Percutaneous embolotherapy for life-threatening hemoptysis

Bronchial artery diameter in massive hemoptysis in cystic fibrosis

Background

Massive hemoptysis is a rare but potentially life-threatening condition of patients with cystic fibrosis (CF) and advanced pulmonary disease. Hypertrophied bronchial arteries are understood to cause massive hemoptysis when rupturing. Risk factors to predict massive hemoptysis are scarce and bronchial artery diameters are not part of any scoring system in follow-up of patients with CF. Aim of this study was to correlate bronchial artery diameter with massive hemoptysis in CF.

Methods

Bronchial artery and non-bronchial systemic artery diameters were measured in contrast enhanced computed tomography (CT) scans in patients with massive hemoptysis and compared to patients with end-stage CF and no history of hemoptysis. Demographic and clinical data and side of bronchial artery/non-bronchial systemic artery hypertrophy and coil embolization were documented.

Results

In this retrospective multicenter study 33 patients with massive hemoptysis were included for bronchial artery/non-bronchial systemic artery diameter measurements, (13 female, 20 male, median age 30 years (18–55)). Bronchial artery diameters were significantly larger in the case group than in the control group with median 4 mm (2.2–8.2 mm), and median 3 mm (1–7 mm), respectively (p = 0.002). Sensitivity of bronchial arteries ≥ 3.5 mm to be associated with hemoptysis was 0.76 and specificity 0.71 with ROC creating an area under the curve of 0.719. If non-bronchial systemic arteries were present, they were considered culprit and embolized in 92% of cases.

Conclusion

Bronchial arteries ≥ 3.5 mm and presence of hypertrophied non-bronchial systemic arteries correlate with massive hemoptysis in patients with CF and might serve as risk predictor for massive hemoptysis. Therefore, in patients with advanced CF we propose CT scans to be carried out as CT angiography to search for bronchial arteries ≥ 3.5 mm and for hypertrophied non-bronchial systemic arteries as possible risk factors for massive hemoptysis.

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.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

ADVANCES IN KNOWLEDGE

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

Life-Threatening Hemoptysis

Life-threatening hemoptysis (LTH) is any amount of hemoptysis that causes significant hemodynamic decompensation or respiratory distress which may lead to death if left untreated. While the amount of hemoptysis that qualifies as massive hemoptysis has continued to be debated, any amount between 100 to 1,000 mL/day is considered significant. Up to 15% cases of hemoptysis are LTH and need urgent life-saving intervention. Understanding of pulmonary vascular anatomy is of paramount importance to manage LTH. The goal of treatment lies in airway protection, appropriate oxygenation, and prevention of exsanguination. Once the airway is stabilized, a quick diagnosis and control of bleeding site is targeted. This chapter highlights current practices and approach to LTH including medical management, bronchoscopic approach, and advanced therapies such as bronchial artery embolization and surgical resection. We review situations, such as bronchiectasis, vascular malformation, diffuse alveolar hemorrhage, and tracheostomy bleed and specific approach to management of these conditions in a systematic and evidence-based manner.

Bronchial Artery Embolization, an Increasingly Used Method for Hemoptysis; Treatment and Avoidance

Objectives

Hemoptysis is an alarming symptom. It may cause some severe life-threatening complications. Hypertrophic and fragile bronchial artery causes hemoptysis and occurs mostly in bronchiectasis, sarcoidosis, active or sequelae tuberculosis, aspergilloma, lung cancer or cystic fibrosis. Bronchial artery embolization is one of the angiographic methods used in diagnosis and treatment for years performed by radiologists. Hemoptysis is used mostly in patients with hemoptysis. Using this method, surgical management with high mortality and morbidity rates can be avoided or better conditions for surgery can be provided via stopping hemorrhage before surgery. We aim to share the experiences of our hospital about patients who underwent bronchial artery embolization and compare our results with the literature.

Methods

Thirty-nine patients (29 male, 10 female) underwent angiography-aiming embolization. Pathologies were hemoptysis in 37 patients, Castleman disease in two patients. Embolization was performed in 33 patients; 31 for hemoptysis, two for Castleman disease. Bilateral embolization was performed in six patients.

