normal computed tomography, active tuberculosis (TB), post-infectious sequelae, non-TB active infection, cystic fibrosis (CF), non-CF bronchiectasis, congenital heart disease (CHD), interstitial lung disease, vasculitis, pulmonary thromboembolism and idiopathic pulmonary haemosiderosis. Abnormal bronchial arteries (BAs) and non-bronchial systemic collateral arteries (NBSCs) were assessed for number and site and their correlation with underlying aetiologies.

RESULTS

A total of 86 patients (45 males, age from 0.3 to 18 yr, mean 13.88 yr) were included in the study; among these only two patients were less than five years of age. The most common cause of haemoptysis was active infection (n=30), followed by bronchiectasis (n=18), post-infectious sequelae (n=17) and CHD (n=7). One hundred and sixty five abnormal arteries were identified (108 BA and 57 NBSC), and were more marked in bronchiectasis group.

INTERPRETATION & CONCLUSIONS

Active infections and bronchiectasis are the most common causes of haemoptysis in children. While post-infectious sequelae are less common, in patients with haemoptysis, the presence of any abnormal arteries correlates with a more frequent diagnosis of bronchiectasis. NBSCs are more common in post-infectious sequelae and CHD.

Myriad Faces of Active Tuberculosis: Intrapulmonary Bronchial Artery Pseudoaneurysm

Bronchial artery (BA) pseudoaneurysm is an uncommon vascular complication of tuberculosis (TB), and early diagnosis is crucial due to risk of rupture and life-threatening hemorrhage. Immediate intervention is warranted in massive hemoptysis due to high mortality. Various causes of massive hemoptysis are TB, bronchiectasis, aspergilloma, lung abscess, lung cancer, necrotizing pneumonia, and cystic fibrosis. Active pulmonary TB as well as chronic pulmonary TB can manifest with massive hemoptysis. Hemoptysis in active TB occurs due to ulceration in bronchiolar wall, eroding the wall of the adjacent BA or pulmonary artery, and in chronic TB due to hypertrophied bronchial arteries, or bronchiectasis, or aspergilloma. Herein, we report a case of pulmonary TB causing intrapulmonary BA pseudoaneurysm in a young male patient who presented with acute massive hemoptysis. The BA pseudoaneurysm as well as other hypertrophied bronchial arteries were embolized using polyvinyl alcohol (PVA) particles.

Imaging of congenital lung diseases presenting in the adulthood: a pictorial review

Congenital lung diseases in adults are rare diseases that can present with symptoms or be detected incidentally. Familiarity with the imaging features of different types of congenital lung diseases helps both in correct diagnosis and management of these diseases. Congenital lung diseases in adults are classified into three main categories as bronchopulmonary anomalies, vascular anomalies, and combined bronchopulmonary and vascular anomalies. Contrast-enhanced computed tomography, especially 3D reconstructions, CT, or MR angiography, can show vascular anomalies in detail. The tracheobronchial tree, parenchymal changes, and possible complications can also be defined on chest CT, and new applications such as quantitative 3D reconstruction CT images, dual-energy CT (DECT) can be helpful in imaging parenchymal changes. In addition to the morphological assessment of the lungs, novel MRI techniques such as ultra-short echo time (UTE), arterial spin labeling (ASL), and phase-resolved functional lung (PREFUL) can provide functional information. This pictorial review aims to comprehensively define the radiological characteristics of each congenital lung disease in adults and to highlight differential diagnoses and possible complications of these diseases.

Six Cases of Hemoptysis with Angiogenesis from Non-Bronchial Systemic Arteries

BACKGROUND Although bronchial arteries are the most common cause of hemoptysis, other systemic arteries can cause hemoptysis and are potential pitfalls for successful embolization. CASE REPORT We present 6 cases of hemoptysis showing vascularization from systemic arteries other than bronchial arteries that presented to our department between 2013 and 2020. Chronic inflammatory diseases such as tuberculosis and pulmonary aspergillosis were the underlying diseases in 4 of the 6 cases. In all 6 cases, the lesions were close to the pleura. The abnormal non-bronchial systemic arteries were the internal thoracic artery in 4 cases, intercostal artery in 2 cases, lateral thoracic artery in 2 cases, and the subclavian, thyrocervical, and inferior phrenic arteries in 1 case each, all of which formed a shunt with the pulmonary artery. Additionally, depending on the location of the lesion, the non-bronchial systemic arteries near the lesion proliferated into the lung parenchyma through the adherent pleura. CONCLUSIONS When lesions are in contact with the pleura, various non-bronchial systemic arteries near the lesion can develop in the pulmonary parenchyma via the adherent pleura, which can cause hemoptysis. In patients with hemoptysis, it may be useful to evaluate chest contrast-enhanced computed tomography and angiography, while always accounting for the potential involvement of non-bronchial systemic arteries to ensure a safer and more reliable treatment.

