Bronchial artery embolisation in haemoptysis

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2. INTRODUCTION Massive hemoptysis or chronic recurrent hemoptysis are potentially life-threatening conditions.Despite advances in medical and intensive care unit management, massive hemoptysis remains a serious threat. Mortality rate for patients with massive hemoptysis can be as high as 75% .Superselective catheterization of the bronchial arteries feeding the affected areas followed by particulate embolization has proven to be an effective treatment for the control of bleeding. 3. WHY ?? 1) Bronchial circulation (90% of cases) - Pulmonary circulation (5%) . - Aorta (5%)(eg, aortobronchial fistula, ruptured aortic aneurysm). 2) Surgery - Mortality ~18% when performed electively, rising to 40% when performed emergently. - conservative approach , mortality risk of at least 50%. 3) Minimally invasive - clinical success - 85% to 100%, - recurrence of hemorrhage 10%. 4. ANATOMICAL CONSIDERATION Variable anatomy in terms of origin, branching pattern, and course.The standard or orthotopic origin is from the aorta between the levels of T5 and T6 (80%).ANOMALOUS Outside the levels of T5 and T6 .ANOMALOUS - Aortic arch, Internal mammary artery, Thyrocervical trunk, Subclavian, Costocervical trunk, Pericardicophrenic artery, Inferior phrenic artery. 5. BRANCHING PATTERN (CAULDWELL)Type 1 (40.6 %) . one right bronchial artery from ICBT .Two left bronchial arteriesType 2(21.3 %) .one on the right from ICBT .One on the leftType 3(20.6 %) .Two on the right (1 from ICBT & 1 bronchial artery) . Two on the left.Type 4(9.7 %) .Two on the right (1 from ICBT & 1 bronchial artery). .one on the left. 6. SPINAL ARTERIES When bronchial artery embolization is performed, consideration must be given to the arterial supply to the spinal cord.Most important is Anterior Spinal Artery.Anterior spinal artery receives contributions from the anterior radiculomedullary branches of the intercostals and lumbar arteries.6-8 , hairpin loop course. 7. ARTERY OF ADAMKIEWICZ The largest anterior medullary branch. Has variable origin from T5 L5 level, but most commonly from T8 L1 level.In 5 % of population Rt. IBT contributes to artery of Adamkiewicz. The left bronchial arteries very rarely contribute the anterior spinal artery. 8. Source : internet. 9. TECHNIQUE Prior to the procedure, a brief neurological exam is performed to establish a baseline.Femoral route.A preliminary descending thoracic aortogram can be performed as a roadmap to the bronchial arteries.Reverse curve catheter mikaelsson, simmons 1, shepherds hook.Low arotic arch forward looking catheters ( cobra or RC ) used. 10. The left main stem bronchusserves as a convenient fluoroscopic landmark for the general location of the bronchial arteries The catheter is directed lateralor anterolateral for the right bronchial and more anterior for the left. Bronchial arteries course ofmain stem bronchi towards hila. Intercoastal arteries initialcephalic course , then laterally along undersurface of rib 11. REVERSE CURVECOBRA HEAD 12. COMPLICATIONS Chest pain is the most common complication.Dysphagia due to embolization of esophageal branches may also be encountered.The most disastrous complication is spinal cord ischemia due to the inadvertent occlusion of spinal arteries. When the artery of Adamkiewicz is visualized at angiography, embolization should not be performed.Other rare complications include aortic and bronchial necrosis, bronchoesophageal fistula, nontarget organ embolization (eg, ischemic colitis), pulmonary infarction. 13. REPORT 9 cases (march-september).All electively.Prior HRCT all cases.Bronchiectasis with alveolar opacities .Mass like lesion two cases.Tuberculosis.Right -6Left 2Bilateral - 1 14. Embolisation Polyvinyl alcohol (PVA) particles- 300 to 500 m.1mm PVA one case .Right bronchial artery alone 3Left bronchial artery alone 1B/L Bronchial artery 2Left Bronchial and LIMA 1.Left Axillary , Left LIMA and B/L Bronchial 1Incomplete 1. 15. 60 YR MALE C/O HEMOPTYSIS - 3YRS. KNOWN TUBERCULAR AND SMOKER 16. 25 YR/FEMALE C/O HEMOPTYSIS 2YRS. K/C/O TUBERCULOSIS 17. 47YR/MALE HEMOPTYSIS 6 MONTHS K/C/O TUBERCULOSIS 18. REPORT INCOMPLETE EMBOLISATION 1.SURGERYSUCEESFUL EMBLOISATION 8.FOLLOW UP 7clinical success 19. NO COMPLICATIONS 20. CONCLUSION 1.The development of bronchial artery embolization techniques has revolutionized the approach to hemoptysis patients.2.Bronchial artery embolization possesses high rates of immediate clinical success coupled with low complication rates.3.When bronchial artery angiography and embolization is performed, consideration must be given to the arterial supply to the spine.4.Surgery should be considered only in case where embolisation not possible due technical difficulty and in case of embolisation failure. Otherwise bronchial artery embolisation is considered as the mainstay treatment for hemoptysis. 21. REFERNCES 1) Haponik E F, Fein A, Chin R. Managing life-threatening hemoptysis: has anything really changed? Chest. 2000;118(5):14311435.2)Shigemura N, Wan I Y, Yu S C, et al. Multidisciplinary management of life-threatening massive hemoptysis: a 10-year experience. Ann Thorac Surg. 2009;87(3):849853.3)Marshall T J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization for haemoptysis. Eur Radiol. 1997;7(8):12211227.4)Yoon W, Kim J K, Kim Y H, Chung T W, Kang H K. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22(6):13951409.5)Fernando H C, Stein M, Benfield J R, Link D P. Role of bronchial artery embolization in the management of hemoptysis. Arch Surg. 1998;133(8):8628666)Ramakantan R, Bandekar V G, Gandhi M S, Aulakh B G, Deshmukh H L. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology. 1996;200(3):691694.