Bronchial artery embolization for the management of nonmassive hemoptysis in cystic fibrosis

Bronchial artery embolization versus conservative treatment for hemoptysis: a systematic review and meta-analysis

BACKGROUND

Bronchial artery embolization (BAE) is currently an important treatment for hemoptysis. However, there is no consensus in the efficacy and safety of BAE compared to conservative treatment for hemoptysis, which limits the widespread use of BAE in hemoptysis. The objective was to assess the clinical benefit of BAE versus conservative treatment in patients with hemoptysis.

METHODS

A systematic search was conducted on the PubMed, Embase, ScienceDirect, CochraneLibrary, and ClinicalTrials up to March 2023. Both randomized controlled trials (RCTs) and cohort studies reporting rates of recurrent hemoptysis, clinical success, mortality, and complication by BAE and conservative treatment alone for hemoptysis were included. Data were pooled and compared by the use of odds ratio (OR) and 95% confidence interval (CI).

RESULTS

Twelve studies (three RCTs, nine cohorts) involving 1231 patients met the eligibility criteria. Patients treated with BAE had lower recurrence rates of hemoptysis (26.5% vs. 34.6%; OR 0.37, 95% CI 0.14-0.98), higher clinical success rates (92.2% vs. 80.9%; OR 2.77, 95% CI 1.66-4.61), and lower hemoptysis-related mortality (0.8% vs. 3.2%; OR 0.20, 95% CI 0.05-0.84) compared with conservative treatment alone. There was no significant difference in all-cause mortality between the two groups. In terms of security, the incidence of major complications and minor complications in patients undergoing BAE treatment was 0.2% (1/422) and 15.6%, respectively.

CONCLUSIONS

BAE was more effective than conservative treatment alone in controlling hemoptysis, reducing recurrence, and decreasing hemoptysis-related mortality, with an almost negligible risk of major complications.

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.

Bronchial Artery Embolization in Management of Hemoptysis in a Developing Country: An Initial Experience

Purpose This article evaluates the immediate success, recurrence rate, complications, and the culprit vessel of bronchial artery embolization (BAE) in patients presenting with hemoptysis.

Methods and Materials All patients who underwent BAE from July 1, 2018 to August 31, 2021 were included. BAE was done for moderate to severe hemoptysis or for mild hemoptysis which was recurrent and not controlled by medical management. Patients referred for surgical intervention and hemoptysis controlled on medical management were excluded.

Results One hundred and thirty patients underwent BAE in the study period. Mean age was 41.5 years and majority (73.1%) was male. Forty-three (33.1%) patients had mild, 46 (35.4%) had moderate, and 41 (31.5%) with the duration of symptoms ranging from 3 days to 25 years. Most common culprit vessel was posterior intercostal artery closely followed by the intercostobronchial artery. Hypervascularity was the most common angiographic abnormality encountered. On an average, 2.75 vessels were embolized per BAE with a wide range of 1 to 8 vessels. Hemoptysis control was seen in 96.1% patients immediately, 90.7 % at 1 month, 82.3 % at 3 months, and 66.9 % at 6 months. Overall recurrence was seen in 43 patients (33.1%). Chest pain was the most common minor side effect occurring in 77.1% cases.

Conclusion BAE is a safe and effective procedure that can be performed routinely in patients presenting with moderate to massive hemoptysis or with mild hemoptysis refractory to medical management.

Comparison of Bronchial Artery Embolisation Versus Conservative Treatment for Bronchiectasis-Related Nonmassive Haemoptysis: A Single-Centre Retrospective Study

OBJECTIVE

To compare the safety and effectiveness between bronchial artery embolisation (BAE) and conservative treatment for bronchiectasis-related nonmassive haemoptysis patients.

MATERIALS AND METHODS

From January 2015 to December 2020, consecutive bronchiectasis-related nonmassive haemoptysis patients who underwent either BAE (n = 98) or conservative treatment (n = 118) were included. Treatment-related complications, length of hospital stays, clinical success rate, patient satisfaction, and recurrence-free survival rates were compared between groups. Prognostic factors related to recurrence were also analysed.