Hypervascularized bronchial arteries as a risk factor for intraoperative bleeding and prolonged surgery

Background

The present study investigated whether highly vascularized bronchial arteries affect the intraoperative blood loss and the operative time of video-assisted thoracic surgery (VATS) lobectomy for patients with non-small cell lung cancer.

Results

Among the 175 patients enrolled, risk factors for intraoperative blood loss >50 mL were being male (P=0.005), a history of smoking (P=0.01), percent forced expiratory volume in 1 s (FEV1.0%) <70% (P=0.012), squamous cell carcinoma (P=0.049), and a bronchial artery diameter >2.0 mm (P<0.001) in the unadjusted analysis, and a bronchial artery diameter >2.0 mm (P<0.001) in the multivariable analysis. Risk factors for an operative time >200 min were being male (P<0.001), a history of smoking (P=0.007), FEV1.0% <70% (P=0.011), squamous cell carcinoma (P=0.046), a bronchial artery diameter >2.0 mm (P<0.001), and experience of surgeon <10 years (P=0.011) in the unadjusted analysis, and being male (P=0.047), a bronchial artery diameter >2.0 mm (P=0.024), and experience of surgeon <10 years (P=0.047) in the multivariable analysis.

Conclusions

Bronchial artery diameter was the most important risk factor of intraoperative bleeding and prolonged operative time during VATS lobectomy.

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.

Imaging in non-cystic fibrosis bronchiectasis and current limitations

Non-cystic fibrosis bronchiectasis represents a heterogenous spectrum of disorders characterised by an abnormal and permanent dilatation of the bronchial tree associated with respiratory symptoms. To date, diagnosis relies on computed tomography (CT) evidence of dilated airways. Nevertheless, definite radiological criteria and standardised CT protocols are still to be defined. Although largely used, current radiological scoring systems have shown substantial drawbacks, mostly failing to correlate morphological abnormalities with clinical and prognostic data. In limited cases, bronchiectasis morphology and distribution, along with associated CT features, enable radiologists to confidently suggest an underlying cause. Quantitative imaging analyses have shown a potential to overcome the limitations of the current radiological criteria, but their application is still limited to a research setting.

In the present review, we discuss the role of imaging and its current limitations in non-cystic fibrosis bronchiectasis. The potential of automatic quantitative approaches and artificial intelligence in such a context will be also mentioned.

Variations of bronchial artery origin in 600 patients: Systematic analysis with multidetector computed tomography and digital subtraction angiography

To identify and evaluate the spectrum and prevalence of variations in bronchial artery (BA) origin by multidetector computed tomography (MDCT) and digital subtraction angiography (DSA) in a large population with hemoptysis.From July 2008 to June 2015, data from 600 individuals with hemoptysis who underwent MDCT and DSA were retrospectively analyzed. The pattern of BA origin was investigated and classified according to distribution.A total of 1674 BAs were evaluated, 866 were right BA and 808 were left BA. Most BAs originated from the upper descending thoracic aorta, classified as orthotopic origin (n = 1464, 87.5%). Among ectopic origin BAs (n = 210, 12.5%), concavity of the aortic arch was the most common (n = 107). The most common distribution pattern was a single artery in each side (n = 262). According to our classification, Type I was most common (n = 457), including BAs originating in orthotopic fashion from the descending thoracic aorta. Type II (n = 2) was defined as BAs originating from the aortic arch or ascending aorta. Type III (not found) was defined as BAs originating from subclavian arteries, common carotid arteries, and their branch vessels. Type IV (n = 92) was Type I and II combined, Type V (n = 41) was Type I and III combined, Type VI (not found) was Type II and III combined, and Type VII (n = 8) was Type I, II, and III combined.Variations of BA origin could be systematically described in detail.