Results

Computed tomography (CT) was helpful in diagnosing the side of bleeding in 91.8% of the patients with hemoptysis. Bronchoscopy was diagnostic in 53% of patients. Polyvinyl alcohol (n=27) was mostly used for embolization. Hemoptysis recurred in six patients (19.3%). All were managed successfully, of four with re-embolization. One major complication, transient blindness, was observed.

Conclusion

Bronchial artery embolization is minimally invasive, more tolerable compared to surgery can be managed with high success and lower complication rates, especially hemoptysis and in some other situations. It provides time for evaluating the underlying disease and delaying surgery for elective conditions. That is why this method has been used increasingly.

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

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

Risk Factors for Fatal Pulmonary Hemorrhage following Concurrent Chemoradiotherapy in Stage 3B/C Squamous-Cell Lung Carcinoma Patients

We aimed to identify the fatal pulmonary hemorrhage- (FPH-) related risk factors in stage 3B/C squamous-cell lung carcinoma (SqCLC) patients treated with definitive concurrent chemoradiotherapy (C-CRT). Medical records of 505 stage 3B/C SqCLC patients who underwent 66 Gy radiotherapy plus 1-3 cycles of concurrent chemotherapy with available pretreatment thoracic computerized tomography scans were retrospectively analyzed. Primary end-point was the identification of FPH-related risk factors. Examined factors included the basal patient and tumor characteristics with specific emphasis on the tumor cavitation (TC) status, tumor size (TS) and cavitation size (CS), tumor volume and cavitation volume (TV and CV), relative cavitation size (RCS = CS/TS), and relative cavitation volume (RCV=CV/TV). FPH emerged in 13 (2.6%) patients, with 12 (92.3%) of them being diagnosed ≤12 months of C-CRT. All FPHs were diagnosed in patients with TC (N=60): group-specific FPH incidence: 21.6%. TC (P<0.001) was the unique independent factor associated with higher FPH risk in multivariate analysis. Further analysis limited to TC patients exhibited the RCV>0.14 (37.5% versus 11.1% for RCV≤0.14; P<0.001), major RCS group [31.0% versus 19.0% for minor versus 0% for minimum RCS; P=0.008), and baseline hemoptysis (26.3% versus 13.6% for no hemoptysis; P=0.009) as the independent risk factors for higher FPH incidence. FPH was an infrequent (2.6%) complication of C-CRT in stage 3B/C SqCLC patients, but its incidence increased to 37.5% in patients presenting with TC and RCV>0.14. Diagnosis of >90% FPHs ≤12 months of C-CRT stresses the importance of close and careful follow-up of high-risk patients after C-CRT for multidisciplinary discussion of possible invasive preventive measures.

Management of severe hemoptysis

INTRODUCTION

Though rare, severe hemoptysis (SH) is associated with a mortality rate exceeding 50% when not managed properly. Areas covered: This paper reviews the recent epidemiological data regarding SH, the role of multidetector computed tomography angiography (MDCTA), and fiberoptic bronchoscopy (FOB) in its management, as well as the value of current treatments. Expert commentary: MDCTA is becoming an essential modality, since it allows determining the location, etiology, and mechanism of the bleeding. FOB can be delayed, except when local control of bleeding is required. Emergency treatment relies on interventional radiology. Both bronchial and non-bronchial arteries should be explored during bronchial arteriography. Surgery must be considered in all operable patients if the cause of hemoptysis persists.

An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis

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

An applied anatomical study of bronchial artery

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

Bronchial artery embolization for the treatment of haemoptysis in pulmonary hypertension

PURPOSE

To test the efficacy of bronchial artery embolization (BAE) to treat haemoptysis in pulmonary hypertension (PH).