RESULTS

During a median follow-up time of 44.8 months (range, 2.4-83.6 months), 34 and 66 patients in the BAE and conservative treatment groups suffered relapse. The 1-year, 2-year, 3-year and 5-year haemoptysis-free survival rates in the BAE and conservative treatment groups were 79.2%, 68.1%, 62.8%, and 57.6% and 64.0%, 52.8%, 44.1%, and 37.0%, respectively (P = 0.007). The minor complication rate after BAE was higher than that after conservative treatment (23/98 vs. 12/118, P = 0.008). BAE was associated with shorter hospital stays (5.0 vs. 7.0 days, P = 0.042) and higher patient satisfaction (88.8% vs. 74.6%, P = 0.008) than those for conservative treatment and with comparable clinical success rates (95.9% vs. 91.5%, P = 0.192). Treatment type, haemoptysis duration, and bronchiectasis severity were independently significant predictors of recurrence for these patients.

CONCLUSIONS

BAE could be another option for bronchiectasis-related nonmassive haemoptysis patients. In the patients with longer duration and more severe bronchiectasis, BAE still appeared to have better long-term haemoptysis control than conservative therapy.

Role of Bronchial Artery Embolization as Early Treatment Option in Stable Cystic Fibrosis Patients with Sub-Massive Hemoptysis: Personal Experience and Literature Review

(1) Background: We describe our experience with cystic fibrosis (CF) patients treated with bronchial artery embolization (BAE) for sub-massive hemoptysis to understand if early treatment of sub-massive hemoptysis can reduce the volume of any subsequent bleedings. (2) Materials: We performed a retrospective study including CF patients who underwent angiographic procedures for BAE following sub-massive hemoptysis, from March 2016 to December 2021. All patients underwent an initial chest angio-CT study. BAE was realized with microspheres or coils. (3) Results: Thirteen patients were included, subjected to at least one BAE after sub-massive hemoptysis, for a total of 19 procedures. Technical success was 94.7%; in a single case, the catheterization of the bronchial arterial feeder was not achievable and the procedure was repeated. Primary clinical success was 92.3%; secondary clinical success was 69.2%. Relative clinical success was 85%. A higher incidence of recurrent hemoptysis following treatment with coils was observed (100% of cases) compared to treatment with microspheres (54.5% of cases) χ2 = 5.43 (p < 0.05). (4) Conclusions: BAE is a safe and effective method for the treatment of hemoptysis in CF patients; it should be practiced not only after massive or recurrent hemoptysis but also in patients with sub-massive bleeding to improve their life expectancy and quality of life.

Evaluating hemoptysis hospitalizations among patients with bronchiectasis in the United States: a population-based cohort study

Background

The burden of hospitalizations and mortality for hemoptysis due to bronchiectasis is not well characterized. The primary outcome of our study was to evaluate in-hospital mortality in patients admitted with hemoptysis and bronchiectasis, as well as the rates of bronchial artery embolization, length of stay, and hospitalization costs.

Methods

The authors queried the Nationwide Inpatient Sample (NIS) claims database for hospitalizations between 2016 and 2017 using the ICD-10-CM codes for hemoptysis and bronchiectasis in the United States. Multivariable regression was used to evaluate predictors of in-hospital mortality, embolization, length of stay, and hospital costs.

Results

There were 8240 hospitalizations (weighted) for hemoptysis in the United States from 2016 to 2017. The overall in-hospital mortality was 4.5%, but higher in males compared to females. Predictors of in-hospital mortality included undergoing three or more procedures, age, and congestive heart failure. Bronchial artery embolization (BAE) was utilized during 2.1% of hospitalizations and was more frequently used in those with nontuberculous mycobacteria and aspergillus infections, but not pseudomonal infections. The mean length of stay was 6 days and the median hospitalization cost per patient was USD $9,610. Having comorbidities and procedures was significantly associated with increased length of stay and costs.

Conclusion

Hemoptysis is a frequent indication for hospitalization among the bronchiectasis population. In-hospital death occurred in approximately 4.5% of hospitalizations. The effectiveness of BAE in treating and preventing recurrent hemoptysis from bronchiectasis needs to be explored.