CT for Evaluation of Hemoptysis

Hemoptysis, which is defined as expectoration of blood from the alveoli or airways of the lower respiratory tract, is an alarming clinical symptom with an extensive differential diagnosis. CT has emerged as an important noninvasive tool in the evaluation of patients with hemoptysis, and the authors present a systematic but flexible approach to CT interpretation. The first step in this approach involves identifying findings of parenchymal and airway hemorrhage. The second step is aimed at determining the mechanism of hemoptysis and whether a specific vascular supply can be implicated. Hemoptysis can have primary vascular and secondary vascular causes. Primary vascular mechanisms include chronic systemic vascular hypertrophy, focally damaged vessels, a dysplastic lung parenchyma with systemic arterial supply, arteriovenous malformations and fistulas, and bleeding at the capillary level. Evaluating vascular mechanisms of hemoptysis at CT also entails determining if a specific vascular source can be implicated. Although the bronchial arteries are responsible for most cases of hemoptysis, nonbronchial systemic arteries and the pulmonary arteries are important potential sources of hemoptysis that must be recognized. Secondary vascular mechanisms of hemoptysis include processes that directly destroy the lung parenchyma and processes that directly invade the airway. Understanding and employing this approach allow the diagnostic radiologist to interpret CT examinations accurately in patients with hemoptysis and provide information that is best suited to directing subsequent treatment. ^©RSNA, 2021.

Thoracic Cardiovascular Complications of Tuberculosis

ABSTRACT

Mycobacterium infection remains a leading cause of morbidity and mortality worldwide. Although rare, thoracic cardiovascular complications are associated with devastating consequences if not promptly diagnosed using computed tomography. Intrapulmonary complications include tuberculous aortitis, Rasmussen aneurysms, involvement of bronchial and nonbronchial systemic arteries, and thromboembolic events. Extrapulmonary complications include pericarditis, myocarditis, endocarditis, involvement of coronary arteries, annular-subvalvular left ventricle aneurysms and mediastinal fibrosis. This article will review these complications and their computed tomography features.

[Cystic fibrosis and computed tomography of the lungs]

With its high detail of morphological changes in lung parenchyma and airways as well as the possibilities for three-dimensional reconstruction, computed tomography (CT) represents a solid tool for the diagnosis and follow-up in patients suffering from cystic fibrosis (CF). Guidelines for standardized CT image acquisition in CF patients are still missing. In the mostly younger CF patients, an important issue is the well-considered use of radiation in CT imaging. The use of intravenous contrast agent is mainly restricted to acute emergency diagnostics. Typical morphological findings in CF lung disease are bronchiectasis, mucus plugging, or signs of decreased ventilation (air trapping) which can be detected with CT even in early stages. Various scoring systems that have become established over time are used to grade disease severity and for structured follow-up, e.g., in clinical research studies. With the technical development of CT, a number of postprocessing software tools were developed to help clinical reporting and overcome interreader differences for a standardized quantification. As an imaging modality free of ionizing radiation, magnetic resonance imaging (MRI) is becoming increasingly important in the diagnosis and follow-up of CF patients and is already frequently a substitute for CT for long-term follow-up at numerous specialized centers.

Detection of Shunting Into Pulmonary Artery on Multidetector Row Computed Tomography Arteriography Before Bronchial Arterial Embolization: A Preliminary Study

OBJECTIVE

The aim of this study was to investigate the diagnostic performance of detecting systemic arterial pulmonary circulation shunts on multidetector row computed tomography arteriography (MDCTA).

METHODS

Thirty-five consecutive bronchial artery embolization sessions with preprocedural MDCTA were performed for 32 patients and 35 sessions. The MDCTA studies with computed tomography value of pulmonary trunk visually lower than that of ascending aorta were defined as "diagnostic MDCTA." Angiographic studies and "diagnostic MDCTA" were evaluated, respectively, for shunting into pulmonary artery. Based on the results of angiographic studies, diagnostic performance of "diagnostic MDCTA" was evaluated.

RESULTS

The rate of diagnostic MDCTA was 63% (23 of 35). On "diagnostic MDCTA," sensitivity, specificity, and positive and negative predictive values for detecting shunts were 83% 100%, 100%, 94%, respectively.

CONCLUSIONS

Systemic arterial pulmonary circulation shunts were detected on "diagnostic MDCTA" with high sensitivity and specificity.

Cardiac catheterization for hemoptysis in a Children's Hospital Cardiac Catheterization Laboratory: A 15 year experience

OBJECTIVES

The aim of this study was to evaluate the diagnostic utility of cardiac catheterization and the efficacy of transcatheter intervention in patients with hemoptysis.

BACKGROUND

Cardiac catheterization may play a role in identifying the etiologies of hemoptysis with the potential for transcatheter intervention.

METHODS

This was a retrospective study of all the patients who were brought to the pediatric cardiac catheterization laboratory for the indication of hemoptysis over a 15-year period (2006-2020).

