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

Bronchial artery embolization using small particles is safe and effective: a single center 12-year experience

BACKGROUND

Bronchial artery embolization (BAE) using particles is an established treatment for hemoptysis. The use of polyvinyl alcohol (PVA) with a particle size of 300 µm or larger is thought to reduce the risk of non-target embolization but may result in more proximal vessel occlusion than is ideal, resulting in a high rate of early recurrent hemorrhage.

OBJECTIVE

This study evaluates the safety and efficacy of BAE using PVA particles with a size of less than 300 µm.

METHODS

All patients who underwent BAE between 2010 and 2022 at a tertiary center were included. Demographic data, etiology and volume of hemoptysis, technical and clinical success, procedure-related complications, and follow-up information were collected from patients' electronic records. 150-250 µm PVA particles were used to commence embolization in all patients with the subsequent use of larger-sized particles in some individuals. The Kaplan-Meier method was used to estimate recurrence and survival rates.

RESULTS

One hundred forty-four patients underwent 189 embolization procedures between 2010 and 2022 and were followed up for a median of 35 months [IQR 19-89]. 150 µm to 250 µm PVA particles were used as the sole embolic agent in 137 cases. Hemoptysis recurred within 30 days in 7%. The median time to repeat intervention was 144 days [IQR 42-441]. Seventeen out of 144 patients had a pulmonary artery branch pseudoaneurysm. The rate of major complications was 1% with no instances of stroke or spinal artery ischemia. Thirty-day mortality was 2% (4/189).

CONCLUSION

BAE using 150-250 µm PVA particles is safe and effective with few complications and low rates of early hemoptysis recurrence.

CLINICAL RELEVANCE STATEMENT

BAE using small particles is likely to improve outcomes, particularly the rate of early recurrence, in patients with hemoptysis, without an increase in procedural complications.

KEY POINTS

BAE is a safe and effective treatment for patients with hemoptysis. Using small PVA particles in BAE has few complications and low rates of early recurrence. Pulmonary artery pseudoaneurysms should be actively sought in those with hemoptysis undergoing BAE.

[An outline of pulmonary hemorrhage - A pulmonologists perspective]

Hemoptysis resembles a clinical emergency and necessitates a fast and well-coordinated diagnostic and therapeutic approach. While up to 50% of the underlying causes remain unidentified, the majority of cases in the western world can be attributed to respiratory infections and pulmonary neoplasm. While 10% of the patients present with massive, life-threatening hemoptysis, which require a timely airway protection in order to secure a sustained pulmonary gas-exchange, the vast majority presents with non-critical pulmonary bleeding events. Most critical pulmonary bleeding events arise from the bronchial circulation. An early chest imaging is key for identifying the bleeding cause and localization. While chest x-rays are widely implemented in the clinical work-flow and rapidly applicable, computed tomography and computed tomography angiography exhibit the highest diagnostic yield. Bronchoscopy can add diagnostic information especially in pathologies of the central airways, while offering multiple therapeutic options to maintain pulmonary gas exchange. The initial therapeutic regimen comprises early supportive care, but treatment of the underlying etiology is of prognostic relevance and avoids recurrent bleeding events. Bronchial arterial embolization usually is the therapy of choice in patients with massive hemoptysis, while definitive surgery is reserved for patients with refractory bleeding and complex pathologies.

Bronchial artery embolization for hemoptysis: A systematic review and meta-analysis

Objective

To assess the safety and efficacy of bronchial artery embolization (BAE) for hemoptysis.

Methods and materials

Databases with articles published in English, including Pubmed, Embase, Web of science and Chochrane library, were comprehensively searched to get accurate, up-to-date and sufficient literature about BAE for hemoptysis until March 2020. The technical success rates, immediate control rates, recurrence rates, mortality rates, and total complication rates (minor and major complication rates) extracted from the articles were pooled to estimate and assess the efficacy and safety of BAE using random-effect and fixed-effect models.

