Bronchial Artery Bronchial Artery Embolization Sanjeeva P. Kalva, MD Massive hemoptysis is a life-threatening

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    ronchial Artery Embolization anjeeva P. Kalva, MD

    Massive hemoptysis is a life-threatening emergency. Chest radiograph, computed tomog- raphy, and bronchoscopy play a complementary role in diagnosing the underlying cause of hemorrhage and localizing the bleeding site. Bronchial artery embolization remains the primary and most effective method in controlling massive hemoptysis. Bronchial and nonbronchial systemic arteries are the main source of bleeding and are embolized with polyvinyl alcohol particles or gelatin sponge. Immediate cessation of bleeding occurs in more than 75% of patients; however, long-term recurrences are common in patients with progressive lung disease. Complications are infrequent except for a rare occurrence of spinal cord ischemia. Tech Vasc Interventional Rad 12:130-138 © 2009 Elsevier Inc. All rights reserved.

    KEYWORDS bronchial arteries, hemoptysis, intercostal arteries, transcatheter embolization

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    emoptysis may present as an acute medical emergency, for which a vascular interventionalist may be called on

    or angiographic evaluation and therapeutic intervention. emoptysis refers to the expectoration of blood that origi- ates from the respiratory tract. Although the exact definition f massive hemoptysis varies widely, a blood loss totaling 00-600 mL over a 24-hour period is considered massive.1

    ecurrent small amounts of hemoptysis are also considered ignificant if the blood loss exceeds 100 mL/d over 3 days in week. However, any amount of hemoptysis is clinically

    ignificant if it compromises the airway and/or ventilation of oth of the lungs. Thus, active intervention is indicated, ir- espective of hemodynamic stability, if imminent or potential irway compromise is suspected in the presence of hemop- ysis.

    auses he causes of hemoptysis vary depending on the geographic

    ocation of the patient; infectious diseases, such as tubercu- osis, remain the most prevalent cause in the developing orld countries, whereas cystic fibrosis and congenital heart isease are usually the main causes in the western world. arious causes of hemoptysis are listed in Table 1.2

    arvard Medical School, Massachusetts General Hospital, Boston, MA. ddress reprint requests to Sanjeeva P. Kalva, MD, Harvard Medical School,

    Massachusetts General Hospital, GRB-290, 55 Fruit Street, Boston, MA

    c02114. E-mail: skalva@partners.org.

    30 1089-2516/09/$-see front matter © 2009 Elsevier Inc. All rights reserved. doi:10.1053/j.tvir.2009.08.006

    athophysiology he pathophysiology of hemoptysis is dependent on whether n inflammatory process is involved. Chronic inflammatory onditions of the lung (such as tuberculosis, aspergillosis, istoplasmosis, cystic fibrosis, bronchiectasis, chronic bron- hitis, etc) recruit systemic blood supply to the inflamed egions through bronchial arteries. When the disease process nvolves the pleura and/or the chest wall, nonbronchial sys- emic arteries are often recruited to the inflamed areas. These ecruited systemic arteries rupture due to vascular fragility, in- reased regional blood pressure, and/or formation of pseudoa- eurysms or arteriovenous fistulae.3 Often, hemoptysis is pre- eded by respiratory infection. A few disease processes such avitary tuberculosis and lung abscesses may involve the pul- onary arteries and may result in pseudoaneurysms. He- optysis occurs from the rupture of such pulmonary artery seudoaneurysms. Noninflammatory processes, such as malignancy (pri- ary bronchial carcinoma, metastatic osteosarcoma, and

    ther sarcomas) and congenital heart diseases, may also esult in hemoptysis. Although bronchial arteries remain he main supply to the bronchial tumors, nonbronchial ystemic arteries are often the source of hemoptysis when he malignancy invades the pleura or the chest wall. Bron- hial tumors erode into the vessels and thus lead to bleed- ng. Congenital heart diseases that result in pulmonary ligemia lead to recruitment of systemic arteries to supply he lungs and may eventually cause hemoptysis. Infection f a sequestrated lung (perfused by an aberrant arterial lood supply from the aorta) is another rare congenital

    ause of hemoptysis.

