[Bronchial artery embolization with polyvinyl alcohol foam and gelatinum sponge for serious hemoptysis]

OBJECTIVE

To evaluate the effect of bronchial artery embolization (BAE) with polyvinyl alcohol (PVA) foam and gelatinum sponge (GS) for serious hemoptysis.

METHOD

Of 46 patients with severe hemoptysis, BAE with only GS was performed in 21 cases and with both PVA and GS in 25 cases.

RESULT

The total efficacy rate of BAE was 91.3%; and comparable between PVA+GS and GS groups (92.0%; vs 90.5%;, P>0.05). The total recurrence rate after BAE was 26.2%;, but lower in PVA+GS group than in GS group (11.3%; vs 42.1%;, P<0.05). No serious complications occurred in these patients after BAE.

CONCLUSION

BAE is effective and safe for management of serious hemoptysis, and treatment with PVA+GS may effectively lower the recurrence rate.

Bronchialarterien-Embolisation mit Platin-Coils bei 52 Patienten mit schwerer pulmonaler Blutung

BACKGROUND

Severe pulmonary hemorrhage ist life-threatening. One of the treatment options in case of severe pulmonary hemorrhage is bronchial artery embolisation (BAE) with different embolisation materials.

PATIENTS AND METHODS

Efficacy of BAE using platinum coils was investigated retrospectively in a total of 52 patients. 22 suffered from benign lung diseases (angiodysplasia, inflammation, bronchiectasia) and 30 patients had lung cancer (lung metastases in two cases).

RESULTS

Primary hemostasis was achieved in over 90 % of the patients (47 of 52). Recurrent BAE was necessary in 23 % of patient with benign etiologies and in 50 % of the tumor patients. Comparing the results of the lung cancer patients with a control group from a teaching hospital without BAE we found survival-advantages for those patients treated with BAE.

CONCLUSION

Our results underline the usefulness of BAE in severe pulmonary hemorrhage.

Major haemoptysis in children with cystic fibrosis: a 20-year retrospective study

BACKGROUND

Major haemoptysis occurs in approximately 1% of children with cystic fibrosis (CF). This report describes management and follow-up of these children at a tertiary centre in Australia.

METHODS

Retrospective review of medical records from 1980-1999.

RESULTS

Fifty-one children (45% female) had major haemoptysis (102 episodes). Mean age at first episode was 15 years (range 7-19) and mean FEV(1) was 56% predicted (range 14-98). Massive life-threatening haemoptysis was not confined to those with severe lung disease (FEV1 < 50% predicted). Bronchial artery embolisation (BAE) was more likely to be the initial treatment for those with massive haemoptysis and chronic recurrent bleeding tended to be treated conservatively (P = 0.01). Overall, 52 BAE were performed in 28 children with an immediate success rate of 98%; 13 children (46%) had repeated BAE. Four patients died as a direct result of severe haemoptysis. Mean follow-up was 54 months (range 0.5-183). Median survival time (Kaplan-Meier estimate) after first haemoptysis was 70 months, with a significantly longer survival for male patients independent of age (RR 3.8; 95% CI 1.7-8.8; P = 0.001). Median survival time following initial treatment with BAE was longer (103 months) compared to conservative treatment (52 months, P = 0.09).

CONCLUSIONS

Massive haemoptysis was unrelated to the severity of lung disease and was more likely to be treated with embolisation. BAE was highly effective, however, 46% of the children required re-embolisation at some time, which is similar to the recurrence risk for major hemoptysis treated conservatively on longer term follow-up.

