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ronchial Artery Embolizationanjeeva 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 ofhemorrhage and localizing the bleeding site. Bronchial artery embolization remains theprimary and most effective method in controlling massive hemoptysis. Bronchial andnonbronchial systemic arteries are the main source of bleeding and are embolized withpolyvinyl alcohol particles or gelatin sponge. Immediate cessation of bleeding occurs inmore than 75% of patients; however, long-term recurrences are common in patients withprogressive lung disease. Complications are infrequent except for a rare occurrence ofspinal 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 definitionf massive hemoptysis varies widely, a blood loss totaling00-600 mL over a 24-hour period is considered massive.1

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

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

auseshe 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 developingorld countries, whereas cystic fibrosis and congenital heartisease 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

athophysiologyhe pathophysiology of hemoptysis is dependent on whethern inflammatory process is involved. Chronic inflammatoryonditions of the lung (such as tuberculosis, aspergillosis,istoplasmosis, cystic fibrosis, bronchiectasis, chronic bron-hitis, etc) recruit systemic blood supply to the inflamedegions through bronchial arteries. When the disease processnvolves the pleura and/or the chest wall, nonbronchial sys-emic arteries are often recruited to the inflamed areas. Theseecruited 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 suchavitary tuberculosis and lung abscesses may involve the pul-onary arteries and may result in pseudoaneurysms. He-optysis occurs from the rupture of such pulmonary arteryseudoaneurysms.Noninflammatory processes, such as malignancy (pri-ary bronchial carcinoma, metastatic osteosarcoma, and

ther sarcomas) and congenital heart diseases, may alsoesult in hemoptysis. Although bronchial arteries remainhe main supply to the bronchial tumors, nonbronchialystemic arteries are often the source of hemoptysis whenhe 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 pulmonaryligemia lead to recruitment of systemic arteries to supplyhe lungs and may eventually cause hemoptysis. Infectionf a sequestrated lung (perfused by an aberrant arteriallood supply from the aorta) is another rare congenital

ause of hemoptysis.

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Bronchial artery embolization 131

linical Considerationshe workup of a patient with hemoptysis requires a mul-

idisciplinary team effort involving a pulmonary criticalare specialist, a thoracic surgeon, and an interventionaladiologist. A complete history and physical examinationrovide clues to the underlying pathology and the locationf bleeding. Often, patients are able to identify the side ofleeding. Chest radiograph provides information on theisease process, location, and involvement of the pleurand 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 bothungs. Additionally, the chest radiograph is normal in0%-30% of patients presenting with hemoptysis.4 Bron-hoscopy is useful in identifying the site of bleeding and isften 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 followingmbolization or surgery. It provides detailed evaluation ofhe 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 diseasesBronchitisBronchiectasisBronchial tumors

arenchymal diseasesTuberculosisHistoplasmosisSarcoidosisCystic fibrosisAspergillosisLung abscessPneumoniaPneumoconiosisInfected sequestrationOther granulomatous and vasculitidiesardiovascular diseasesPulmonary arteriovenous malformation/aneurysmsPulmonary artery hypertension (primary and secondary)Pulmonary embolismCongenital heart diseases causing pulmonary oligemiaAortobronchial fistulaAortic aneurysmsBronchial artery aneurysmsthersTraumaForeign bodyCoagulopathy

emoptysis, as aspirated blood makes it difficult to locate p

he bleeding site. The overall accuracy of bronchoscopy invaluating 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 CTngiography 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 vascularnatomy, anomalies, and cause of bleeding (eg, bronchial vsulmonary). 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 of5-T6, gives off the first intercostal artery, and continues as the rightronchial artery. The artery is enlarged and there is parenchymalypervascularity. (B) Following embolization, the artery is com-

letely occluded.