Results

21 articles published between 2008 and 2019, which include a total of 2511 patients, were studied to evaluate the safety and efficacy of BAE. The technical success and immediate control rates are 99.9% (95%CI: 99%–100%) and 99.5% (95%CI: 97.8%–99.2%), respectively. This study showed hemoptysis recurrence in 23.7% (95%CI: 18.5%–28.9%) with a mortality rate of 2% (95%CI: 0–3%). Additionally, the assessment of complications revealed a total complication rate of 13.4% (95% CI: 7.6–19.2%), in which 0.2% (95% CI: 0.2–0.4%) were major complications and 10% (95% CI: 4.7–9.6%) were minor complications.

Conclusion

BAE is an effective, safe, and feasible procedure with a low complication rate for hemoptysis patients. However, recurrence of hemoptysis is still at high risk after BAE due to different underlying diseases.

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

Purpose

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

Materials and methods

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

Results

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

Conclusions

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

Embolotherapy in Bronchial Hemorrhage

Hemoptysis, defined as bleeding into the tracheobronchial tree, is a serious symptom that can cause asphyxiation if inadequately treated. Massive hemoptysis carries a very high mortality risk, and therefore, a prompt multidisciplinary approach to hemoptysis is highly encouraged. Bronchial artery embolization has evolved as the mainstay of treatment in control of hemoptysis. It is a low-risk procedure that carries high initial clinical success rates. Despite relatively high recurrence rates, it can be repeated until the underlying disease process can be definitively treated.

Feasibility and long-term safety of Ho:YAG laser lithotripsy in broncholithiasis patients

BACKGROUND

Treatment of broncholithiasis is complex, especially in the case of a large or transbronchial broncholith. Holmium-yttrium aluminum garnet (Ho:YAG) laser lithotripsy may be a useful treatment in broncholithiasis; however, as it is not yet common practice, the optimal parameters are unknown.

METHODS

We performed a single-center retrospective analysis of the clinical data of 13 broncholithiasis patients who underwent Ho:YAG laser lithotripsy from May 2012 to October 2018.

RESULTS

For the 13 patients (2 males and 11 females), Ho:YAG laser lithotripsy was performed 17 times, in total. All procedures were performed under general anesthesia with rigid bronchoscopy. We initially set the Ho:YAG laser to a pulse frequency of 5 Hz and a pulse energy of 0.8 J, gradually increasing these as required. The pulse frequency range we employed was 5-15 Hz, and the pulse energy range was 0.8-1.6 J. All broncholiths were successfully extracted after lithotripsy, and all symptoms improved. Hemoptysis, bronchial esophageal fistula, and pneumonia were the most common complications; however, there were no long-term complications.

CONCLUSIONS

Ho:YAG laser lithotripsy is an effective and safe treatment for broncholithiasis, over a long-term follow up.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

ACR Appropriateness Criteria® Hemoptysis

Hemoptysis, the expectoration of blood, ranges in severity from nonmassive to massive. This publication reviews the literature on the imaging and treatment of hemoptysis. Based on the literature, the imaging recommendations for massive hemoptysis are both a chest radiograph and CT with contrast or CTA with contrast. Bronchial artery embolization is also recommended in the majority of cases. In nonmassive hemoptysis, both a chest radiograph and CT with contrast or CTA with contrast is recommended. Bronchial artery embolization is becoming more commonly utilized, typically in the setting of failed medical therapy. Recurrent hemoptysis, defined as hemoptysis that recurs following initially successful cessation of hemoptysis, is best reassessed with a chest radiograph and either CT with contrast or CTA with contrast. Bronchial artery embolization is increasingly becoming the treatment of choice in recurrent hemoptysis, with the exception of infectious causes such as in cystic fibrosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Morphological Analysis of Bronchial Arteries and Variants with Computed Tomography Angiography

The aim of our study was to determine the prevalence of anatomical variants of bronchial arteries using computed tomographic angiography in a population of northeastern Mexico. An observational, transversal, descriptive, comparative, retrospective study was performed using 139 imaging studies of Mexican patients in which we evaluated the following parameters from the left and right bronchial arteries: artery origin, branching pattern, arterial ostium, vertebral level of origin, diameter, and mediastinal trajectory. The anatomies of the bronchial arteries were similar in both genders, except distribution for vertebral origin level (p  0.006) and the diameter (p  0.013). Left and right arteries were similar, except for the mediastinal trajectory in reference to the esophagus (p < 0.001) as well as the arterial diameter (p < 0.001) and lumen diameter.