Original article

Bronchial artery embolization in patients with hemoptysis

including follow-up

Armand Daliri1, Nikolaus H Probst1, Bertram Jobst1, Philipp M Lepper2, Ralph Kickuth3,

Zsolt Szucs-Farkas1, Juergen Triller1 and Hanno Hoppe1

1Radiology, University Hospital Bern, Switzerland; 2Radiology, University Hospital Wuerzburg, Germany; 3Pneumology,

University Hospital Bern, Switzerland

Correspondence to: Hanno Hoppe. Email: hanno.hoppe@insel.ch

AbstractBackground: 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 2082 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 arteryembolization 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.

Keywords: Hemoptysis, bronchial arteries, intercostal arteries, transcatheter embolization, lung cancer,bronchiectasis

Submitted April 13, 2010; accepted for publication October 17, 2010

Hemoptysis may present as an acute medical emergency aseven small amounts of blood (e.g. 150 mL) can lead toasphyxia. Hemoptysis refers to the expectoration of bloodfrom the bronchial tree. Despite the lack of a uniform de-nition, most authors agree that a blood loss of approx.200600 mL during a 24 h period is massive. In recurrenthemoptysis, a blood loss that exceeds 100 mL/d over 3days in a week can be regarded as massive hemoptysis, aswell (1). Massive hemoptysis occurs in approx. 1.5% ofpatients presenting with hemoptysis. Regardless of thesedenitions, any hemoptysis that threatens the airways orcompromises ventilation is signicant. If imminent or

potential impact on airways or oxygenation is present orsuspected, active intervention is indicated.Bronchial artery embolization has become a relevant and

common treatment option in patients with massive or recur-rent hemoptysis (29). Hemoptysis may be caused byvarious underlying conditions including airway diseasessuch as pulmonary malignancies or bronchiectasis, parench-ymal disease such as cystic brosis, tuberculosis and vascu-litides, and cardiovascular disorders such as congenitalheart disease and pulmonary artery hypertension(primary and secondary). Tuberculosis remains theleading cause in developing countries, whereas cystic

Acta Radiologica 2011; 52: 143147. DOI: 10.1258/ar.2010.100302

brosis, chronic inammatory lung diseases and broncho-genic carcinoma are usually the main causes in theWestern world (10, 11). Chest trauma, mostly including for-mation of pulmonary pseudocysts, is a rare cause of hemop-tysis (12), and iatrogenic causes, e.g. pulmonary arteryrupture due to Swan-Ganz catheters, may occur but arelow in incidence as well (13).Massive hemoptysis may be fatal, caused by asphyxiation

rather than blood loss. In these patients, mortality risk inonly conservatively treated patients was reported to bebetween 50% and 85%, death occurring within the rsthour most of the time (14). Previously, resection of theaffected lung has been considered denitive treatment ofmassive hemoptysis. However, emergency surgery has amortality rate of 1735% and the majority of patients arehigh-risk surgical candidates due to a combination ofacute hypoxemia and limited lung capacity caused bysevere diffuse chronic pulmonary disease (15, 16). As mor-tality rates are high in patients with massive hemoptysis,rapid multidisciplinary assessment and therapeutic inter-vention is mandatory. Bronchoscopy prior to embolizationmay be helpful and might allow locoregional therapy,however, overall accuracy of bronchoscopy in evaluatingpatients with hemoptysis was as low as 031% (17).The purpose of this study was to report our experience

with selective bronchial artery embolization in patientswith acute or recurrent hemoptysis and to evaluate thesafety and effectiveness of this technique includingfollow-up for a maximum of eight years post initialembolization.