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rteries can be visualized on thin-section contrast-enhancedT. 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. CTan provide added information when bronchoscopy andhest radiograph are nondiagnostic. Also, it is noninvasive,oses less potential risk compared with bronchoscopy androvides essential information for therapy planning. Theain disadvantages of CT are radiation risk, the need forotentially nephrotoxic contrast material, and potential timeelays 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 formerourses 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 bloodounts, coagulation profile, blood type, renal function), andemodynamic status. Patients with mild hemoptysis may bereated with bed rest, postural drainage, and supportive mea-ures for cough and infection. However, in patients withoderate and massive hemoptysis, airway management is

ritical and early intubation is recommended to preventrowning of the lungs by the blood-filled airways. Hemody-amic stability can be achieved with transfusion of bloodroducts and systemic vasoconstrictors. Early interventionhrough bronchial artery embolization or surgery should beought as early as possible. When CT suggests involvement ofhe pulmonary arteries, evaluation of the electrocardiogramfor left bundle branch block) and echocardiography (forulmonary artery hypertension) are necessary before pulmo-ary angiography is undertaken.Bronchial artery embolization is now recognized as the

rst-line management for bleeding control in patients withoderate to massive hemoptysis, while surgery is pre-

erred for definitive treatment of the patient with hemop-ysis, given the long-term efficacy of removing the underlyingiseased pulmonary tissue. Bronchial artery embolizationay therefore be employed as a temporary measure in

ontrolling bleeding in patients who otherwise would ben-fit from definitive surgery (specifically, in patients withocalized diseases, such as bronchial adenoma, aspergil-oma, hydatid disease, and trauma) or as a palliative measuren patients who cannot undergo surgery due to the extent of theisease (eg, bilateral disease), nonresectable tumor, poor pulmo-ary reserve, prior lobectomy, and other comorbid conditions.

able 2 Bronchial Artery Branching Patterns (described byauldwell et al7)

Type Description Incidence (%)

ype 1 Right intercostobronchial trunkand two left bronchialarteries

40

ype 2 Right intercostobronchial trunkand one left bronchial artery

21

ype 3 Right intercostobronchialtrunk, one right bronchialartery, and 2 left bronchialarteries

20

ype 4 Right intercostobronchialtrunk, one right bronchialartery and 1 left bronchialartery

9

able 3 Angiographic Signs that Suggest Source of Bleeding

. Hypertrophy/enlarged (>3 mm in diameter), tortuousbronchial arteries with parenchymal hypervascularity,and parenchymal staining

. Bronchial artery aneurysms

. Bronchial artery to pulmonary vein shunting

. Bronchial artery to pulmonary artery shunting

. Active extravasation

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nfortunately, recurrence rates following bronchial artery em-olization are high in patients with progressive lung disease.

natomical Considerationsthorough knowledge of bronchial artery anatomy is essen-

ial when bronchial artery embolization is attempted. Manyariations exist in the number, origin, and course of the bron-hial arteries.

rigin of the Bronchial Arteriesn 70% of individuals the bronchial arteries arise from theescending thoracic aorta between T5 and T66 (Fig. 1). In

igure 4 Bronchial artery to pulmonary vein shunting in a patient pre-enting with massive hemoptysis. Contrast injection through right in-ercostobronchial trunk shows hypertrophy, hypervascularity, and earlylling of the pulmonary vein (arrow in A). A delayed image (B) confirms

hat the arrow in (A) corresponds to the right superior pulmonary vein. t

0%, the bronchial arteries have an aberrant origin anday arise from the subclavian, brachiocephalic, internalammary, thyrocervical trunk, inferior phrenic, and peri-

ardio-phrenic arteries or from the abdominal aorta6 (Fig.). In 10%, the bronchial arteries arise from other seg-ents of the descending thoracic aorta, and aortic arch.6

berrant bronchial arteries can be distinguished from the

igure 5 Bronchial artery to pulmonary artery shunting in a patientresenting with massive hemoptysis. Contrast injection into theight bronchial artery demonstrates filling of the right inferior pul-onary artery (arrow).

igure 6 Active extravasation during bronchial artery injection. Se-ective left bronchial artery injection in a patient with massive he-

optysis demonstrates active extravasation of contrast material into

he right lower lobe bronchus (arrow).

