Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review

Renal and splenic micro-infarctions following bronchial artery embolization with tris-acryl microspheres

A bronchial artery embolization (BAE) is an important therapeutic method used to control acute and chronic hemoptysis. We report a case of multiple micro-infarcts involving both the kidneys and spleen, following a BAE with 500-700 µm crossed-linked tris-acryl microspheres (Embospheres) in a patient with bronchial artery pulmonary vein shunts. The superior penetration characteristics of the microspheres may have resulted in the greater tendency to cross the bronchial artery pulmonary vein shunts, which subsequently caused the systemic infarcts in our patient. We propose the use of larger sized microspheres (700-900 µm), which may aid in avoiding this complication.

Transarterial microcatheter glue embolization of the bronchial artery for life-threatening hemoptysis: technical and clinical results

OBJECTIVES

To report our experience with transarterial glue embolization of the bronchial artery for life-threatening hemoptysis.

MATERIALS AND METHODS

Twenty-five patients underwent bronchial artery embolization, using coaxial microcatheter technique, with a liquid agent, n-butyl-2-cyanoacrylate (NBCA), named glue, for life-threatening hemoptysis. The technical and clinical outcomes were followed in terms of immediate control of bleeding, recurrence of hemoptysis and complications of the procedure.

RESULTS

Four patients had acute hemoptysis when they were evaluated. The average number of arteries embolized per patient was 2.9. BAEs were successful in controlling hemoptysis immediately in all 25 patients (100%) and in 24 patients (96%) at 1 month follow-ups. One patient had recurrent hemoptysis on the tenth day after embolization. The follow-up time ranged from 2 to 63 months (mean 14 months). Six patients (25%) died all as a result of their disease process. Bleeding recurred in 3 patients after 30 days (7th, 11th, 12th months). One patient had vomitting attacks with dysphagia after the procedure that lasted 24h. Three patients had transient thoracic pain lasting 3-5 days. There were no procedure related spinal or vascular complications.

CONCLUSIONS

Glue embolization with microcatheter technique is a safe and effective treatment in cases of life-threatening hemoptysis with a very high rate of success and low rate of complications.

Isolated absence of the right pulmonary artery as a cause of massive hemoptysis

Isolated absence of a pulmonary artery is a rare cause of massive hemoptysis. We report a case of unilateral absence of the right pulmonary artery in an adult without any other cardiovascular anomalies. The patient presented massive hemoptysis, which was successfully treated with a right pneumonectomy.

Bronchial artery embolization with detachable coils for the treatment of haemoptysis. Preliminary experience

PURPOSE

This paper reports our early experience in the treatment of haemoptysis with embolization of the bronchial arteries using detachable coils.

MATERIALS AND METHODS

Ten patients (mean age 45 years, range 23-83) with haemoptysis due to bronchoscopic biopsy of indeterminate lung nodules, lung cancer, tubercular bronchiectasis, cystic bronchiectasis or sarcoidosis underwent embolization of the bronchial arteries responsible for the bleeding using detachable coils. Patients were followed-up for a median of 14 months.

RESULTS

In all patients the procedure halted the bronchial bleeding within 24 hours. Eight patients had no recurrence of haemoptysis. In one patient with lung cancer and another with sarcoidosis, haemoptysis recurred within 1-3 months due to recruitment of additional feeding arteries and to a missed large feeding artery originating from the subclavian artery, which required a new procedure.

CONCLUSIONS

Use of detachable coils for embolization of bronchial arteries in patients with haemoptysis is advantageous since it eliminates the risk of migration typical of other embolic materials and enables rapid and permanent vessel occlusion.

Coronary-to-bronchial artery fistula: demonstration by 64-multidetector computed tomography with retrospective electrocardiogram-gated reconstructions

OBJECTIVE

The aim of this study was to evaluate the incidence of coronary-to-bronchial artery fistula (CBF) and clinical significance in 1300 patients examined with 64-multidetector computed tomography (MDCT) coronary angiography.

METHODS

One thousand three hundred ten patients underwent coronary MDCT for atypical chest pain or screening. Volume-rendering and multiplanar reconstruction images were reviewed, and subsequent cineangiographies were compared.

RESULTS

Eight cases of CBF were detected-6 originated from the left circumflex artery, and 2 originated from the right coronary artery. A hypertrophied anomalous branch of left circumflex artery was observed in 1 case, and underlying bronchiectasis was noted. Seven cases had a thin-wall communicating vessel. Subsequent cineangiography revealed identical appearance with MDCT reconstruction images.

CONCLUSIONS

The incidence of CBF (0.61%) in this study is similar to those of a few cineangiographic studies in the literature. Our study showed that 64-MDCT coronary angiography is an accurate and noninvasive tool for detection of CBF.

Pulmonary artery access embolization in patients with massive hemoptysis in whom bronchial and/or nonbronchial systemic artery embolization is contraindicated

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 possible. 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 systemic arteries and 7 patients were embolized via pulmonary artery. Femoral arterial access for systemic artery catheterization 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.

Pre-existing left pulmonary artery stenosis and other anomalies associated with device occlusion of patent ductus arteriosus

A retrospective analysis was performed on 200 consecutive patients who underwent cardiac catheterization for occlusion of Patent Ductus Arteriosus (PDA) at a single center by a single operator. Four significant anomalies were observed: pre-existing Left Pulmonary Artery (LPA) stenosis, left recurrent laryngeal nerve (LRLN) injury, electrocardiogram (EKG) changes, and aorto-pulmonary (AP) collateral arteries. The observation of pre-existing LPA stenosis, marked EKG changes, and permanent LRLN injury have not been previously reported. Incidence, etiology, and clinical significance of these anomalies are discussed with specific new recommendations for the prevention of LRLN injury and occlusion of AP collaterals.