METHODS

33 patients were treated by BAE for haemoptysis associated with PH (PH group = 21) or non-associated with PH (control group = 12). The details of procedure, outcome, and rate of relapse were compared between the two groups. Within the PH group, the comparison was operated between subjects with congenital heart disease-associated pulmonary artery hypertension (CHD-APAH subgroup = 12) and non-CHD (non-CHD-APAH subgroup = 9).

RESULTS

The rate of relapse at 30 and 90-days was similar between the PH group and control group. BAE in the PH group was more challenging (median 2 arteries embolized per procedure) compared to the control group (median 1 artery embolized per procedure; p = 0.001). Bleeding arteries were more heterogeneous in the PH group, while a single right bronchial artery was the only clinical finding in 66.7% of controls (p = 0.001). Within the PH group, the CHD subgroup showed higher survival rate compared to the non-CHD-APAH group (p = 0.007).

CONCLUSION

BAE is effective and safe for the treatment of haemoptysis in PH, yet more challenging than other conditions. In PH-associated haemoptysis, BAE provides higher survival rate for subjects with PH associated with CHD.

Management considerations of massive hemoptysis while on extracorporeal membrane oxygenation

BACKGROUND:

Veno-arterial extracorporeal membrane oxygenation (V-A ECMO) is a life-saving procedure in patients with both respiratory and cardiac failure. Bleeding complications are common since patients must be maintained on anticoagulation. Massive hemoptysis is a rare complication of ECMO; however, it may result in death if not managed thoughtfully and expeditiously.

METHODS:

A retrospective chart review was performed of consecutive ECMO patients from 7/2010-8/2014 to identify episodes of massive hemoptysis. The management of and the outcomes in these patients were studied. Massive hemoptysis was defined as an inability to control bleeding (>300 mL/day) from the endotracheal tube with conventional maneuvers, such as bronchoscopy with cold saline lavage, diluted epinephrine lavage and selective lung isolation. All of these episodes necessitated disconnecting the ventilator tubing and clamping the endotracheal tube, causing full airway tamponade.

RESULTS:

During the period of review, we identified 118 patients on ECMO and 3 (2.5%) patients had the complication of massive hemoptysis. One case was directly related to pulmonary catheter migration and the other two were spontaneous bleeding events that were propagated by antiplatelet agents. All three patients underwent bronchial artery embolization in the interventional radiology suite. Anticoagulation was held during the period of massive hemoptysis without any embolic complications. There was no recurrent bleed after appropriate intervention. All three patients were successfully separated from ECMO.

CONCLUSIONS:

Bleeding complications remain a major issue in patients on ECMO. Disconnection of the ventilator and clamping the endotracheal tube with full respiratory and cardiac support by V-A ECMO is safe. Early involvement of interventional radiology to embolize any potential sources of the bleed can prevent re-hemoptysis and enable continued cardiac and respiratory recovery.

Diagnosis and management of hemoptysis

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

Palliative procedures in lung cancer

Palliative care aims to optimize comfort and function when cure is not possible. Image-guided interventions for palliative treatment of lung cancer is aimed at local control of advanced disease in the affected lung, adjacent mediastinal structures, or distant metastatic sites. These procedures include endovascular therapy for superior vena cava syndrome, bronchial artery embolization for hemoptysis associated with lung cancer, and ablation of osseous metastasis. Pathophysiology, clinical presentation, indications of these palliative treatments, procedural techniques, complications, and possible future interventions are discussed in this article.

Bronchial artery embolization in life-threatening massive hemoptysis

Background

Massive hemoptysis is a potentially life threatening respiratory emergency and mandates immediate investigation and intervention. There is no universal consensus regarding the optimal management of these patients, and there are no large series of patients studied.

Objectives

Here we reported thirty Iranian patients who were managed with bronchial artery embolization.

Patients and Methods

All the patients had already been assessed by computerized tomography (CT) to localize and delineate the underlying etiology except 2 patients who had not undergone CT scan.