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onbronchial systemic arteries as they course along theentral bronchi.

ranching Patternhe most consistently identified artery (seen in 80%) is theight intercostobronchial trunk (Fig. 1). It usually arises fromhe anterior-medial surface of the aorta at T5-T6 (classicallyocated at the site where the left main bronchus crosses theescending thoracic aorta). It gives origin to the first intercostal

igure 7 Hemoptysis in a patient with metastatic sarcoma. Rightronchial arteriogram demonstrates multiple hypervascular masses

n the right lower lobe.

igure 8 Nonbronchial systemic arterial supply to the lung throughhe left internal mammary artery. The artery was selectively cathe-erized with a Davis catheter. The branches of the internal mammary

rtery show hypertrophy with parenchymal hypervascularity. p

ranch and continues as the right bronchial artery. Left bron-hial arteries arise separately from the anterior surface of theorta. A left intercostobronchial trunk is uncommon (Fig. 3),hereas a common bronchial trunk is relatively common,

rising from the anterior surface of the aorta, usually be-ow the level of the right intercostobronchial trunk. Itivides into the right and left bronchial arteries after ahort course. In addition, the bronchial arteries mayourse vertically upward or downward before coursingnto either lung and, as such, the accurate identification ofheir origin from the thoracic aortogram may be difficult.

igure 9 Nonbronchial systemic arterial supply to the lunghrough the long thoracic artery in a patient who presented withassive hemoptysis, secondary to lung metastases from osteo-

arcoma. Selective long thoracic arteriogram demonstrates a fo-al hypervascular mass in the left lung.

igure 10 Nonbronchial systemic arterial supply through intercostalrtery. Arteriography via a right intercostal artery demonstrates hy-

ertrophy of the artery with lung parenchymal hypervascularity.

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Bronchial artery embolization 135

auldwell et al identified 4 classic patterns of bronchialrtery branching,7 as listed in Table 2. Bronchial and in-ercostal arteries give off dorsal and ventral radicular ar-eries that supply the dorsal and ventral nerve roots. An-erior medullary arteries also arise from the bronchial andntercostal arteries and communicate with the anterior spi-al artery to supply the spinal cord. These have a charac-eristic “hairpin” appearance on angiography and courseertically in the midline, centered over the spine.

upplyronchial arteries are the main nutrient supply to the lungnd course along the bronchi before anastomosing withhe pulmonary circulation at the level of the respiratory

ronchioles. In addition to supplying the bronchi, the a

ronchial arteries supply the diaphragmatic and mediasti-al portions of the visceral pleura, the middle third of thesophagus, and the subcarinal lymph nodes. The venousrainage is through bronchial veins and pulmonary veins.s described earlier, radicular arteries and medullary ar-

eries supply the nerve roots and spinal cord. The compli-ations related to bronchial artery embolization resultrom ischemic necrosis (spinal cord infarction, bronchialecrosis, and esophageal necrosis) of organs that are sup-lied by the bronchial arteries.

echnical Considerationsronchial artery embolization was described as early as 19748

Figure 11 Hemoptysis in a patient with exten-sive right lower lobe pulmonary disease. (A)Contrast injection into the right intercosto-bronchial trunk demonstrates enlargement ofthe artery, with parenchymal hypervascularityand staining in the right lower lobe. (B, C) In-jection of the right inferior phrenic artery dem-onstrates enlargement of the artery with re-gional hypervascularity, parenchymal staining(arrowhead in C) and shunting into the pulmo-nary veins (arrows in C).

nd the technique of embolization has not changed signifi-

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antly since then. The arterial access is gained through aemoral (most often) or brachial approach. Some physiciansrefer to obtain a thoracic aortogram before selective bron-hial artery angiography. Aortography has the advantage ofdentifying the origin, number, and course of the bronchialrteries and nonbronchial systemic arteries. Selective cathe-erization of the bronchial arteries may be achieved usingarious catheter configurations, such as the Cobra, Simmons,hepherd’s crook, Mikaelsson, or Yashiro catheters. Aberrantronchial arteries arising from the thoracic aortic arch arextremely difficult to catheterize; a Simmons 2 or a Head-unter catheter may be useful if this situation is encounterednd a brachial artery access approach may also be helpful.nce the bronchial artery is selectively catheterized, an an-

iogram is performed by hand injection of 5-10 mL iodinatedontrast material. Digital subtraction angiography is highlyseful in identifying the spinal arteries, as is correct anatom-

cal positioning of the patient. The latter allows for rapiddentification of the spinal arteries as they course over theenter of the spine. A low-osmolar contrast material is rec-mmended for bronchial and intercostal angiography, as usef high-osmolar contrast material is often implicated as onef the causes of spinal ischemia.It is rare to identify active extravasation of contrast me-

