TECHNICAL NOTE

Pulmonary Artery Access Embolization in Patients with MassiveHemoptysis in Whom Bronchial and/or Nonbronchial SystemicArtery Embolization Is Contraindicated

Alberto Tamashiro Æ Marisa H. Miceli Æ Cristian Rando Æ Gustavo A. Tamashiro ÆMiguel O. Villegas Æ Andres E. Dini Æ Aristobulo E. Balestrin ÆJose A. Diaz

Received: 11 March 2007 / Accepted: 28 November 2007 / Published online: 3 January 2008

� Springer Science+Business Media, LLC 2007

Abstract The objective of this paper is to present an

alternative therapeutic approach for the treatment of

patients with massive hemoptysis in whom bronchial and/

or nonbronchial systemic arterial embolization is not pos-

sible. We describe a percutaneous procedure for pulmonary

segmental artery embolization. Between May 2000 and

July 2006, 27 adult patients with hemoptysis underwent

percutaneous treatment at our department; 20 of 27 patients

were embolized via bronchial and or nonbronchial sys-

temic arteries and 7 patients were embolized via pulmonary

artery. Femoral arterial access for systemic artery cathe-

terization and femoral vein access for pulmonary arterial

catheterization were used. Gelfoam particles and coils were

used for embolization. In this study, we report on three

cases of massive hemoptysis from a systemic arterial

source in whom bronchial and/or nonbronchial arteries

embolization was not possible. Percutaneous embolization

via the pulmonary artery access was successful in all three

patients. In conclusion, embolization via pulmonary artery

is presented as an alternative approach for the management

of hemoptysis in patients in whom bronchial arterial

embolization is not possible.

Keywords Hemoptysis � Embolization � Endovascular

percutaneous treatment � Systemic-pulmonary shunt �Pulmonary artery embolization

Introduction

The cause of bleeding in chronic inflammatory processes of

the lungs is rupture of the friable hyperneovascular net-

work, which is exposed to systemic arterial pressure. In

these cases, bronchial and nonbronchial systemic arteries

as supplying vessels are the primary source of bleeding [1].

Therefore, embolization of these vessels is the treatment of

choice for this condition [1–7]. However, technical diffi-

culties, anatomic variations of the supplying arteries, or

risk of neurological complications may render endovascu-

lar treatment impossible or hazardous. In these

circumstances, if systemic-pulmonary shunt is present, the

bleeding network can be embolized via the pulmonary

arterial branches [1, 6, 7].

Patients and Methods

Between May 2000 and July 2006, 27 adult patients with

hemoptysis underwent percutaneous treatment at our

department: 24 males and 3 females, with a mean age of 40

years (range, 18–78 years). Twenty of the 27 patients

(74%) were embolized via bronchial and or nonbronchial

systemic arteries. Seven (26%) of the patients were

embolized via pulmonary artery; three of them are the

subject of this study. The remaining four were excluded

A. Tamashiro � C. Rando � G. A. Tamashiro �M. O. Villegas � A. E. Dini � A. E. Balestrin � J. A. Diaz

Department of Hemodynamics, Hospital Nacional Alejandro

Posadas, Buenos Aires, Argentina

M. H. Miceli

Myeloma Institute for Research and Therapy, University of

Arkansas for Medical Sciences, Little Rock, Arkansas

J. A. Diaz (&)

Hospital Nacional Alejandro Posadas Pte IlliaS/n y Marconi, El

Palomar (CP 1706), Pcia de Buenos Aires, Argentina

e-mail: jadhemosurg@hotmail.com

123

Cardiovasc Intervent Radiol (2008) 31:633–637

DOI 10.1007/s00270-007-9265-5

because of the bleeding being exclusively from a pul-

monary artery source: two patients had a pulmonary artery

pseudoaneurysm, one patient presented a pulmonary arte-

rial-venous fistula, and in one patient neither bronchial nor

nonbronchial systemic arteries could be found on

angiography.

Diagnostic and therapeutic procedure

Four- to six-French end-hole angiographic catheters with

an appropriate shape for selective angiography of bronchial

and nonbronchial systemic arteries were used through

femoral arterial access. Systemic arterial angiography was

performed to visualize the systemic-pulmonary artery

shunt leading to the pulmonary artery branch to be treated

[8]. Disappearance of the shunt was used as a marker of

successful embolization and, therefore, an indicator to end

the procedure.

Five- or six-French non-side-hole multipurpose or short

angled-tip angiographic catheters were inserted into the

pulmonary artery through femoral vein access. Emboliza-

tion through a wedged catheter in one or more segmental

branches was performed.