Results

Tuberculosis, bronchiectasis, and lung cancer/metastasis were the most common causes, detected in 14(47%), 5(17%) and 4(13%) patients respectively. Other causes of hemoptysis including chronic bronchitis, interlobar artery aneurysm, hydatid cyst, arteriovenous fistula, pulmonary embolism, and exposure to chemical weapons each detected in one patient separately. All of them had abnormal chest CT scans, except for 2 patients who had not undergone CT scan (one with hydatid cyst and another with bronchial tumor diagnosed with bronchoscopy). Bleeding location which has been confirmed with angiography could be predicted with CT scan among 7 of 14 patients with TB, (sensitivity=50%). While this rate was 100% among all other patients with other diagnosis who had undergone CT scan.

Conclusions

In conclusion complementary to the previous studies our results have demonstrated that bronchial artery embolization remains as one of the most efficient procedures in managing massive hemoptysis, with minimal rate of complications.

Endovascular treatment of haemoptysis: medium and long-term assessment

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Bronchial artery embolization for hemoptysis

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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Posterior circulation stroke after bronchial artery embolization. A rare but serious complication

Bronchial artery embolization (BAE) is the treatment of choice for massive hemoptysis with rare complications that generally are mild and transient. There are few references in the medical literature with acute cerebral embolization as a complication of BAE. We report a case of intracranial posterior territory infarctions as a complication BAE in a patient with hemoptysis due to bronchiectasis.

64-detector row CT evaluation of bronchial and non-bronchial systemic arteries in life-threatening haemoptysis

OBJECTIVE

To retrospectively evaluate the depiction of bronchial and non-bronchial systemic arteries with 64-detector row CT in patients undergoing endovascular treatment for life-threatening haemoptysis.

METHODS

64-detector row helical CT and conventional angiography of the thorax were performed in 28 patients (25 males, 3 females; age range, 18-65 years; mean age, 40 years) with life-threatening haemoptysis. CT images were analysed to identify abnormal bronchial and non-bronchial systemic arteries and also to localise them in two planes.

RESULTS

Using multidetector CT (MDCT), 43 bronchial arteries were identified on the right side and 46 on the left side. 89% of the right bronchial arteries originated from the right intercostobronchial arteries. A common trunk of origin of the right and left bronchial artery was noted in 46% of cases. 23 non-bronchial systemic arteries were noted on the right side and 41 on the left side. Pleural thickening >3 mm was confirmed to be a good predictor of non-bronchial systemic supply. An internal mammary artery diameter of >3 mm and an inferior phrenic artery diameter of >2 mm were sensitive indicators for non-bronchial systemic supply.

CONCLUSION

MDCT is a good investigation tool for evaluating life-threatening haemoptysis as it confirms the disease process, identifies the origin and ostial position of bronchial arteries, detects non-bronchial systemic arteries and acts as a roadmap for percutaneous transcatheter embolisation.

Clinical impact of multidetector row computed tomography before bronchial artery embolization in patients with hemoptysis: a prospective study

PURPOSE

To evaluate prospectively the role and impact of multidetector row computed tomography (MDCT) before bronchial artery embolization (BAE) in patients with hemoptysis.

METHODS

MDCT of the thorax was performed in 27 patients (21 men, 6 women; age range, 22-70 years; mean, 39 years) with hemoptysis who were referred for BAE. Transverse, multiplanar reconstruction, and 3-dimensional reconstruction (maximum intensity projection and volume rendered) images were analysed to identify the abnormal hypertrophied bronchial and nonbronchial systemic arteries causing hemoptysis, their origin and course were noted. Digital subtraction angiography was performed with the knowledge of findings of MDCT. Selective arteriogram of abnormal bronchial as well as nonbronchial arteries was performed. Embolization was attempted in 25 of these patients (92.6%) by using polyvinyl alcohol particles (350-500 μm), Gelfoam or Embospheres (400-700 μm). Follow-up was done for a mean period of 20.5 months.