Clinical outcomes of cystic fibrosis patients with hemoptysis treated with bronchial artery embolization

OBJECTIVE

Massive hemoptysis is one of the most serious complications in patients with cystic fibrosis (CF). This study aimed to evaluate the hemoptysis-free period following bronchial and non-bronchial artery embolization (BAE/non-BAE) in CF patients and to investigate predictors of recurrent bleeding and mortality by any cause.

METHODS

This was a retrospective cohort study of CF patients ≥ 16 years of age undergoing BAE/non-BAE for hemoptysis between 2000 and 2017.

RESULTS

We analyzed 39 hemoptysis episodes treated with BAE/non-BAE in 17 CF patients. Hemoptysis recurrence rate was 56.4%. Of the sample as a whole, 3 (17.6%) were hemoptysis-free during the study period, 2 (11.8%) underwent lung transplantation, and 3 (17.6%) died. The median hemoptysis-free period was 17 months. The median hemoptysis-free period was longer in patients with chronic infection with Pseudomonas aeruginosa (31 months; 95% CI: 0.00-68.5) than in those without that type of infection (4 months; 95% CI: 1.8-6.2; p = 0.017). However, this association was considered weak, and its clinical significance was uncertain due to the small number of patients without that infection.

CONCLUSIONS

BAE appears to be effective in the treatment of hemoptysis in patients with CF.

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.

Predictors of massive haemoptysis after a first episode of mild-to-moderate haemoptysis in patients with cystic fibrosis

The main cause of death of cystic fibrosis (CF) patients is respiratory disease due to secondary infections, haemoptysis, pneumothorax, and respiratory failure [1]. In a study of 129 French CF patients who died between 2007 and 2010 without receiving lung transplantation, 8.5% of deaths were due to haemoptysis [2]. Factors associated with an increased risk of haemoptysis in CF patients include older age, advanced lung disease (forced expiratory volume in 1 s (FEV₁) <70% predicted), airway colonisation by Pseudomonas aeruginosa [3], CF-related diabetes, portal hypertension, and liver cirrhosis [4]. To our knowledge, there have been no studies of the risk factors for the development of massive haemoptysis (MH) in CF patients who have previously experienced an episode of mild-to-moderate haemoptysis.

Mild-to-moderate haemoptysis (m-mH) is common in patients with cystic fibrosis but the risk of subsequent massive haemoptysis (MH) is not known. Allergic bronchopulmonary aspergillosis and diabetes were significant predictors of MH subsequent to m-mH.https://bit.ly/30093Hw

[Clinical effect of endovascular embolization in treatment of hemoptysis of systemic arterial origin in children]

OBJECTIVE

To investigate the clinical effect of endovascular embolization (EVE) in the treatment of hemoptysis of systemic arterial origin in children.

METHODS

A total of 20 children with hemoptysis of systemic arterial origin who underwent EVE from January 2016 to November 2017 were enrolled. The method for embolization was analyzed and the clinical outcome was evaluated.

RESULTS

Offending vessels were bronchial artery (BA) in 14 children, non-bronchial systemic artery (NBSA) in 1 child, and BA and NBSA in 5 children. Of all the children, 13 underwent EVE with peripheral embolization agents and 7 underwent EVE with mechanical coils. A total of 41 offending vessels were embolized (34 BAs and 7 NBSAs) and all the children achieved immediate arrest of hemoptysis. Two children experienced recurrence within 6 months after EVE and 2 experienced recurrence with 6-24 months after EVE. The peripheral embolization agent group had a lower overall recurrence rate than the mechanical coil group [8%(1/13) vs 43%(3/7); P=0.10]. One child experienced intracranial ectopic embolism after surgery and had good quality of life during 20 months of follow-up after treatment. No other complications were observed.

CONCLUSIONS

EVE is a safe and effective method for the treatment of hemoptysis of systemic arterial origin in children and thus holds promise for clinical application.

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.