[Evaluation of bronchial arterial infusion (BAI) for metastatic lung tumor from colorectal cancer]

Three cases of metastatic lung tumor from colorectal cancer with an ineffectual systemic chemotherapy were examined based on the therapeutic effectiveness and safety of bronchial infusion (BAI) as a symptomatic therapy. Two out of three cases were rectal cancer and the third case being ascending colon cancer. After the operations, each of the three cases showed a multiple lung metastases recurrence at the primary and metastatic lesions of the lung. The lung metastases became large in size and thoracic symptoms (severe cough, chest pain) appeared in spite of the systemic chemotherapy of CPT-11, 5-FU and CDDP. A low dosage of BAI was administered by using CPT-11 (40 mg/m2) + CDDP (40 mg/m2) as one shot, and was repeated (three and six times respectively) for the two cases. When the low dosage of BAI was administered, there were light side effects and no complications were observed. The average hospital stay was 7.8 days. All three patients were stable and showed improvement in the condition of the disease. The prognoses from the first BAI were 3, 6, and 9 months in all three cases, respectively. BAI using low dosage of anti-cancer agents was effective, as means of improving the chest condition and quality of life in patients with metastatic lung tumor from colorectal cancer, with an ineffectual systemic chemotherapy.

[Application of interlocking detachable coil (IDC) in superselective bronchial artery embolization]

Bronchial artery embolization (BAE) is almost the only effective nonsurgical treatment for massive hemoptysis. Metallic coils with plastic fibers are widely used as embolic materials. We have introduced an interlocking detachable coil (IDC) for BAE. IDC is a mechanically detachable coil, allowing the operator to seek the ideal shape until its final release. We compared hemoptysis patients treated with conventional metallic coils (24 patients, non-IDC group) with those treated with conventional coils and IDCs (26 patients, IDC group). The hemoptysis rate after three months is significantly lower in the IDC group than in the non-IDC group (7.7% vs. 16.3%, p = 0.035 Fisher's exact method). Total procedure time (in staged or repetitive BAE cases, procedure times are added together) is significantly shorter in the IDC group than in the non-IDC group (3.4 +/- 1.4 hours vs. 4.4 +/- 2.5 hours, p = 0.040 unpaired t-test). IDC is a useful device for BAE. This is the first-ever report documenting the usefulness of IDC for BAE.

[Bronchial bleeding]

The acute and general management of patients with massive hemoptysis is described. Initial priorities are insuring adequate airway protection, ventilation, and cardiovascular function. Major priorities of ongoing hemoptysis to prevent gas exchange are intubation with a large bore endotracheal tube and protection of nonbleeding lung by selective intubation into nonbleeding main stem bronchus. Once the patient stabilized, bronchoscopic procedure to stop bleeding following by bronchial arterial embolization should be planned. While surgery remains only definitive therapy, it should not be used in the acute emergent setting unless it cannot be avoided. Bronchial artery and other feeding arteries in the chest wall should be shut off before surgery to prevent massive bleeding during operation.

Soluble gas exchange in the pulmonary airways of sheep

We studied the airway gas exchange properties of five inert gases with different blood solubilities in the lungs of anesthetized sheep. Animals were ventilated through a bifurcated endobronchial tube to allow independent ventilation and collection of exhaled gases from each lung. An aortic pouch at the origin of the bronchial artery was created to control perfusion and enable infusion of a solution of inert gases into the bronchial circulation. Occlusion of the left pulmonary artery prevented pulmonary perfusion of that lung so that gas exchange occurred predominantly via the bronchial circulation. Excretion from the bronchial circulation (defined as the partial pressure of gas in exhaled gas divided by the partial pressure of gas in bronchial arterial blood) increased with increasing gas solubility (ranging from a mean of 4.2 x 10(-5) for SF6 to 4.8 x 10(-2) for ether) and increasing bronchial blood flow. Excretion was inversely affected by molecular weight (MW), demonstrating a dependence on diffusion. Excretions of the higher MW gases, halothane (MW = 194) and SF6 (MW = 146), were depressed relative to excretion of the lower MW gases ethane, cyclopropane, and ether (MW = 30, 42, 74, respectively). All results were consistent with previous studies of gas exchange in the isolated in situ trachea.