RESULTS

Based on MDCT, 2 of 27 patients were found unsuitable for BAE. On computed tomography, 38 arteries (27 bronchial and 11 nonbronchial systemic arteries) were identified as abnormal hypertrophied vessels. On angiography, 34 of these arteries (25 bronchial and 9 nonbronchial systemic arteries) were found to be responsible for hemoptysis. Three of these arteries could not be evaluated during angiography, and 1 artery that was identified as abnormal on computed tomography was found normal on angiography. All 25 bronchial and 9 nonbronchial systemic arteries that cause hemoptysis were detected at MDCT. Embolization was successful in 23 of 25 patients.

CONCLUSION

MDCT enables detection and depiction of all bronchial and nonbronchial systemic arteries causing hemoptysis.

[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.

Risk factors associated with fatal pulmonary hemorrhage in locally advanced non-small cell lung cancer treated with chemoradiotherapy

BACKGROUND

The purpose of this study was to identify the risk factors associated with fatal pulmonary hemorrhage (PH) in patients with locally advanced non-small cell lung cancer (NSCLC), treated with chemoradiotherapy.

METHODS

The medical records of 583 patients with locally advanced NSCLC, who were treated with chemoradiotherapy between July 1992 and December 2009 were reviewed. Fatal PH was defined as PH leading to death within 24 h of its onset. Tumor cavitation size was defined by the cavitation diameter/tumor diameter ratio and was classified as minimum (< 0.25), minor (≥ 0.25, but < 0.5), and major (≥ 0.5).

RESULTS

Of the 583 patients, 2.1% suffered a fatal PH. The numbers of patients with minimum, minor, and major cavitations were 13, 11, and 14, respectively. Among the 38 patients with tumor cavitation, all 3 patients who developed fatal PH had major cavitations. On multivariate analysis, the presence of baseline major cavitation (odds ratio, 17.878), and a squamous cell histology (odds ratio, 5.491) proved to be independent significant risk factors for fatal PH. Interestingly, all patients with fatal PH and baseline major cavitation were found to have tumors with squamous cell histology, and the occurrence of fatal PH in patients having both risk factors was 33.3%.

CONCLUSIONS

Patients at high risk of fatal PH could be identified using a combination of independent risk factors.

Posterior circulation stroke after bronchial artery embolization

We report on a 66-year-old woman with a posterior circulation stroke that occurred after bronchial artery embolization (BAE) due to post-tuberculous bronchiectasis. Stroke is a rare complication of BAE and is usually thought to be caused by inadvertent embolization via a bronchial artery-pulmonary vein shunt. However, the possibility of thromboembolic stroke should be considered, because of the patient's possible underlying anatomical variations or atherothrombosis.

[Treatment of non-cystic fibrosis bronchiectasis]

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients.

Controlling hemoptysis: An alternative approach

Hemoptysis is a very common symptom in the practice of pulmonary physicians of India. We present a case of uncontrolled hemoptysis managed with bronchial artery embolization. Bronchial artery embolization is an effective treatment for patients with hemoptysis. Serious complications are rare, but may occur if the arterial supply to other structures is compromised.

Complications of embolization

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

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

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

Bronchial artery embolization in patients with hemoptysis including follow-up

BACKGROUND; Hemoptysis can be an acute medical emergency, which can be localized angiographically and controlled by therapeutic intervention.

PURPOSE

To evaluate the effectiveness and safety of bronchial artery embolization, and including follow-up in patients with hemoptysis.

MATERIAL AND METHODS

Thirty-five vascular interventions were performed in 28 patients (nine women and 19 men, mean age 42 years, age range 20-82 years) treated for hemoptysis between January 1998 and October 2008. Underlying diseases were cystic fibrosis (n = 9), lung cancer (n = 6), chronic inflammatory disease (n = 4), bronchiectasis (n = 3), chronic obstructive pulmonary disease (n = 2), and other (n = 4). Bronchial artery embolization was performed using particles. Patients were followed up for a median of 23 months (range 1 month to 8 years).

RESULTS

Bronchial artery embolization was technically successful in all patients (bleeding halted within 24 hours). Recurrent bleeding occurred in four patients with cystic fibrosis (14%) at one, 16, 19 and 48 months, respectively. Within this subset, multirecurrence bleeding occurred in one patient with cystic fibrosis. Cumulative patient survival rate was 74% at eight years. No patient died due to hemoptysis but due to underlying disease.