Common clinical features of CF (respiratory disease and exocrine pancreatic insufficiency)

First described as a disease of the pancreas, cystic fibrosis is a genetically inherited progressive disease affecting multiple organ systems. Pulmonary and pancreatic involvement is common in individuals with cystic fibrosis, and the former is attributable to most of the mortality that occurs with the condition. This chapter provides an overview of a clinical approach to the pulmonary and pancreatic manifestations of cystic fibrosis.

Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

BACKGROUND

Bronchial artery embolisation (BAE) becomes a mainstay in the treatment of hemoptysis.

OBJECTIVE

To characterise patients with hemoptysis undergoing bronchial artery angiography (BAA) for embolisation, evaluating outcomes.

METHODS

We retrospectively evaluated patients with acute severe or chronic recurrent hemoptysis admitted to the Pulmonology department and submitted to BAA for purpose of embolisation.

RESULTS

A total of 88 patients were submitted to BAA, 47 (53.4%) were male, with a mean age of 61.4 ± 15.8 years. In 64 (72.7%) patients, hemoptysis presented as chronic recurrent episodes. Hemoptysis was considered severe in 40 (45.5%) patients. Bronchiectasis (other than cystic fibrosis) (n=35; 38.0%) and tuberculosis sequelae (n=31; 35.2) were the major aetiology for hemoptysis. The main angiographic abnormality was hypertrophy and tortuosity (n=68; 77.3%). BAE was performed in 67 (76.1%) of the 88 patients submitted to BAA. Immediate success was achieved in 66 (98.5%) patients. Recurrence of hemoptysis occurred in 25 (37.3%) patients, and was related to presence of shunting (p=0.049). The procedure-related complications were self-limited.

CONCLUSION

Our results suggest that BAE is a safe and effective treatment for acute severe and chronic recurrent hemoptysis, supporting the current literature. Besides this, bleeding recurrence was relatively high, and correlated with presence of systemic pulmonary shunting.

Iron supplementation does not worsen respiratory health or alter the sputum microbiome in cystic fibrosis

BACKGROUND

Iron supplementation for hypoferremic anemia could potentiate bacterial growth in the cystic fibrosis (CF) lung, but clinical trials testing this hypothesis are lacking.

METHODS

Twenty-two adults with CF and hypoferremic anemia participated in a randomized, double-blind, placebo-controlled, crossover trial of ferrous sulfate 325mg daily for 6weeks. Iron-related hematologic parameters, anthropometric data, sputum iron, Akron Pulmonary Exacerbation Score (PES), and the sputum microbiome were serially assessed. Fixed-effect models were used to describe how ferrous sulfate affected these variables.

RESULTS

Ferrous sulfate increased serum iron by 22.3% and transferrin saturation (TSAT) by 26.8% from baseline (p<0.05) but did not affect hemoglobin, sputum iron, Akron PES, and the sputum microbiome.

CONCLUSIONS

Low-dose ferrous sulfate improved hypoferremia without correcting anemia after 6weeks. We did not observe significant effects on sputum iron, Akron PES, and the sputum microbiome. Although we did not identify untoward health effects of iron supplementation, a larger blinded randomized controlled trial would be needed to fully demonstrate safety.

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

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

Beta-blocker management of refractory hemoptysis in cystic fibrosis: a novel treatment approach

Background/objective:

Recurrent hemoptysis is a debilitating complication of cystic fibrosis (CF) and likely results from mucosal erosions into abnormal bronchial blood vessels due to chronic respiratory infection. We hypothesize that the use of beta-blockade will decrease mean arterial pressure resulting in lower bronchial artery blood flow and, subsequently, decrease the frequency and severity of hemoptysis, rate of hospitalizations, and usage of intravenous antibiotics.

Methods:

Retrospective chart review was performed on 12 CF patients with recurrent hemoptysis, aged 13–40 years old, along with a follow-up telephone survey to assess the effectiveness of beta-blockade for hemoptysis, tolerance of inhaled respiratory medications, activity tolerance, and potential adverse effects. A beta-blocker, specifically atenolol, was initiated in all subjects within 24 hours after experiencing recurrent hemoptysis episodes.