RESULTS

Twenty-one patients underwent 28 cardiac catheterizations. The median age was 17.4 years (range 0.3-60.0 years), and the underlying cardiac diagnoses were normal heart n = 3, pulmonary hypertension 1, heart transplant 1, pulmonary arteriovenous malformation 1, pulmonary vein disease 3, biventricular congenital heart diseases 5, and single ventricles 7. The diagnostic utility of catheterization was 81% (17/21). At two-thirds (18/28) of catheterizations, transcatheter interventions were performed in 14/21 (67%) patients: aortopulmonary collateral embolization 14, aortopulmonary and veno-venous collateral embolization 1, and pulmonary arteriovenous malformation embolization 3. Although recurrent hemoptysis was frequent (50%) post-intervention, the final effectiveness of transcatheter interventions was 79% (11/14 patients). Overall mortality was 19% (4/21), all in those presenting with massive hemoptysis.

CONCLUSIONS

Cardiac catheterization was shown to have good diagnostic utility for hemoptysis especially in patients with underlying congenital heart disease. Despite the high mortality and recurrent hemoptysis rate, transcatheter interventions were effective in our cohort.

Non-bronchial causes of haemoptysis: imaging and interventions

Purpose

To describe non-bronchial causes of haemoptysis on imaging and the role of interventional radiology in their management from cases of haemoptysis archived from our database at a tertiary care, federally funded institution.

Material and methods

Retrospective analysis of cases that presented with haemoptysis in our institution from 2008 to 2013 was done, and details of cases in which the bleeding was from a non-bronchial source were archived and details of imaging and treatment were recorded.

Results

Retrospective analysis of patients presenting with haemoptysis yielded 24 (n = 24) patients having haemoptysis from non-bronchial sources. Causes of haemoptysis were: Rasmussen aneurysms (n = 12/24), costocervical trunk pseudoaneurysm (n = 1/24), left internal mammillary artery pseudoaneurysm (n = 1/24), left ventricular aneurysms (n = 3/24), pulmonary arteriovenous malformations (AVMs) (n = 5/24), and proximal interruption of pulmonary artery (n = 2/24). Imaging and interventional radiology management are described in detail.

Conclusions

Haemoptysis can be from non-bronchial sources, which may be either from systemic or pulmonary arteries or cardio-pulmonary fistulas. Bronchial computed tomography angiography (CTBA), if feasible, must always be considered before bronchial artery embolisation because it precisely identifies the source of haemorrhage and vascular anatomy that helps the interventional radiologist in pre-procedural planning. This circumvents chances of re-bleed if standard bronchial artery embolisation is done without CTBA.

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.

A case of Marfan syndrome with massive haemoptysis from collaterals of the lateral thoracic artery

BACKGROUND

Marfan Syndrome (MFS) is a heritable connective tissue disorder with a high degree of clinical variability including respiratory diseases; a rare case of MFS with massive intrathoracic bleeding has been reported recently.

CASE PRESENTATION

A 32-year-old man who had been diagnosed with MFS underwent a Bentall operation with artificial valve replacement for aortic dissection and regurgitation of an aortic valve in 2012. Warfarin was started postoperatively, and the dosage was gradually increased until 2017, when the patient was transported to our hospital due to sudden massive haemoptysis. Computed tomography (CT) with a maximum intensity projection (MIP) revealed several giant pulmonary cysts with fluid levels in the apex of the right lung with an abnormal vessel from the right subclavian artery. Transcatheter arterial embolization was performed with angiography and haemostasis was achieved, which suggested that the bleeding vessel was the lateral thoracic artery (LTA) branch. CT taken before the incident indicated thickening of the cystic wall adjacent to the thorax; therefore, it was postulated that the bleeding originated from fragile anastomoses between the LTA and pulmonary or bronchial arteries. It appears that the vessels exhibited inflammation that began postoperatively, which extended to the cysts.

CONCLUSION

We experienced a case of MFS with massive haemoptysis from the right LTA. We have to be aware of the possibility that massive haemoptysis could be induced in MFS with inflamed pulmonary cysts.

Imaging protocols for CT chest: A recommendation

Computed Tomography (CT) is the mainstay of diagnostic imaging evaluation of thoracic disorders. However, there are a number of CT protocols ranging from a simple non-contrast CT at one end of the spectrum, and CT perfusion as a complex protocol available only on high-end scanners. With the growing diversity, there is a pressing need for radiologists, and clinicians to have a basic understanding of the recommended CT examinations for individual indications. This brief review aims to summarise the currently prevalent CT examination protocols, including their recommended indications, as well as technical specifications for performing them.