Material and Methods

Patients

Twenty-eight patients underwent embolization therapy formanagement of hemoptysis at a large tertiary care centerand were included in this study. Nine women and 19men with a mean age of 41.8 years (age range 2082years) were treated for hemoptysis between January 1998and October 2008. This retrospective study was approvedby our local ethics committee and informed consent waswaived. Patients were assessed by a pulmonary carespecialist, a thoracic surgeon, and an interventional radiol-ogist. Patients were included in the study if hemoptysiswas (a) recurrent despite conservative management or (b)acute or imminent airway or ventilation compromise waspresent or clinically suspected. Prior medical managementincluded conservative strategies such as bronchoscopicassessment and locoregional intervention, e.g. using vaso-active drugs or argon plasma coagulation. Vital signsand oxygen saturation were monitored in all patients.Additionally, hemoglobin, coagulation parameters, electro-lytes, blood typing and cross-match were determined.Renal and liver function tests were also conducted.Etiologies of hemoptysis were cystic brosis (n 9), lungcancer (n 6), aspergillosis (n 2), tuberculosis (n 2),bronchiectasis (n 3), chronic obstructive pulmonarydisease (n 2), iatrogenic post bronchoscopy (n 1),coagulation disorder (n 2), and idiopathic (n 1). For

follow-up, medical charts were reviewed and primarycare physicians were interviewed by telephone.

Interventional technique

Angiography was performed via femoral access in allpatients. An initial angiogram was performed using a 5-Fdiagnostic pigtail catheter and power injector to identifybronchial supplying arteries. A cobra-shape catheter (C-1or C-2, Cook Medical Inc., Bloomington, IN, USA) orreverse-curve catheter (VS-2 or Simmons, Cook MedicalInc., Bloomington, IN, USA) was used for bronchial arterycatheterization. Digital subtraction angiography was per-formed using Axiom Artis (Siemens Medical Solutions,Erlangen, Germany) or Integris V-5000 (Philips MedicalSystems, Hamburg, Germany) standard angiographysuites. For selective peripheral bronchial artery angiographyand embolization, a coaxial microcatheter system(Renegade; Boston Scientic, Natick, MA, USA) was used.For angiography, non-ionic contrast material (Iopamiro300; Bracco Diagnostic Inc., Princeton, NJ, USA) was used.A potential source of bronchial bleeding was determinedif bronchial artery hypervascularization was present.Mapping of branches potentially supplying the spinalcord was performed and if present, a more selective cathe-terization was performed. After safe positioning of the cath-eter tip, embolization with particles includingpolyvinyl-alcohol particles (Contour; Boston Scientic,Natick, MA, USA), Embospheres (Biosphere Medical,Rockland, MA, USA), or Bead Block (Terumo Inc.,Somerset, NJ, USA) sized between 350900 mm suspendedin contrast medium was performed through a microcath-eter. A postembolization angiogram was performed todocument procedural technical success. The endpoint ofembolization was stagnation or stasis of antegrade owwithin embolized branches. Clinical success of bronchialartery embolization was determined by cessation of bleed-ing within 24 hours.In the case of suspected collaterals from the internal thor-

acic artery, formerly known as internal mammary artery orrecurrent bleeding, selective catheterization of the internalthoracic artery was performed using a 5-F Berenstein cath-eter (Cook Medical Inc., Bloomington, IN, USA) and selec-tive angiography was performed. In the case of collateralarterial supply, a microcatheter (Renegade; BostonScientic, Natick, MA, USA) was used to catheterize thisvessel close to the lesion and embolize with particles(Contour; Boston Scientic, Natick, MA, USA),Embospheres (Biosphere Medical, Rockland, MA, USA), orBead Block (Terumo Inc., Somerset, NJ, USA) sizedbetween 350900 mm suspended in contrast medium.

Statistical analysis

Occurrence of post-interventional bleeding and cumulativesurvival were evaluated using the Kaplan-Meier life-tablemethod, and survival curves were plotted (16). Statisticalanalysis was performed using GraphPad statistical software(Prism v. 4.01 and InStat v 3.0; GraphPad Software, SanDiego, CA, USA).