Results:

A majority of patients (72.7%) had complete cessation of hemoptysis. There were significant decreases in the frequency of hemoptysis ( p = 0.02) and the amount of hemoptysis ( p = 0.004). The rate of hospitalizations significantly decreased from 1.33 to 0.67 ( p = 0.05) after initiation of atenolol. There was a trend toward statistical significance in the reduction of intravenous antibiotics use ( p = 0.08). No statistical difference was found when comparing the pre- and post-treatment means of forced expiratory volume in 1-second ( p = 0.59). Very minimal adverse effects were observed with only one patient reporting intermittent facial flushing.

Conclusion:

Beta-blockade, particularly with atenolol, appears to successfully treat, if not resolve, recurrent hemoptysis refractory to conservative therapy in CF. Beta-blocker therapy appears to maintain an effective safety profile in CF.

Cystic fibrosis: management of haemoptysis

Haemoptysis is a common complication in cystic fibrosis (CF), occurring in approximately 9% of the population. Massive haemoptysis is associated with older patients, more severe disease and carries a high mortality rate. Despite this there are few robust published studies of effective treatments and knowledge of the precise pathogenesis is limited. Current guidelines for treatment from the Cystic Fibrosis Foundation (CFF) are based on consensus opinion of experts. Patients with massive haemoptysis who do not respond to initial medical treatments should undergo bronchial artery embolization. This will control the bleeding in the majority of cases but recurrence rates are high and there are little data to support long-term improved outcomes. Surgery is a last resort in patients with CF.

Pulmonary exacerbations in cystic fibrosis

PURPOSE OF REVIEW

The chronic infection and inflammation of cystic fibrosis (CF) lung disease causes a progressive decline of lung function resulting in daily symptoms such as cough and sputum production. There are intermittent episodes of acute worsening of symptoms, more commonly referred to as pulmonary exacerbations. Despite this being a common event, there is still no standardized definition of an exacerbation. A recent set of guidelines from the CF Foundation Pulmonary Therapies Committee on the treatment of exacerbations noted the paucity of data supporting commonly used therapies. This review describes our current understanding of pulmonary exacerbations and the therapies used to treat them.

RECENT FINDINGS

The treatment of an exacerbation is intended to resolve the worsened symptoms and to restore the lung function that is commonly lost in the acute presentation. A most striking finding is the observation that for many patients there is no restoration of lung function, suggesting we either need better therapies to prevent exacerbations or better treatment of exacerbations.

SUMMARY

We have established recommendations on specific treatment of a pulmonary exacerbation and have outlined the areas where we need better information on appropriate therapies. Once we have a standardized definition of an exacerbation, we can proceed with clinical trials of therapies specific for its treatment.

Bronchial artery embolization for treatment of life-threatening hemoptysis

Massive hemoptysis is an emergent and life-threatening condition with a broad range of underlying causes. Fortunately, massive hemoptysis accounts for a minority of cases of hemoptysis, ~5%. Unlike hemorrhage in other areas of the body, the primary cause of death from pulmonary hemorrhage is most commonly asphyxiation rather than exsanguination. Given the limited capacity for the lung to preserve oxygen transfer in the setting of massive hemoptysis, a rapid and effective method for controlling hemorrhage is essential to minimize death in patients demonstrating respiratory compromise. Since its introduction in 1973, bronchial artery embolization has proven to be a safe and effective tool for the treatment of massive hemoptysis and is now considered the treatment of choice, with initial success rates ranging from 77 to 94%. The long-term control rate of hemoptysis ranges from 70 to 85% and is largely a function of the degree of inflammation and the natural progression of the underlying disease. This article reviews the current literature on bronchial artery embolization for the treatment of massive hemoptysis.

Cystic fibrosis and the thoracic surgeon

Indications for thoracic surgery in patients with cystic fibrosis (CF) are principally represented by pleural diseases including pneumothorax, pleural effusion, and empyema and by parenchymal lung diseases including bronchiectasis, hemoptysis, and pulmonary abscess. Moreover, lung transplantation has proved a viable therapeutic option for progressive respiratory failure due to end-stage CF. Main surgical experiences in this setting are reviewed and discussed.