ium during angiography of the bronchial and nonbronchialystemic arteries. Angiographic signs that help identify theource of bleeding are listed in Table 3 (Figs. 1, 2, 4, 5, and). Tumors may demonstrate localized hypervascularity andtaining of the tumor (Fig. 7). After identifying an abnormalronchial/nonbronchial systemic artery, a microcatheter is

ntroduced coaxially through the initially used catheter and isdvanced into a more stable location. One should confirmhat the microcatheter tip is distal to any radicular/spinalrteries before embolization is performed. Embolization iserformed slowly under direct fluoroscopy to prevent refluxf the embolic materials as this could result in nontargetmbolization of the particles into other vessels, including theorta and its branches. Embolization is continued until com-lete occlusion of all the abnormal vessels and near stasis ofhe contrast medium within the bronchial artery is achievedFig. 1).

mbolic Materialshe preferred embolic materials include polyvinyl alcoholarticles and gelatin sponge. The appropriate size of thembolic materials is determined by several considerations.ne must insure that the size of the embolic particles is

ufficient to prevent these materials from crossing theronchial artery to pulmonary arterial/venous anastomo-es. Generally, particles of size larger than or equal to 300m are used. Smaller particles often will lead to bronchialnd esophageal necrosis. In addition, very small particlesay more easily result in nontarget embolization into the

pinal arteries and may thus cause spinal cord infarction.iquid embolic agents, such as alcohol and cyanoacrylate,hould be avoided as these can cause very distal emboli-ation and lead to complications. In the presence of large

ronchial artery to pulmonary shunts, larger particles or e

elfoam pledgets may be used. Routine use of emboliza-ion coils should be avoided as these occlude the proximalronchial artery segments and preclude repeat emboliza-ion if hemoptysis recurs. However, coils are preferred tocclude proximal (or mediastinal) bronchial artery aneu-ysms. Another important use of coils is for embolizingbnormal communication pathways between the bron-hial and systemic arteries for prevention of nontarget

igure 12 Hemoptysis in a child with infected pulmonary sequestra-ion. (A) Abdominal aortogram demonstrates an enlarged anoma-ous artery (arrow) arising from the aorta and supplying the rightung. There is parenchymal hypervascularity (arrowheads). (B) Se-ective contrast injection into the anomalous artery (open arrow)hows parenchymal hypervascularity and venous drainage throughulmonary vein (arrow).

mbolization.

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Bronchial artery embolization 137

onbronchial Systemic Collateralss discussed in the previous sections, nonbronchial sys-

emic arteries supply the lung when a disease process in-olves the pleura and chest wall. These nonbronchial sys-emic arteries may be the main source of bleeding inatients with hemoptysis or may be a cause of recurrentemoptysis following bronchial artery embolization. A de-ailed search for nonbronchial systemic arteries should beerformed in all patients presenting with hemoptysis, es-ecially in patients with extensive inflammatory disease,uch as tuberculosis. The common culprit, nonbronchialystemic arteries, includes the branches of the subclavianthyrocervical trunk, internal mammary artery (Fig. 8),

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ostocervical arteries] and axillary arteries [long thoracic v

rtery (Fig. 9)], as well as the intercostal (Fig. 10) andnferior phrenic arteries (Fig. 11). The intercostal arteries

ay be selectively catheterized using Cobra or reverseurve catheters. The internal mammary artery may be se-ected with Davis, Vert, or rim catheters, while the thyro-ervical trunk and other branches of the subclavian andxillary arteries can usually be selected with a Davis cath-ter. The inferior phrenic artery may arise either from theorta immediately above the celiac axis or from the prox-mal segment of the celiac axis. This can be catheterizedith Cobra or reverse curve catheters. As with bronchial

rtery embolization, superselective cannulation with a mi-rocatheter is recommended before embolization to pre-

Hemoptysis in a patient with septic emboli from bacterial en-s of right-sided heart valves. Right pulmonary angiogram dem-a bilobed, irregularly marginated pseudoaneurysm (arrows in Ahe aneurysm was successfully treated with metallic coils (arrow

ure 13carditistratesd B). TC).