Particles of ground gelatin sponge (Curamedical B.V.,

Amsterdam) diluted in low-osmolar contrast medium and

saline solution were used. The embolization material was

prepared from an 80 9 50 9 5-mm gelatin sponge pad

ground in a sterilized grinder, yielding 50- to 500-lm

threads diluted in 20 ml low-osmolarity contrast medium

and saline solution.

Coils (Cook Inc., Bloomington, IN) of appropriate size

were deployed in the target segmental pulmonary vessels in

two cases to prevent removal of the embolization material

by the reversal flow.

Case Reports

Case 1

A 32-year-old white male with hemoptysis was admitted to

the hospital. He had a history of pulmonary tuberculosis

with recent treatment discontinuation. He had an abnormal

chest CT, with a cavitary lesion in the right upper lobe and

bilateral scattered nodular infiltrates. During hospitaliza-

tion, he had massive hemoptysis. Active bleeding from the

right bronchus was observed on bronchoscopy. Angiogra-

phy showed right intercostobronchial trunk hypertrophy, a

hypervascularization network, and a systemic-pulmonary

shunt in the upper lobe (Fig. 1).

Catheter instability did not allow proper embolization of

the right intercostobronchial trunk. Pulmonary artery

angiography revealed an amputation-like image and

reverse flow in the apical branches of the right pulmonary

artery, which helped identify the pulmonary vessels to be

occluded. Embolization of these branches was performed

with gelatin sponge particles and three coils (size: 5 9 5

mm). The patient remained alive and without relapses at

27-month follow-up.

Case 2

A 57-year-old white male with hemoptysis was admitted to

the hospital for diagnostic workup and treatment. Chest x-

ray revealed alveolar infiltrates in the left upper lobe. Acid-

fast stain of sputum was positive. Bronchoscopy exami-

nation was complicated by massive bleeding of

approximately 1000 ml from the left bronchus. An emer-

gency angiography was performed. No bleeding from

bronchial or intercostal arteries could be identified. The left

Fig. 1 Case 1. (a) Systemic

artery catheterization: systemic-

pulmonary shunt in the upper

lobe (1). (b) Pulmonary artery

catheterization showing an

amputation-like image and

reverse flow (2) in the apical

branches of the right pulmonary

artery that helped identify the

pulmonary vessels to be

occluded. (c) Control

angiography after successful

pulmonary embolization

634 A. Tamashiro et al.: Pulmonary Artery Access Embolization in Patients with Massive Hemoptysis

123

thyrocervical trunk showed a hypervascular web draining

into the left pulmonary artery (Fig. 2).

The short length of the thyrocervical trunk increased the

risk of undesirable vertebral artery embolization, thus

embolization via the pulmonary artery using gelatin sponge

particles and a coil implantation (size: 5 9 5 mm) was

performed. The pulmonary artery branch to be occluded

was identified after systemic-pulmonary shunt visualization

on thyrocervical trunk angiography. The patient remained

alive and free of relapses at 14-month follow-up.

Case 3

A 57-year-old white female with hemoptysis was admitted

to the hospital for diagnosis and treatment. She had a

history of pulmonary tuberculosis treated 34 years previ-

ously. Chest x-ray showed interstitial fibrosis of the left

upper pulmonary lobe. A partially occlusive organized clot

in the left upper lobe bronchus was observed in a bron-

choscopy. After admission, the patient had four episodes of

hemoptysis (150 ml each) and required red blood cell

transfusions. The angiography showed the third and fourth

left intercostal arteries emerging from a common trunk

supplying a hypervascular area in the left upper lobe

draining into the pulmonary artery; the fifth left intercostal

artery supplied the same area and also shunted to the pul-

monary vein. A paravertebral arterial web with radicular

irrigation was also observed.

The segmental left upper pulmonary artery branches

were embolized to prevent systemic embolization and/or

neurological injury. The pulmonary artery was embolized

with gelatin sponge particles until the shunt disappeared

(Fig. 3). The patient was alive and without hemoptysis at

10-month follow-up.

Discussion

It is generally held that bleeding occurs from friable net-

works of neovessels in inflamed pulmonary tissue which is

exposed to systemic arterial pressure; therefore the target

area to be treated is the bleeding network fed by the

bronchial and/or nonbronchial systemic arteries. Using

systemic arterial access, embolization particles can be

driven by the bloodstream to the bleeding network. If there

are difficulties with the systemic artery access, the bleeding

network can be treated via pulmonary artery as an alter-

native approach [1, 6, 7, 9, 10]. Wedging the catheter into

segmental arteries in the procedure prevents the embolic

agent from being driven away into pulmonary arterial

branches supplying normal lung. Although small amount of

particles reflow could not be completely avoided, there

were no complications in our patient population. The bal-

loon catheter could be useful in preventing it. No retrograde

passage of embolization material to systemic arteries was

observed during the injections. We used a homogeneous

solution of Gelfoam particles, forming an adherent network

of 50- to 500-lm particle size that ultimately activates

platelet aggregation and the coagulation cascade [11].