Fatal hemoptysis after bronchoscopic biopsy in a dog

An 8‐year‐old 24.6 kg mixed breed dog underwent bronchoscopy for evaluation of a persistent progressive cough. Bronchoscopy documented a markedly thick and irregular, cobblestone appearance of the mucosa. A bronchoscopic biopsy was obtained; immediately after the biopsy, a large amount of hemorrhage poured from the endotracheal tube. Multiple efforts to control the hemorrhage were unsuccessful and the dog suffered a cardiopulmonary arrest and could not be revived. A necropsy was performed, which was significant for pallor, evidence of prior heartworm disease, prominent bronchial arteries, and erosion of the submucosal vessels at the site of the biopsy. The cause of death was hemorrhage associated with transbronchial biopsy of an enlarged bronchial artery associated with heartworm disease. This report describes a rare complication of a routine diagnostic procedure.

Non-aortic vascular findings on chest CT angiogram: including arch vessels and bronchial arteries

CT angiogram (CTA) has become the modality of choice for imaging of thoracic vascular pathologies, involving the aorta and the pulmonary arteries. Apart from showing exquisite details of these large arteries, pathologies and anatomic variants of their branches can also be studied to a great extent. The major branches of aortic arch can be affected by a wide variety of pathologies ranging from atherosclerosis to trauma and vasculitis. Bronchial arteries in spite of supplying only 1% of lung parenchyma can become hypertrophied in various congenital and acquired conditions, becoming an important source of collateral circulation as well as a source for life threatening hemoptysis. CT also plays an important role in diagnosis of vascular compression at the thoracic outlet. With advances in CT technology, the acquisition, interpretation and clinical applications of CT angiography will continue to grow in the years to come.

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.

[Pulmonary hemorrhage in rheumatic diseases]

In the article, we report the causes of pulmonary hemorrhage (PH) according to the literature data and own experience, with an emphasis on patients suffering from rheumatic diseases. Methods of diagnosis and modern approaches to the treatment of PH are analyzed.

The Diagnosis and Treatment of Hemoptysis

BACKGROUND

Hemoptysis, i.e., the expectoration of blood from the lower airways, has an annual incidence of approximately 0.1% in ambulatory patients and 0.2% in inpatients. It is a potentially life-threatening medical emergency and carries a high mortality.

METHODS

This review article is based on pertinent publications retrieved by a selective search in PubMed.

RESULTS

Hemoptysis can be a sign of many different diseases. Its cause remains unknown in about half of all cases. Its more common recognized causes include infectious and inflammatory airway diseases (25.8%) and cancer (17.4%). Mild hemoptysis is self-limited in 90% of cases; massive hemoptysis carries a worse prognosis. In patients whose life is threatened by massive hemoptysis, adequate oxygenation must be achieved through the administration of oxygen, positioning of the patient with the bleeding side down (if known), and temporary intubation if necessary. A thorough diagnostic evaluation is needed to identify the underlying pathology, site of bleeding, and vascular anatomy, so that the appropriate treatment can be planned. The evaluation should include conventional chest x-rays in two planes, contrastenhanced multislice computerized tomography, and bronchoscopy. Hemostasis can be achieved at bronchoscopically accessible bleeding sites with interventionalbronchoscopic local treatment. Bronchial artery embolization is the first line of treatment for hemorrhage from the pulmonary periphery; it is performed to treat massive or recurrent hemoptysis or as a presurgical measure and provides successful hemostasis in 75-98% of cases. Surgery is indicated if bronchial artery embolization alone is not successful, or for special indications (traumatic or iatrogenic pulmonary/vascular injury, refractory asper gilloma).

CONCLUSION

The successful treatment of hemoptysis requires thorough diagnostic evaluation and close interdisciplinary collaboration among pulmonologists, radiologists, and thoracic surgeons.

Single-phase Split-bolus Dual Energy Computed Tomography Angiography for Evaluation of Hemoptysis: A Novel Application

PURPOSE

The purpose of this study was to assess feasibility and overall utility of single-phase split-bolus dual energy computed tomography (DECT) angiography (DECTA) for evaluation of hemoptysis, and to establish an injection protocol for evaluation of hemoptysis, by comparing 2 contrast injection protocols.

MATERIALS AND METHODS

Using dual-source (80 and 140 kV), 2×128-slice equipment, DECTA was performed using 400 mg iodine/mL, 50 to 80 mL iodinated contrast in 257 patients (189 male individuals, 68 female individuals, age range: 15 to 76 y) presenting with hemoptysis. Initially, 50 patients were randomized into 2 groups for 2 different injection protocols (A and B). Images were assessed quantitative and qualitatively. Later, 207 patients were randomized using protocol B, which was technically simpler, and single-CT acquisition, for simultaneous opacification of systemic and pulmonary vessels.