Carinal resection after induction bronchial arterial infusion for locally advanced non-small cell lung cancer

We herein describe 3 cases of a carinal resection after induction bronchial arterial infusion (BAI) for locally advanced non-small cell lung cancer (NSCLC). Case 1 was a 44-year-old man with T1N2M0 adenocarcinoma. After undergoing Nd-YAG laser treatment (5079 J) and BAI [cis-diamminedichloro platinum (CDDP) 100 mg/body], a right sleeve upper lobectomy with a carinal resection and reconstruction (Montage type) was performed. Case 2 was a 67-year-old man with T4N1M0 squamous cell carcinoma. After BAI (CDDP 120 mg/body), an operation (same as case 1) was performed. Case 3 was a 72-year-old man with T4N2M0 squamous cell carcinoma. After BAI (CDDP 120 mg/body), a right sleeve peumonectomy was performed. There was neither BAI-related intraoperative nor postoperative complications. BAI with CDDP was thus found to be a useful and effective therapeutic modality for locally advanced NSCLC invading the carina.

[Clinical benefit of bronchial arterial infusion chemotherapy to pulmonary metastasis from colorectal cancer--report of two cases]

Case 1: A 60-year-old woman with sigmoid colon cancer and multiple lung metastases developed dyspnea 34 months after sigmoidectomy and following systemic chemotherapy. Chest X-ray revealed left atelectasis and obstruction of the left main bronchus by lung metastasis, and stenosis of the right main bronchus was also suspected. Bronchial arterial infusion of CDDP, 5-FU and MMC relieved the atelectasis and dyspnea. The left bronchus remained patent for 12 months. Case 2: A 70-year-old man who had a pulmonary recurrence of rectal cancer suffered from hemoptysis and dyspnea, which had improved with systemic chemotherapy but then become exacerbated again. Bronchoscopic examination revealed intraluminal bleeding from a metastatic tumor. The symptoms were relieved after bronchial arterial infusion of CDDP, 5-FU and MMC. The diameter of the treated tumor was reduced by 15%. Hemoptysis was negligible until he died 8 months later. Bronchial arterial infusion chemotherapy for pulmonary metastasis from colorectal cancer is clinically beneficial, especially for patients with life-threatening respiratory symptoms like airway obstruction or intraluminal bleeding.

Mediastinal bronchial artery aneurysm with hematemesis

Mediastinal bronchial artery aneurysm is a rare condition which can lead to potentially fatal hemorrhage. In most cases it presents respiratory symptoms due to rupture into pleural parenchyma. But when it develops mediodorsally and compresses the esophagus, it may cause dysphagia or hematemesis. Here we report a case of mediastinal bronchial artery aneurysm which presented with hematemesis. Computed tomography and endoscopic ultrasound showed what seemed to be a submucosal tumor on the esophagus. We were able to correctly diagnose the aneurysm using magnetic resonance imaging and probe thoracoscopy, and were able to successfully treat with transluminal artery embolization.

[Ruptured bronchial artery aneurysm; report of a case]

A 74-year-old man who went into shock following an acute hemomediastinum and left hemothorax was operated on. Postoperative angiographies revealed a saccular aneurysm of the left bronchial artery of 2.0 cm in diameter. Sixty days after the initial operation, the aneurysm was resected under F-F bypass. A saccular aneurysm was found at the root of the left bronchial artery, which had a very short segment between the aneurysm and the aorta. Pathological study of aneurysm revealed thinning of the wall and lack of tunica media.

[Hemoptysis]

Hemoptysis is a common respiratory symptom that always requires investigation. Its severity varies from bloodstained sputum to life-threatening hemoptysis. Blood originates most often from bronchial circulation. The most common causes of hemoptysis are tuberculosis, lung carcinoma, bronchiectasis but idiopathic forms are frequent. The diagnostic investigation is based mainly on history, chest radiograph, fibroscopy and CT scan of the thorax. The goal is to determine the cause as well as the site of bleeding. The management of life-threatening hemoptysis is mainly based on either surgical approach or bronchial artery embolization. The majority of centers favor this latter approach.

Massive hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT

PURPOSE

To evaluate the diagnostic accuracy of chest computed tomography (CT) in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis.