144 A Daliri et al.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Results

Angiography and transcatheter embolization was per-formed early during assessment of hemoptysis.Embolization was performed to prevent connements inoxygenation and clinical deterioration. Twenty-six of 28patients (93%) had recurrent hemoptysis prior toembolization. In two patients with bronchial carcinoma,hemoptysis leading to transcatheter embolization was therst event. Four of 28 patients (14%) required blood trans-fusions and one patient had to be intubated and mechani-cally ventilated due to airway obliteration by blood.Clinical success of bronchial artery embolization, deter-mined by cessation of bleeding within 24 hours, wasachieved in all patients. Stagnation or stasis of bloodow in feeding vessels was achieved using particles inall patients (Figs. 1 and 2). Hypervascularization was loca-lized as follows: right upper lobe (n 15), left upper lobe(n 12), right middle lobe (n 8), lingula (n 1), rightinferior lobe (n 4) and left inferior lobe (n 7).Bronchial arteries included 10 intercostobronchial trunks,10 isolated bronchial arteries, and six common trunksfrom the right and left bronchial arteries. Additional collat-eral arterial supply from the internal mammary artery wasfound in nine patients and embolization was performed.Selective embolization was performed in a total of 35interventions.The follow-up period ranged from one month to eight

years (mean 23 months). Twenty-four patients had no evi-dence of recurrent bleeding. In the remaining four patients,recurrent bleeding was found in two men and two women,all with cystic brosis. One patient received embolizationwith Embospheres (Biosphere Medical, Rockland, MA,USA), three patients received Bead Block (Terumo Inc.,Somerset, NJ, USA) particles. Two patients had recurrentbleeding from the same vascular bed and two patientsfrom a different vessel. The rst episode of re-bleedingoccurred at 1, 16, 24 or 48 months post initial embolization.Multiple episodes (4) of recurrent bleeding occurred inone of these patients. This was a 20-year old woman withcystic brosis who had her rst embolization of themiddle lobar artery in 2004. Subsequently, she hadre-interventions in 2006 for the right upper lobar artery(2) and middle lobar artery (1).Rates of patients without re-bleeding were 96% (standard

error of mean 3.5) at one month, 91% (standard error ofmean 6.0) at 16 months, 86% (standard error of mean 7.9)at 19 months, 71% (14.6 standard error of mean) at eightyears (Fig. 3).Seven patients died between 1 and 17 months (mean 6.6

months) post initial intervention. One patient with bronchialcarcinoma died on post-interventional day 1 due to hisunderlying disease; there was no hemoptysis present atthe time of death. All other patients also died due to under-lying disease. Patient survival rates were 89% (standarderror of mean 5.8) at one month, 86% (standard error ofmean 6.6) at two months, 78% (standard error of mean 8)at ve months, and 74% (standard error of mean 8.7) ateight years (Fig. 4).

Fig. 1 43-year old patient with hepatocellular carcinoma metastasis to the

right lung and recurrent hemoptysis. (a) Pigtail catheter aortic angiogram

demonstrates the right bronchial artery originating from the descending

aorta at the level of the carina (arrow); (b) An angiogram using a 2.7-F micro-

catheter positioned peripherally in the right bronchial artery demonstrates

pathologic vessels in the middle lobe due to metastasis (arrows); (c)

Angiographic image post embolization with particles demonstrates vessel

pruning (arrow)

Bronchial artery embolization in patients with hemoptysis including follow-up 145. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Discussion

The present study was performed to evaluate effectivenessand safety of bronchial artery embolization in patients

with hemoptysis including follow-up post initial interven-tion. Bronchial artery embolization was effective in mostof our patients with hemoptysis. The post-interventionalsurvival rate was 74% from 19 months until eight years offollow-up. In our study, bronchial artery embolization wasdemonstrated to be an effective non-invasive treatment ofhemoptysis.In patients with acute and chronic lung disease, smaller

vessels originating from the pulmonary arteries mayalready have a constricted lumen or occlusion due tohypoxic vasoconstriction, thrombosis, or inammatorychanges. This induces compensatory hypertrophy of thesmall vessels originating from the bronchial arteries whichcan rupture following erosion of the vessel wall caused byinammation, tumor growth, or regional increase of bloodpressure (8, 9, 1820).Recently, Poyanli et al. found that in up to 90% of patients

with hemoptysis, bronchial arteries are the source of bleeding(21). However, other authors report that 4188% of hemopty-sis cases stem from non-bronchial systemic arteries (9, 20, 22),underlining the high variability of bleeding sources.Bronchial artery anatomy is highly variable in terms of

origin, branching pattern, and course. In most patients,bronchial arteries originate from the descending thoracicaorta at the level T5/6 vertebrae. Bronchial arteries originat-ing outside this area are considered ectopic; this ranges from8.335% (17). In the majority of cases, bronchi are suppliedby two separate bronchial arteries, one on the left andanother one on the right side as intercostobronchial trunk.