RESULTS

Injection protocol A resulted in higher vessel attenuation, both in the aorta and in the pulmonary artery and its segmental branches; however, the difference was not statistically significant. No significant difference was noted in signal-to-noise ratio, contrast-to-noise ratio, as well as subjective image quality parameters. Overall optimal opacification of both systemic and pulmonary arteries was achieved in 247/257 patients. A total of 308 abnormal bronchial arteries were noted. A total of 392 nonbronchial systemic arteries were noted, the majority arising from posterior intercostals and subclavian artery branches. The pulmonary source of hemoptysis was identified in 9 patients (3 pulmonary thromboembolisms, 5 pulmonary artery pseudoaneurysms, and 1 pulmonary venous ectasia).

CONCLUSION

Combined DECTA is a novel technique that enables simultaneous evaluation of both systemic and pulmonary vascular cause of hemoptysis in a single acquisition with small contrast dose. Both injection protocols "A" and "B" were equally efficacious in simultaneous opacification of both the aorta and pulmonary arteries. To the best of our knowledge, such a protocol has never been described for hemoptysis evaluation.

A novel approach to the diagnosis and treatment of hemoptysis in infants: A case series

INTRODUCTION

Hemoptysis in children is an uncommon presenting symptom but can be life-threatening if massive. Cardiac catheterization and coil embolization of aorto-pulmonary collateral vessels (APCs) is uncommon in pediatric hemoptysis patients without congenital heart disease.

METHODS

We present a series of seven infants (≤12 months of age) with hemoptysis, all of whom underwent cardiac catheterization to look for and intervene upon APCs, if found. Only those patients who underwent both bronchoscopy as well as cardiac catheterization from January 1995 to January 2015 were included in this retrospective review.

RESULTS

Seven patients met inclusion criteria, and three had a history of recurrent hemoptysis. The mean age was 3 months. Four had evidence of bleeding on bronchoscopy. All seven had respiratory distress which necessitated ICU admission; five required mechanical ventilation. Cardiac catheterization showed significant APCs (>2 mm) in six of the seven studied patients, all of which were coil embolized. One patient had no significant APCs and therefore, no embolization. All patients had complete resolution with no recurrences during the 10-20-year outpatient follow-up period. Chest CT scans were not helpful in delineating the site or etiology of bleeding in any patient.

CONCLUSIONS

APCs should be considered as a differential diagnosis for pulmonary hemorrhage in infants after more common causes have been ruled out.

Pictorial review of the pulmonary vasculature: from arteries to veins

Pathology of the pulmonary vasculature involves an impressive array of both congenital and acquired conditions. While some of these disorders are benign, disruption of the pulmonary vasculature is often incompatible with life, making these conditions critical to identify on imaging. Many reviews of pulmonary vascular pathology approach the pulmonary arteries, pulmonary veins and bronchial arteries as individual topics. The goal of this review is to provide an integrated overview of the high-yield features of all major disorders of the pulmonary vasculature. This approach provides a more cohesive and comprehensive conceptualisation of respiratory pathology. In this review, we present both the salient clinical and imaging features of congenital and acquired disorders of the pulmonary vasculature, to assist the radiologist in identifying pathology and forming a robust differential diagnosis tailored to the presenting patient. TEACHING POINTS: • Abnormalities of the pulmonary vasculature are both congenital and acquired. • Pathology of a single pulmonary vascular territory often affects the entire pulmonary vasculature. • Anomalous pulmonary venous flow is named as a function of its location and severity. • Bronchial arteries often undergo dilatation secondary to cardio-respiratory pathology.

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.

2018 Korean Clinical Imaging Guideline for Hemoptysis

In 2014, the American College of Radiology (ACR) announced the guideline for the appropriate diagnostic approach and treatment of patients according to the severity of hemoptysis and risk for lung cancer. However, the application of the ACR guideline in Korea may not be appropriate, because many patients in Korea have active tuberculosis or pulmonary fibrosis due to previous tuberculosis. The Korean Society of Radiology and Korean Society of Thoracic Radiology have proposed a new guideline suitable for Korean practice. This new guideline was prepared through the consensus of a development committee, working party, and an advisory committee. The guideline proposal process was based on an evidence-based clinical imaging guideline proposed by the development committee. Clinical imaging guideline for adult patients with hemoptysis is as follows: Chest radiography is an initial imaging modality to evaluate hemoptysis. Contrast-enhanced chest CT is recommended in patients with two risk factors for lung cancer (> 40 years old and > 30 pack-year smoking history), moderate hemoptysis (> 30 mL/24 hours) or recurrent hemoptysis. Contrast-enhanced chest CT is also recommended in patients with massive hemoptysis (> 400 mL/24 hours) without cardiopulmonary compromise.

