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: [email protected]
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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