CONCLUSION

Bronchial artery embolization was highly effective in patients with hemoptysis. It may help to avoid surgery in patients who are poor candidates for surgery. Should hemoptysis recur in these patients, repeated embolization can be performed.

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

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

Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization

Hemoptysis can be a life-threatening respiratory emergency and indicates potentially serious underlying intrathoracic disease. Large-volume hemoptysis carries significant mortality and warrants urgent investigation and intervention. Initial assessment by chest radiography, bronchoscopy, and computed tomography (CT) is useful in localizing the bleeding site and identifying the underlying cause. Multidetector CT angiography is a relatively new imaging technique that allows delineation of abnormal bronchial and nonbronchial arteries using reformatted images in multiple projections, which can be used to guide therapeutic arterial embolization procedures. Bronchial artery embolization (BAE) is now considered to be the most effective procedure for the management of massive and recurrent hemoptysis, either as a first-line therapy or as an adjunct to elective surgery. It is a safe technique in the hands of an experienced operator with knowledge of bronchial artery anatomy and the potential pitfalls of the procedure. Recurrent bleeding is not uncommon, especially if there is progression of the underlying disease process. Prompt repeat embolization is advised in patients with recurrent hemoptysis in order to identify nonbronchial systemic and pulmonary arterial sources of bleeding. This article reviews the pathophysiology and causes of hemoptysis, diagnostic imaging and therapeutic options, and technique and outcomes of BAE.

Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience

BACKGROUND

Life-threatening massive hemoptysis requires prompt action and thoracic surgical input. Although there are a number of reports regarding each therapeutic modality for medical or surgical treatment, the significance of a multidisciplinary strategy remains undetermined.

METHODS

From January 1995 to December 2005, 120 patients were referred to our cardiothoracic center with massive hemoptysis. We retrospectively reviewed and compared the outcomes of a recent 5-year period (2000 to 2005) with those from the previous 5 years (1995 to 1999), as we made major changes in our practice in 2000. We currently try to avoid surgery within 48 hours after onset of active hemoptysis and adopt bronchial artery embolization as a first-line therapy. Treatment decisions are made after discussions among intensive care unit physicians, thoracic surgeons, and interventional radiologists.

RESULTS

The former group had 49 patients (57.9 +/- 14.1 years old, 41 males), and the recent group, 71 (62.2 +/- 23.5 years old, 52 males). There were no significant differences for any characteristics studied between the groups. In analyses of short-term complications after surgery, the former had a higher in-hospital mortality rate than the recent group (15% versus 0%). Furthermore, postoperative complications were seen in 8 patients (30%) in the former, whereas those occurred in 3 patients (18%) in the recent group.

CONCLUSION

Bronchial artery embolization is an effective therapeutic tool and plays a pivotal role in management of life-threatening massive hemoptysis. Surgery is indicated when bronchial artery embolization is not suitable and can be safely performed in combination with a rigid bronchoscopy or bronchial artery embolization procedure. Our results indicate that a multidisciplinary approach should be adopted for management of life-threatening massive hemoptysis.

Aetiology, diagnosis and management of infective causes of severe haemoptysis in intensive care units

PURPOSE OF THE REVIEW

Infective causes of severe haemoptysis have progressively shifted to causes related to chronic inflammatory lung diseases. Physicians should, however, recognize the most common of them, for example necrotizing parenchymal infections, tuberculosis and mycetoma.

RECENT FINDINGS

The recent increase in the incidence of a devastating Panton-Valentine leukocidin-associated staphylococcal pneumonia has reminded us of the crucial role of prompt diagnosis and management. General supportive care should be administered to prevent asphyxiation in addition to starting appropriate antibiotics as soon as possible. Once the bleeding has been controlled, the diagnostic strategy should integrate a detailed medical history, physical examination, Gram stain of the respiratory specimens and chest radiograph. Computed tomography scan has dramatically improved the diagnosis and the treatment of infective causes of severe haemoptysis by assessing the cause and mechanism(s) of haemoptysis. Although bronchial arteries are the major source of bleeding, nonbronchial systemic and pulmonary arteries' involvement should be feared, especially in haemoptysis related to tuberculosis and mycetoma.