Post-primary pulmonary TB haemoptysis - When there is more than meets the eye

Haemoptysis is concerning for both patient and healthcare provider and points to the presence of severe underlying lung disease warranting investigation. Approximately 8% of patients with pulmonary tuberculosis (PTB) infection will experience haemoptysis at some point during their life ^[1;2]. The aetiology of haemoptysis in the setting of PTB is diverse and may occur during active or following prior PTB infection due to pulmonary complications. We describe the case of a 33-year-old female who presented with massive haemoptysis on two separate occasions within a five-month period. Her background history included PTB 6 years prior and subsequent post-TB bronchiectasis with a destroyed left lung, and the development of apical mycetoma's. Despite numerous pre-existing aetiologies that could account for haemoptysis in this patient, on this admission, a newly identified ruptured Rasmussen's aneurysm was identified by angiography and successfully treated with arterial embolization. This report serves to highlight the multitude of reasons for haemoptysis in a patient with post PTB lung destruction and the associated diagnostic challenges that may be present. In particular, we highlight the Rasmussen's aneurysm, a rare entity, as a hidden cause of haemoptysis, where despite extensive parenchymal lung disease identified on chest radiography, specialised imaging is needed to confirm the diagnosis.

Mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation: a single-centre retrospective observational study

Objectives

In recognition of the significant impairment caused by haemoptysis on a patient’s quality of life, bronchial artery embolisation has been introduced worldwide as one of the first-line treatment options. Since little evidence is available on the mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation (ssBACE), the purpose of the present study is to evaluate these.

Methods

We retrospectively evaluated the mechanisms of recurrent haemoptysis using both enhanced computed tomography and cineangiography following ssBACE by reviewing 299 haemoptysis-related arteries (HRAs) in 57 consecutive patients who underwent 2nd series ssBACE for the management of recurrent haemoptysis between April 2010 and December 2015.

Results

Median age of patients was 69 (interquartile range 64–74) years, and 43.9% were men. This study revealed that (1) recanalisation was the most common mechanism (45.2%) followed by development of new HRA (38.5%), bridging collaterals (14.7%) and conventional collaterals (1.7%); (2) these trends could be modified in several situations such as with antiplatelet or anticoagulant medications; (3) relatively large-diameter HRAs were more likely to recanalise compared with small-diameter HRAs and (4) recurrent haemoptysis could be managed by 2nd series ssBACE with a procedural success rate of 97.7% without any major complications.

Conclusions

Recanalisation was the most common mechanism of recurrent haemoptysis after ssBACE. Our results provide interventionists with indispensable insights.

Key Points

• Recanalisation was the most common mechanism of recurrent haemoptysis after super-selective bronchial artery coil embolisation, followed by development of new haemoptysis-related arteries

• These trends could be modified in several situations such as with antiplatelet or anticoagulant medications

• Recurrent haemoptysis could be managed by 2nd series super-selective bronchial artery coil embolisation with a procedural success rate of 97.7% without any major complications.

Pulmonary artery aneurysms: diagnosis & endovascular therapy

Pulmonary artery aneurysms (PAAs) and pseudoaneurysms are rare entities in the spectrum of pulmonary arterial diseases. The etiology of these aneurysms is varied and patients present with nonspecific symptoms which make their diagnosis both difficult and less often considered. In this review, we will discuss the clinical manifestations, etiologies, methods of detection, imaging features, and the current role of endovascular treatment in the management of PAAs.

Life-threatening airway bleeding after palliation of single ventricle congenital heart disease

Objective

To describe acute and mid-term outcomes following presentation with, and treatment for, life-threatening airway bleeding (hemoptysis) in palliated single ventricle congenital heart disease (SV-CHD).

Methods

Case series of patients with SV-CHD who presented to a large congenital heart centre with hemoptysis between 2004 and 2015.

Results

Twenty-one episodes of hemoptysis occurred in 12 patients (58% female, median 10.5 (IQR 7.2, 16.4) years). First hemoptysis episode occurred after Fontan completion (n=8), after superior cavopulmonary anastomosis (SCPA, n=3) and in one shunt-dependent patient. Bronchoscopy was performed in conjunction with catheterisation in 14/21 (67%) initial catheterisations. A specific anatomic source of airway bleeding was identified in 95% of bronchoscopy cases and was uniformly distributed in all lobar segments. Transcatheter intervention with systemic-to-pulmonary collateral artery (SPC) occlusion was performed in 28/30 catheterisations. Apart from increased airway bleeding during interventional bronchoscopy (37%), there were no procedural complications. Median hospital length of stay was 9.0 (3.5, 14.5) days with patients undergoing 1.0 (1.0,2.0) catheterisations per episode of hemoptysis. Two SCPA patients did not survive to discharge. During a median follow-up of 32.5 (12.5, 87.5) months, freedom from mortality was 75%, with all three deaths occurring in the SCPA group by 4 months posthemoptysis. Recurrent hemoptysis occurred in 60% of patients.