In the three cases reported in this study, bleeding from

bronchial and nonbronchial systemic arteries was suc-

cessfully treated with embolization via the pulmonary

artery. In all of them, systemic-pulmonary shunt was

apparent. Catheter instability in the bronchial artery (case

1) and the risk of vertebral artery embolization (case 2) led

us to proceed via pulmonary artery access. In case 3, the

presence of a paravertebral radicular arterial web was

identified. Even when this fact is not an absolute contra-

indication for occlusion therapy [3, 12], the coexisting

bronchial and nonbronchial systemic artery shunt to the

pulmonary vein [13] contribute to the total risk.

Fig. 2 Case 2: angiographic

sequence. (a) Systemic artery

catheterization using the left

thyrocervical trunk showed a

hypervascular web draining into

the left pulmonary artery

(systemic pulmonary shunt ).

(b) Double arterial (systemic

and pulmonary) catheterization.

(c) Control angiography. (1)

Catheter in systemic artery; (2)

pulmonary artery branch; (3)

catheter in the pulmonary

artery; (4) coil; (5) smokey

appearance of the embolization

area

A. Tamashiro et al.: Pulmonary Artery Access Embolization in Patients with Massive Hemoptysis 635

123

Considering this fact, we performed pulmonary artery

branch embolization.

The smokey appearance shown in Figs. 2 and 3 is the

consequence of the pulmonary embolization through the

wedged catheter; it may suggest the possibility of pulmonary

infarction. Even though lung infarction could have occurred,

none of these patients showed clinical evidence suggesting

that complication. Asymptomatic pulmonary infarction can

occur even after conventional bronchial and nonbronchial

artery embolization [11]. However, no further testing was

performed to rule out this diagnosis in our patient series.

The presence of systemic-pulmonary shunt has been

reported in more than 50% of patients with bleeding origi-

nating from bronchial and nonbronchial systemic arteries [1,

3, 6, 7, 12, 14]; the incidence in our population was 56%. The

presence of a systemic-pulmonary artery shunt was a marker

to spot the segmental pulmonary branch to be embolized.

The pulmonary artery itself is the source of hemoptysis

in a small proportion of cases [1, 6, 8, 9]. The most com-

mon causes of bleeding from the pulmonary artery

circulation are pulmonary pseudoaneurysms due to erosive

inflammatory processes (cavitary tuberculosis, cavitary

aspergilloma, pyogenic abscesses, bronchial carcinoma) or

arteriovenous fistulas. Rabkin et al. reported an overall

90.8% success rate with the transcatheter pulmonary

embolization procedure [6]. In this same series, the authors

reported 28 failures; in 26 of them, the pulmonary artery

was the source of bleeding. Remy et al. reported five cases

of embolization performed through the pulmonary artery in

hemoptysis of pulmonary artery origin [9]. Sanyika et al.

reported eight patients with cavitary tuberculosis who did

not respond to initial systemic arterial embolization [15];

three of these patients who were treated using pulmonary

artery access did respond to the therapeutic procedure.

These reports illustrate that embolization of bronchial

and nonbronchial systemic arteries alone may not be suf-

ficient therapy to control hemoptyis; occlusion of the

pseudoaneurysm via a pulmonary artery approach could be

the elective procedure [8]. However, we must mention that

Corr has reported a group of 10 patients over age 11 with

cavitary aspergillomas successfully treated through sys-

temic arteries [16].

It is noteworthy that in the three cases reported here, we

used the pulmonary artery access for the treatment of

hemoptysis from bronchial and nonbronchial systemic

sources. We did not use coaxial microcatheters for the

embolization of systemic arteries. The therapeutic meth-

odology we propose might increase the chances of success

of percutaneous treatment of hemoptysis.

In conclusion, embolization via the pulmonary artery is

an alternative endovascular procedure for the management

of hemoptysis in patients in whom bronchial or nonbron-

chial systemic artery embolization is not possible.

Acknowledgments The authors would like to thank the nursing,

secretarial, and technical staff of the catheterization laboratory of

Hospital Nacional Alejandro Posadas for their enthusiasm and their

belief that our efforts were worthwhile and useful.

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