SUMMARY

Endovascular therapy should be first attempted to control the bleeding and then elective surgery performed in case of localized lesion and adequate pulmonary function. Fibreoptic bronchoscopy with broncho-alveolar lavage remains the cornerstone of diagnosis in immunocompromised hosts with haemoptysis and in the rare cases of alveolar haemorrhage related to infectious diseases.

Bronchial artery embolization with detachable coils for the treatment of haemoptysis. Preliminary experience

PURPOSE

This paper reports our early experience in the treatment of haemoptysis with embolization of the bronchial arteries using detachable coils.

MATERIALS AND METHODS

Ten patients (mean age 45 years, range 23-83) with haemoptysis due to bronchoscopic biopsy of indeterminate lung nodules, lung cancer, tubercular bronchiectasis, cystic bronchiectasis or sarcoidosis underwent embolization of the bronchial arteries responsible for the bleeding using detachable coils. Patients were followed-up for a median of 14 months.

RESULTS

In all patients the procedure halted the bronchial bleeding within 24 hours. Eight patients had no recurrence of haemoptysis. In one patient with lung cancer and another with sarcoidosis, haemoptysis recurred within 1-3 months due to recruitment of additional feeding arteries and to a missed large feeding artery originating from the subclavian artery, which required a new procedure.

CONCLUSIONS

Use of detachable coils for embolization of bronchial arteries in patients with haemoptysis is advantageous since it eliminates the risk of migration typical of other embolic materials and enables rapid and permanent vessel occlusion.

Preoperative embolization of hypervascular Castleman's disease of the mediastinum

We report the case of a 31-year-old woman with mediastinal Castleman's disease of the hyaline vascular type. This large tumor was safely resected after arterial embolization. We describe the steps of this interventional procedure and discuss related necessary precautions.

[Management of severe hemoptysis: experience in a specialized center]

Bronchiectasis, cancer and tuberculosis account for the majority of haemoptysis requiring intensive care unit admission. Bedside evaluation (volume and bronchoscopic active bleeding) is safe to screen patients for arteriography and bronchial artery embolisation (BAE). First-line interventional arteriography should be favour over surgery in patients with non traumatic life-threatening hemoptysis. Surgery must be reserved in cases of failure or recurrence of bleeding after BAE.

Bronchial Artery and Systemic Artery Embolization in the Management of Primary Lung Cancer Patients with Hemoptysis

PURPOSE

To assess the safety and effectiveness of arterial embolization in lung cancer patients with hemoptysis.

METHODS

Nineteen primary lung cancer patients with hemoptysis underwent bronchial artery and systemic artery embolization from April 2002 to March 2005. There were 17 men and 2 women, with a mean age of 59 years. Histologic analysis revealed squamous cell carcinoma in 10 patients and poorly differentiated adenocarcinoma in 9 patients. The amount of hemoptysis was bleeding of 25-50 ml within 24 hr in 8 patients, recurrent blood-tinged sputum in 6, and bleeding of 100 ml or more per 24 hr in 5. Embolization was done with a superselective technique using a microcatheter and polyvinyl alcohol particles to occlude the affected vessels.

RESULTS

Arterial embolization was technically successful in all patients and clinically successful in 15 patients (79%). The average number of arteries embolized was 1.2. Bronchial arteriography revealed staining (all patients), dilatation of the artery or hypervascularity (10 patients), and bronchopulmonary shunt (6 patients). The recurrence rate was 33% (5/15) and 11 patients were alive with a mean follow-up time of 148 days (30-349 days).

CONCLUSION

Arterial embolotherapy for hemoptysis in patients with primary lung cancer is an effective, safe therapeutic modality despite the fact the vascular changes are subtle on angiography.