    mailto:skalva@partners.org

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    Bronchial artery embolization 131

    linical Considerations he workup of a patient with hemoptysis requires a mul-

    idisciplinary team effort involving a pulmonary critical are specialist, a thoracic surgeon, and an interventional adiologist. A complete history and physical examination rovide clues to the underlying pathology and the location f bleeding. Often, patients are able to identify the side of leeding. Chest radiograph provides information on the isease process, location, and involvement of the pleura nd may confirm the location of the bleeding. However, hen a disease process involves both lungs, a chest radio- raph is of limited use in localization of bleeding. Simi- arly, in the presence of massive hemoptysis, a chest radio- raph is of limited use due to aspiration of blood into both ungs. Additionally, the chest radiograph is normal in 0%-30% of patients presenting with hemoptysis.4 Bron- hoscopy is useful in identifying the site of bleeding and is ften requested before bronchial artery embolization. ronchoscopy is highly useful if the site of bleeding is

    nconclusive on clinical examination and on imaging stud- es, in patients presenting for the first time with hemopty- is, and in the presence of recurrent bleeding following mbolization or surgery. It provides detailed evaluation of he upper airway and the central bronchi and allows lo- oregional therapy through laser coagulation, thrombin/ brinogen instillation, endobronchial balloon occlusion, nd local infusion of vasoactive drugs to control bleeding. owever, it has limited use in the presence of massive

    able 1 Causes of Hemoptysis

    irway diseases Bronchitis Bronchiectasis Bronchial tumors

    arenchymal diseases Tuberculosis Histoplasmosis Sarcoidosis Cystic fibrosis Aspergillosis Lung abscess Pneumonia Pneumoconiosis Infected sequestration Other granulomatous and vasculitidies ardiovascular diseases Pulmonary arteriovenous malformation/aneurysms Pulmonary artery hypertension (primary and secondary) Pulmonary embolism Congenital heart diseases causing pulmonary oligemia Aortobronchial fistula Aortic aneurysms Bronchial artery aneurysms thers Trauma Foreign body Coagulopathy

    emoptysis, as aspirated blood makes it difficult to locate p

    he bleeding site. The overall accuracy of bronchoscopy in valuating patients with hemoptysis reaches 40%-50%, ut it falls to 0%-31% in patients with normal chest radio- raph.5

    The expanding role of computed tomography (CT) and CT ngiography in patients presenting with hemoptysis is be- oming well recognized. CT provides excellent details re- arding the presence, extent, location, and type of lung pa- hology. CT scores high in providing the details of vascular natomy, anomalies, and cause of bleeding (eg, bronchial vs ulmonary). In addition, the origin and course of the bron- hial arteries and the involvement of nonbronchial systemic

    igure 1 (A) Right intercostobronchial trunk arises at the level of 5-T6, gives off the first intercostal artery, and continues as the right ronchial artery. The artery is enlarged and there is parenchymal ypervascularity. (B) Following embolization, the artery is com-

    letely occluded.

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    132 S.P. Kalva

    rteries can be visualized on thin-section contrast-enhanced T. This is useful for planning optimal intraprocedural C- rm orientation and may aid in more rapid selective cathe- erization of the involved arteries during angiography. CT an provide added information when bronchoscopy and hest radiograph are nondiagnostic. Also, it is noninvasive, oses less potential risk compared with bronchoscopy and rovides essential information for therapy planning. The ain disadvantages of CT are radiation risk, the need for otentially nephrotoxic contrast material, and potential time elays in obtaining a CT examination. In addition to the initial patient evaluation through diag-

    ostic studies, attention must be paid to airway management,

    igure 2 Aberrant right bronchial artery arising from the thyrocervi- al trunk. The aberrant artery can be distinguished from nonbron- hial systemic artery by the course of the artery, as the former ourses along the bronchi. Note the hypervascularity and parenchy- al staining.

    igure 3 Left intercostobronchial trunk. Unlike the right intercosto-

    ronchial trunk, a left intercostobronchial trunk is uncommon.

    5

    aboratory analysis (eg, complete and differential blood ounts, coagulation profile, blood type, renal function), and emodynamic status. Patients with mild hemoptysis may be reated with bed rest, postural drainage, and supportive mea- ures for cough and infection. However, in patients with oderate and massive hemoptysis, airway management is

    ritical and early intubation is recommended to prevent rowning of the lungs by the blood-filled airways. Hemody- amic stability can be achieved with transfusion of blood roducts and systemic vasoconstrictors. Early intervention hrough bronchial artery embolization or surge