Conclusions

Despite the potentially life-threatening nature of hemoptysis in patients with SV-CHD, a policy of bronchoscopic evaluation and transcatheter treatment is safe and may contribute to low mortality at mid-term follow-up in Fontan patients. Hemoptysis in SCPA patients may portend a poor prognosis. Recurrent hemoptysis is common.

Embolization of a Bronchial Artery Aneurysm in a Chronic Obstructive Pulmonary Disease (COPD) Patient with Non-Massive Hemoptysis

Background

Bronchial artery aneurysm (BAA) is a rare condition with a reported prevalence of less than 1% of all selective bronchial arterial angiograms. Despite its low incidence, BAA represents a potential cause of hemoptysis.

Case Report

We describe the case of a 63-year-old man suffering from chronic obstructive pulmonary disease (COPD), who presented with non-massive hemoptysis.

CT angiography revealed a single bronchial artery aneurysm of 9 mm in diameter, abutting the esophageal wall.

Other CT findings included hypertrophy of the bronchial arteries along the mediastinal course, diffuse thickening of the walls of numerous bronchial branches and a “ground glass” opacity in the anterior segment of the right upper pulmonary lobe suggestive of alveolar hemorrhage.

The final diagnosis was established based on selective angiography, which was followed by transcatheter arterial embolization (TAE) of the BAA and of the pathological bronchial circulation.

Follow-up CT scans revealed a total exclusion of the aneurysm from the systemic circulation, resolution of the parenchymal “ground glass” opacity and absence of further episodes of hemoptysis over a period of two years.

Conclusions

An incidental finding of a bronchial artery aneurysm necessitates prompt treatment.

CT angiography and TAE represent the methods of choice for an appropriate diagnosis and treatment, respectively.

In case of a BAA associated with chronic inflammatory diseases, such as COPD, in patients with hemoptysis, TAE of the BAA and of the pathological bronchial circulation, in association with the treatment of the underlying disease, represents a valid approach that can improve the pulmonary status and prevent further episodes of hemoptysis.

Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study

OBJECTIVES

Evidence on the safety and long-term efficacy of super selective bronchial artery embolisation (ssBAE) using platinum coils in patients with haemoptysis is insufficient. The objective of the present study was to evaluate the safety and the 3-year postprocedure haemoptysis-free survival rate of de novo elective ssBAE using platinum coils rather than particles for the treatment of haemoptysis.

DESIGN

A single-centre retrospective observational study.

SETTING

Hemoptysis and Pulmonary Circulation Center in Japan.

PARTICIPANTS

A total of 489 consecutive patients with massive and non-massive haemoptysis who underwent de novo elective ssBAE without malignancy or haemodialysis.

INTERVENTIONS

ssBAE using platinum coils. All patients underwent CT angiography before the procedure for identifying haemoptysis-related arteries (HRAs) and for procedural planning.

PRIMARY AND SECONDARY OUTCOME MEASURES

The composite of the 3-year recurrence of haemoptysis and mortality from the day of the last ssBAE session. Each component of the primary end point and procedural success defined as successful embolisation of all target HRAs were also evaluated.

RESULTS

The median patient age was 69 years, and 46.4% were men. The total number of target vessels was 4 (quartile 2-7), and the procedural success rate was 93.4%. There were 8 (1.6%) major complications: 1 aortic dissection, 2 symptomatic cerebellar infarctions and 5 mediastinal haematoma cases. The haemoptysis-free survival rates were estimated by the Kaplan-Meier analysis at 86.9% (95% CI 83.7% to 90.2%) at 1 year, 79.4% (74.8% to 84.3%) at 2 years and 57.6% (45.1% to 73.4%) at 3 years. Although not statistically significant by the adjusted analysis of variance with multiple imputation of missing variables, cryptogenic haemoptysis tended to show the most favourable outcome and non-tuberculous mycobacterium showed the worst outcome (adjusted p=0.250).

CONCLUSIONS

We demonstrated the safety and long-term efficacy of elective ssBAE using platinum coils and established that it can be a valuable therapeutic option for treating patients with haemoptysis.