Fig. 4 Kaplan-Meier plot demonstrating cumulative survival following bron-

chial artery embolization. Cumulative survival rate was 74% at 8 years

Fig. 2 A 30-year-old woman with severe pulmonary manifestation of cystic

fibrosis. (a) Angiographic image demonstrates arterial supply (arrow) originat-

ing from the left internal thoracic artery. A 5-F single-curved catheter was

used to select the left internal thoracic artery; (b) A 2.7-F microcatheter was

used to catheterize the left internal thoracic artery. Angiogram demonstrates

a blush of contrast located in the left upper lobe (arrow). Embolization was

performed using particles sized 300500 mm and 500700 mm.

Fig. 3 Kaplan-Meier plot demonstrating cumulative recurrence-free rates

post bronchial artery embolization. Cumulative rate of recurrent hemoptysis

was 28.6% at 8 years

146 A Daliri et al.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

The second most common variant is two bronchial arterieson both sides including an intercostobronchial trunk onthe right (22). Possible anatomic variants include origin ofthe mammary artery, thyrocervical trunk, subclavianartery, costocervical trunk, brachiocephalic artery, pericar-diophrenic artery, inferior phrenic artery, or abdominalaorta (17). The most common abnormal origins are off theaortic arch, internal mammary artery, or subclavian artery.The most common anatomical variant regarding thenumber of bronchial arteries is: one right as intercostobron-chial trunk and two left.There are different causes of recurrent hemoptysis.

Immediate recurrent hemoptysis may occur due to multiplefeeding arteries that went untreated, whereas later recur-rence may be a result of re-canalization or collateralizationof the feeding artery or other source of bleeding.Recurrent bleeding in this study was found in four patients,all with cystic brosis. Two patients had recurrent bleedingfrom the same vascular bed and two patients from a differ-ent vessel. The rst episode of re-bleeding occurred at 1, 16,24 and 48 months post initial embolization, respectively.Multiple episodes (4) of recurrent bleeding occurred inone of these patients. The recurrence rate of 18% in ourstudy is in the lower range of recurrence rates reported inother studies (1442%) (3, 4, 6, 8). Cystic brosis patientstend to have hemoptysis during the course of the disease.In a retrospective series, almost 10% of patients had hemop-tysis, 20% of those more than once a month (22). Flume et al.estimate that 4.1% of CF patients will experience massivehemoptysis at least once in their life (22). Despite bronchialartery embolization, there is a high recurrence rate of 50%within 4 months (23).The complication rate reported for bronchial artery embo-

lization is generally low. In our series, there was no majorcomplication including non-target embolization or death.Coaxial microcatheters enable superselective catheterizationof small-diameter vessels without damaging the proximalportion of the bronchial artery (8, 19).Embolic materials used for bronchial artery embolization

are particles, as used in the present study. The possibility ofretrograde embolization due to reux or non-target ante-grade embolization may cause lung infarction, esophagealnecrosis, aortic wall necrosis, or spinal cord ischemia.Therefore, recommendation for particle size is 350 mm orlarger mainly to avoid neurological complications (9).There are several limitations of this study. First, the study

is retrospective in nature and therefore not controlled forselection bias, detection of events, and data collection.Second, although a total of 35 vessels were embolized, com-plications that occur at a low rate could have been missed.Third, although 28 patients with hemoptysis were includedin this study, indications and underlying diseases for bron-chial artery embolization varied in our patient cohort.Finally, a control group is lacking.In conclusion, bronchial artery embolization therapy was

effective in patients with hemoptysis. It is a useful therapyto control hemoptysis and may help to avoid surgery inpatients who are poor surgical candidates. Should

hemoptysis recur in these patients, repeated embolizationcan be performed.

Conict of interest: None.

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Bronchial artery embolization in patients with hemoptysis including follow-up 147. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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