MATERIALS AND METHODS

Forty consecutive patients with massive hemoptysis underwent contrast material-enhanced CT. Massive hemoptysis was defined as the expectoration of 300-600 mL of blood per day. Two CT features were considered to be suggestive of a nonbronchial systemic arterial supply: (a) pleural thickness of more than 3 mm adjacent to the parenchymal lesion and (b) enhancing vascular structures within the extrapleural fat layer. Conventional angiography was used as the standard of reference. CT scans were evaluated by two radiologists in consensus. The CT findings were compared with those of conventional angiography. The sensitivity, specificity, predictive values, and accuracy of CT for predicting the presence of a nonbronchial systemic arterial supply were assessed.

RESULTS

In the determination of a nonbronchial systemic arterial supply, CT had a sensitivity of 80%, specificity of 84%, positive predictive value of 73%, negative predictive value of 91%, and accuracy of 84%. Sensitivity was highest for predicting the branches of subclavian and axillary arterial supply and was lowest for predicting the internal mammary arterial supply. Specificity and accuracy were highest for predicting the intercostal arterial supply.

CONCLUSION

CT demonstrates acceptable sensitivity, specificity, and accuracy in the prediction of a nonbronchial systemic arterial supply in patients with massive hemoptysis.

Angiographic findings and surgical treatments of coronary artery involvement in Takayasu arteritis

BACKGROUND

Takayasu arteritis is associated with a low incidence of coronary artery involvement, such as stenosis, obstruction, aneurysm, and coronary steal syndrome, but coronary ischemia can be fatal.

METHODS

Between 1972 and April 2001, 81 of 130 patients given a diagnosis of Takayasu arteritis underwent selective coronary angiography, and among them, 31 patients (4 male and 27 female patients; mean age, 41.1 +/- 13.2 years) had abnormal coronary angiographic findings and were recruited for this study.

RESULTS

Abnormal coronary findings consisted of 24 coronary artery stenoses of greater than 75%, 3 coronary artery-bronchial artery anastomoses, 3 aneurysmal coronary ectasias, and 1 combined coronary ectasia and anastomosis. Among 24 patients with coronary stenosis, the ostium was most frequently involved (87.5%). Twenty-three of 24 patients with coronary artery stenoses were treated surgically. The mean follow-up duration was 9.65 +/- 6.9 years, with a 100% follow-up rate. Four fistulas and 4 aneurysms in 7 patients were not treated surgically. Coronary steal phenomenon was always associated with occluded pulmonary arteries and pulmonary hypertension. Aneurysmal coronary ectasia was related to severe aortic hypertension with or without aortic regurgitation and atypical coarctation. There were 2 (8.7%) in-hospital deaths and 3 (13%) late deaths. The actuarial survival rate, including in-hospital deaths, was 86.5% +/- 7.3% at 5 years and 81.4% +/- 8.4% at 10 years.

CONCLUSION

The incidence of coronary abnormalities is relatively low in patients with Takayasu arteritis; however, surgical treatment is recommended for patients with coronary ostial stenoses because coronary ischemia can be one of the major causes of death.

[A case of pulmonary actinomycosis with recurrent hemoptysis]

A 68-year-old man was admitted to our hospital because of hemoptysis in September 1999. Chest CT scans showed a nodular shadow with infiltration in the right S 7. Bronchial arteriography showed vascularization in the right S 7, and bronchial artery embolization was performed. However, in April and October 2000 hemoptysis recurred, and bronchial arteriography showed recurrence of vascularization in the same area, so embolization was performed again. Then, the patient was admitted in March 2001 because of recurrent hemoptysis. CT scans showed growth of the nodular shadow. Right lower lobectomy was performed, and the microscopic findings in the tissue from the resected lobe showed branching filamentous bacteria, and pulmonary actinomycosis was diagnosed. We concluded that pulmonary actinomycosis should be considered in the differential diagnosis of nodular shadows with recurrent hemoptysis.