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ubclavian arteries and the aorta. In patients with seques-ration, an anomalous systemic blood supply usually arisesrom the aorta just below the diaphragm (Fig. 12). Thisessel can be selectively catheterized using either a Cobrar a Simmons catheter.

ulmonary Arterieshe pulmonary arteries are the source of hemoptysis in less

han 10% of patients presenting with hemoptysis. The com-on causes are pulmonary artery aneurysms in associationith cavitary tuberculosis, septic emboli related pseudoan-

urysms (Fig. 13), and pulmonary arteriovenous malforma-ions (isolated or as a part of hereditary hemorrhagic telangi-ctasia). Pulmonary artery evaluation is indicated when CThows a pulmonary artery abnormality, when no abnormalessels are identified during bronchial arteriography, or ifleeding recurs despite adequate embolization of the sys-emic arteries. Pulmonary artery aneurysms and arterio-enous malformations are embolized with coils or detachablealloons.

esultsechnical success in embolizing the bronchial and other non-ronchial systemic arteries can be achieved in more than 90%f cases. However, immediate clinical success in controllingleeding is achieved in only 75%-90%.5,6 Failure to achieve

mmediate clinical success may be caused by technical diffi-ulties in catheterizing the bronchial arteries, failure to iden-ify and embolize all involved bronchial and nonbronchialystemic arteries, and the asphyxiation death of some pa-ients. Long-term recurrence rates vary depending on thenderlying lung disease; high recurrence rates are noted withspergillosis (close to 100%), tuberculosis, and bronchialarcinoma. Recurrent bleeding may be a result of recanaliza-ion of previously embolized arteries, and/or recruitment ofew bronchial and nonbronchial arteries through diseaserogression. Recurrences can be treated with repeat emboli-ation. It is important to remember that bronchial arterymbolization is aimed at controlling bleeding (a palliativerocedure), not at treating the underlying disease process.urgery remains the definitive therapy for prevention of re-

urrent hemoptysis.

omplicationsomplications following bronchial artery embolizationre rare. Of all, spinal cord infarction is most dreaded andesults in paralysis of both lower extremities. This compli-ation has been reported to occur at a frequency of 1%-%, although the actual incidence may even be less thanhat reported. Other rare complications include bronchialnd esophageal necrosis. Common complications includehest pain, dysphagia, and fever. Other procedure-relatedomplications include groin hematoma, dissection of theorta and great vessels, and contrast material induced ne-hropathy.

onclusionsreatment of hemoptysis requires a proactive, team-basedpproach with early intervention through bronchial arterymbolization in patients with moderate to massive hemop-ysis. Bronchial artery embolization is well tolerated; itecessitates a thorough evaluation of the bronchial andonbronchial arteries and subsequent embolization of allbnormal arteries to achieve a high clinical success in con-rolling bleeding.

eferences. Najarian KE, Morris CS: Arterial embolization in the chest. J Thorac

Imaging 13:93-104, 1998. Andersen PE: Imaging and interventional radiological treatment of he-

moptysis. Acta Radiol 8:780-792, 2006. Liebow AA, Hales MR, Lindskog GE: Enlargement of the bronchial ar-

teries, and their anastomosis with the pulmonary arteries in bronchiec-tasis. Am J Pathol 25:211-231, 1949

. Marshall TJ, Flower CDR, Jackson JE: The role of radiology in the inves-tigation and management of patients with hemoptysis. Clin Radiol 51:391-400, 1996

. Yoon W, Kim JK, Kim YH, et al: Bronchial and nonbronchial systemicartery embolization for life threatening hemoptysis: A comprehensivereview. Radiographics 22:1395-1409, 2002

. Stoll JF, Bettmann MA: Bronchial artery embolization to control hemop-tysis: A review. Cardiovasc Interv Radiol 11:263-269, 1988

. Cauldwell EW, Siekert RG, Lininger RE, et al: The bronchial arteries: An ana-tomic study of 105 human cadavers. Surg Gynecol Obstet 86:395-412, 1948

. Remy J, Voisin C, Dupuis C, et al: Hemoptysies par embolization de la

circulation systemique. Ann Riol (Paris) 17:5-16, 1974