Recombinant activated factor VII for massive hemoptysis in patients with cystic fibrosis

Massive hemoptysis is a common complication in patients with cystic fibrosis (CF) and is associated with significant morbidity and mortality. Conventional treatment with antibiotic therapy and early bronchial artery embolization (BAE) is usually successful in achieving hemostasis in the majority of patients. Recombinant activated factor VII (rFVIIa), originally developed for use in patients with hemophilia, has emerged as a general hemostatic agent that is potentially useful in the management of many life-threatening bleeding conditions. In this article, we present four patients with CF lung disease and massive hemoptysis who were treated successfully with rFVIIa. We suggest that in patients with CF who present with massive hemoptysis, the use of rFVIIa can be considered in patients with refractory hemoptysis despite conventional therapy or as a temporizing therapy when BAE is not immediately available.

Haemoptysis and bronchial artery embolization in children

Haemoptysis varies in significance from trivial to fatal. The most common causes in children are tuberculosis, fungal infections and bronchiectasis of any cause. In populations of European origin, cystic fibrosis is the most common predisposing factor. Chronic or life-threatening haemoptysis requires further investigation. Various forms of treatment are possible, and management is optimized when a multidisciplinary team is available. Bronchial artery embolization (BAE) is effective in controlling haemoptysis in most cases, although recurrent bleeding is not uncommon. BAE is often technically challenging, however, and requires angiographic skills that are not always available in children's hospitals. Although the procedure is usually regarded as relatively safe, complications are not uncommon and may be severe or even fatal.

Hemoptysis in Israeli CF patients--prevalence, treatment, and clinical characteristics

OBJECTIVE

To identify the characteristics of CF patients with hemoptysis in Israel and to compare clinical features and risk factors to a control group of CF patients without hemoptysis.

DESIGN

Retrospective chart review.

PATIENTS

All CF patients in Israel who experienced hemoptysis between 2001 and 2005 and a control group of sex- and age-matched patients with no history of hemoptysis.

RESULTS

40/440 CF patients (9.1%) experienced hemoptysis during the study period, 50% were male. Ten patients (25%) were under 13 years old at the first hemoptysis episode. Pulmonary exacerbation was the precipitating factor in 90%. Twenty three patients showed moderate or major hemoptysis. 35/40 patients responded well to conservative therapy. Bronchial artery embolization (BAE) was performed in 5 patients with no recurrence of bleed within 24 h. However all of these patients experienced recurrent hemoptysis. One patient died during the follow-up period because of end stage lung disease. Pulmonary function tests, body-mass index, coagulation tests, pancreatic status, presence of bronchiectasis, sputum cultures and genetic mutations were similar in the two groups. A high incidence (57.5%) of associated diseases including cystic fibrosis related diabetes, cirrhosis and portal hypertension, and distal intestinal obstruction syndrome was found among hemoptysis patients, compared to only 5.2% in the control group (p<0.001).

CONCLUSIONS

Hemoptysis, even major, did not seem to be a risk factor for mortality in our patients. A higher incidence of hemoptysis was found in our pediatric patients compared to other series. BAE shows a high immediate rate of success in controlling hemoptysis, but does not prevent future disease.

Endovascular therapy in the management of moderate and massive haemoptysis

The aim of this study was to retrospectively evaluate 140 patients with severe (97 massive, 43 moderate) haemoptysis treated by bronchial artery embolisation. Between January 1997 and April 2005, 140 patients (120 males and 20 females, aged 23-71 years) with severe haemoptysis considered surgically inoperable because of limited pulmonary reserve were treated by embolisation. The cause of haemoptysis was tuberculosis in 136 patients and malignancy in four. Embolisation succeeded in controlling haemoptysis immediately after the intervention in 138 patients (98.5%) and at 1 month in 126 patients (90%). Severe haemoptysis recurred in 11 patients with prior massive haemoptysis and 3 patients with prior moderate haemoptysis in a mean time of 3.7 months (1-7 months) after the last intervention. The bleeding source was detected during angiography and embolised in 12 of these patients. Two patients with malignant tumour died because of abundant bleeding, following an asymptomatic period of 30 days. There were no procedure-related major complications. Bronchial artery embolisation is a safe and effective palliative treatment alternative in moderate and massive haemoptysis.