Embolization for hemoptysis in chronic thromboembolic pulmonary hypertension: report of two cases and a review of the literature

Hemoptysis is a known complication in patients with bronchial artery hypertrophy due to a variety of chronic pulmonary disorders. Bronchial artery hypertrophy is observed in most patients with chronic thromboembolic pulmonary hypertension (CTEPH), but surprisingly little is known about the incidence of hemoptysis in these patients. In this paper, we report on 2 patients with CTEPH and recurrent severe hemoptysis, who were treated by bronchial artery embolization. One patient recovered and 1 patient died as a consequence of the bleeding. A systematic review revealed 21 studies on the underlying pathology in 1,844 patients with moderate to severe hemoptysis. CTEPH was reported to be the cause of bleeding in 0.1% (n = 2), pulmonary arterial hypertension without chronic thromboembolic disease in 0.2% (n = 4), and acute pulmonary embolism in 0.7% (n = 12) of the patients. In contrast to this, 5 patients (6%) in our own series of 79 CTEPH patients suffered from moderate to severe hemoptysis requiring medical intervention. Severe hemoptysis appears to be an uncommon, but possibly underreported, life-threatening complication in CTEPH patients. As most CTEPH patients require life-long anticoagulants a therapeutic dilemma may ensue. Therefore, we propose that even mild hemoptysis in CTEPH patients warrants prompt evaluation, and treatment by embolization should be offered as first choice in CTEPH patients.

Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography

The purpose of this study was to determine non-invasively the frequency of ectopic bronchial arteries (BA) (i.e., bronchial arteries originating at a level of the descending aorta other than T5-T6 or from any aortic collateral vessel) on multidetector-row CT angiograms (CTA) obtained in patients with hemoptysis. Over a 5-year period (2000-2005), 251 consecutive patients with hemoptysis underwent multidetector-row CT angiography of the thorax. From this population, 37 patients were excluded because of a suboptimal CTA examination (n = 19), the presence of extensive mediastinal disease (n = 15) or severe chest deformation (n = 3) precluding any precise analysis of the bronchial arteries at CTA. Our final study group included 214 patients who underwent a thin-collimated CT angiogram (contrast agent: 300 to 350 mg/ml) on a 4- (n = 56), 16- (n = 119) and 64- (n = 39) detector-row scanner. The site of origin and distribution of bronchial arteries were analyzed on transverse CT scans, maximum intensity projections and volume-rendered images. The site of the ostium of a bronchial artery was coded as orthotopic when the artery originated from the descending aorta between the levels of the fifth and sixth thoracic vertebrae; all other bronchial arteries were considered ectopic. From the studied population, 137 (64%) patients had only orthotopic bronchial arteries, whereas 77 patients (36%) had at least one bronchial artery of ectopic origin. A total of 147 ectopic arteries were depicted, originating as common bronchial trunks (n = 23; 19%) or isolated right or left bronchial arteries (n = 101; 81%). The most frequent sites of origin of the 124 ostiums were the concavity of the aortic arch (92/124; 74%), the subclavian artery (13/124; 10.5%) and the descending aorta (10/124; 8.5%). The isolated ectopic bronchial arteries supplied the ipsilateral lung in all but three cases. Bronchial artery embolization was indicated in 26 patients. On the basis of CTA information, (1) bronchial embolization was attempted in 24 patients; it was technically successful in 21 patients (orthotopic BAs: 6 patients; orthotopic and ectopic BAs: 3 patients; ectopic BAs: 12 patients) and failed in 3 patients due to an instable catheterization of the ectopic BAs; the absence of additional bronchial arterial supply and no abnormalities of nonbronchial systemic arteries at CTA avoided additional arteriograms in these 3 patients; (2) owing to the iatrogenic risk of the embolization procedure of ectopic BAs, the surgical ligation of the abnormal vessels was the favored therapeutic option in 2 patients. This study enabled the depiction of ectopic bronchial arteries in 36% of the studied population, important anatomical information prior to therapeutic decision making.