Bronchial Artery Embolization in Adults with Cystic Fibrosis: Impact on the Clinical Course and Survival

PURPOSE

Although bronchial artery embolization (BAE) is effective in the acute control of recurrent or major hemoptysis in adults with cystic fibrosis, outcomes after embolization are not well known. The objective of this retrospective study was to evaluate respiratory function, survival, and hemoptysis-free survival in adult patients with cystic fibrosis treated for hemoptysis with BAE.

MATERIALS AND METHODS

Of 297 patients with cystic fibrosis hospitalized from 1990 to 2004, 30 patients (mean age, 26.7+/-9.2 years) presented with major or persistent hemoptysis that required 42 BAE sessions. These patients were compared with a control group of 27 patients without hemoptysis requiring embolization who were matched for age, sex, and forced expiratory volume in 1 second (FEV1).

RESULTS

Hemoptysis stopped within 24 hours after BAE in 96.6% of patients (n=29), and there were no major complications. The change in the slope of FEV1 after the BAE or matching date was significantly worse in the embolization group (P=.0007). At last follow-up, nine and one patients, respectively, had undergone lung transplantation in the BAE and control groups (P=.002). The 5-year survival rates without lung transplantation were 31% and 84%, respectively, in the BAE and control groups (hazard ratio, 5.95; P=.002). Sixty-two percent of patients were free of hemoptysis 5 years after BAE. The number of collateral arteries was the only factor associated with the risk of death or recurrent hemoptysis (P=.001).

CONCLUSIONS

Despite the effectiveness of embolization in controlling recurrent or major hemoptysis, adults with cystic fibrosis who have undergone BAE for hemoptysis are at much higher risk of respiratory function aggravation, death, and the need for lung transplantation than those who have not undergone BAE for hemoptysis. They are more likely to die or to undergo lung transplantation than to present with recurrent major hemoptysis.

[Hemoptysis]

Hemoptysis is a potentially life-threatening complication of various diseases. The most common causes are infectious and inflammatory processes, followed by neoplasms, pulmonary embolisms, mitral stenoses, coagulopathies, and multiple systemic disorders. Primary examinations include a chest x-ray, an angio CT and a bronchoscopy. Sometimes, a bronchial artery angiogram is required. The patient is at risk of suffocation because blood and clots can severely obstruct his airways. Thus, the most important measures are: supplemental oxygen, positioning the patient with the bleeding side down, bronchoscopical suctioning and removal of blood and clots. Coagulopathies have to be corrected. Application of vasoactive drugs may help temporarily. In cases of bleeding from central lesions, coagulation with laser or argon-plasma-coagulator is feasible. Heavy bleeding from the periphery requires a balloon or tube tamponade. Depending on the cause and the severity of the bleeding either anti-inflammatory medical treatment, hemostyptic radiation therapy, bronchial artery embolisation or a surgical procedure must follow.

Techniques and applications of transcatheter embolization procedures in pediatric cardiology

Transcatheter embolization of congenital or acquired superfluous vascular structure has become routine procedures performed by interventional pediatric cardiologists. Embolization procedure is often part of a collaborative effort with cardiac surgeons to palliate complex congenital heart defect, such as in embolizing aortopulmonary collateral arteries in patient with single ventricle physiology. In other cases, the procedure is the definitive treatment as in embolizing coronary artery fistula. Pediatric cardiologists performing embolization procedures should be familiar with available technologies as well as understand the underlying cardiac anatomy and pathophysiology. This article provides a comprehensive review of presently available embolization agents and technologies. Some of the technologies are used only by interventional radiologists but may be useful to pediatric cardiologists. Specific clinical applications in pediatric cardiology are also discussed with summary of current literature. With continue advancement in transcatheter technology and operator expertise, all unwanted vascular communication should be amenable to transcatheter embolization.