Pulmonary arterial thrombosis in eisenmenger syndrome is associated with biventricular dysfunction and decreased pulmonary flow velocity

OBJECTIVES

This study sought to determine what factors are associated with pulmonary artery thrombi in Eisenmenger patients.

BACKGROUND

Pulmonary artery thrombosis is common in Eisenmenger syndrome, although its underlying pathophysiology is poorly understood.

METHODS

Adult patients with Eisenmenger syndrome underwent computed tomography pulmonary angiography, cardiac magnetic resonance imaging, and echocardiography. Measurement of ventricular function, pulmonary artery size, and pulmonary artery blood flow were obtained. Hypercoagulability screening and platelet function assays were performed.

RESULTS

Of 55 consecutive patients, 11 (20%) had a detectable thrombus. These patients were older (p = 0.032), but did not differ in oxygen saturation, hemoglobin, or hematocrit from those without thrombus. Right ventricular ejection fraction by magnetic resonance imaging was lower in those with thrombus (0.41 +/- 0.15 vs. 0.53 +/- 0.13, p = 0.017), as was left ventricular ejection fraction (0.48 +/- 0.12 vs. 0.60 +/- 0.09, p = 0.002), a finding corroborated by tissue Doppler and increased brain natriuretic peptide. Those with thrombus also had a larger main pulmonary artery diameter (48 +/- 14 mm vs. 38 +/- 9 mm, p = 0.007) and a lower peak systolic velocity in the pulmonary artery (p = 0.003). There were no differences in clotting factors, platelet function, or bronchial arteries between groups. Logistic regression showed pulmonary artery velocity to be independently associated with thrombosis.

CONCLUSIONS

Pulmonary arterial thrombosis among adults with Eisenmenger syndrome is common and relates to older age, biventricular dysfunction, and slow pulmonary artery blood flow rather than degree of cyanosis or coagulation abnormalities. Further work to define treatment efficacy is needed.

Right thyrocervical trunk bronchial artery collateral: source of type II Endoleak after endovascular repair of thoracic aortic aneurysm

A patient with an enlarging thoracic aortic aneurysm (TAA) after endovascular repair showed a persistent endoleak on follow-up imaging at three and six months. He subsequently underwent angiography and transcatheter embolization of a right thyrocervical trunk bronchial collateral. Examination of potential anomalous or collateral thoracic pathways is mandatory when considering treatment of a Type II endoleak following endovascular TAA repair.

Delirium due to Brain Microembolism: Diagnostic Value of Diffusion-Weighted MRI

Delirum is a common complication in hospitalized patients and it is characterized by acute disturbances of consciousness, attention, cognition, and perception. Despite the frequency with which it is observed, ischemic stroke is generally considered as an unusual cause of delirium. A subtype of brain embolism is characterized by multiple small emboli in different vascular territories, a condition known as "brain microembolism." Given the high contrast of acute ischemic lesions in diffusion weighted imaging (DWI) this technique is particularly helpful to detect these small infarctions. We present here a patient with pulmonary metastases who was treated with bronchial artery embolization and who subsequently developed delirium due to brain microembolism. The embolic material crossed through pulmonary arteriovenous fistulas, producing multiple areas of cerebral ischemia. The ischemic lesions could be visualized only on DWI, and they affected the periventricular region, caudate nucleus, thalamus, and cerebellum.

Role of MDCT in Identification of the Bleeding Site and the Vessels Causing Hemoptysis

OBJECTIVE

MDCT has improved the management of hemoptysis by providing more precise depiction of bronchial and nonbronchial systemic arteries than conventional CT. The purpose of this article is to review the role of MDCT in the identification of the bleeding site and the vessels causing hemoptysis.

CONCLUSION

Identification of the origin of the involved systemic arteries (bronchial and nonbronchial) or involved pulmonary artery on MDCT enables the interventional radiologist to treat them, especially in elderly patients with a tortuous aorta and atheroma.

Bronchial artery arising from the left gastric artery in a patient with massive haemoptysis

This report describes a bronchial artery originating from the left gastric artery in a patient with recurrent massive haemoptysis caused by chronic pulmonary tuberculosis. The artery was not evident on the initial angiographic work-up including thoracic aortography, but it was evident in the selective angiography upon follow-up study. Haemoptysis was successfully controlled with transarterial embolisation. The left gastric artery should be included as a location for the possible origin of the bronchial artery.

Release of ibuprofen from beads for embolization: In vitro and in vivo studies

Ibuprofen (IBU) loaded polyvinyl alcohol-based hydrogel beads (IBU-BB) were designed to alleviate side effects such as inflammation and pain following uterine artery embolization for the treatment of leiomyomata. The present in vitro and in vivo study examines whether IBU-BB provide a sustained-release of the drug. In vitro release studies of IBU from IBU-BB (10, 50, 100 mg/mL), IBU solution (PEDEA) and IBU powder were compared using the T apparatus and the beaker method. The pharmacokinetic profile of IBU release was examined in vivo, following sheep uterine artery embolization with 100 mg/mL IBU-BB or after intra-arterial injection of IBU solution. IBU-BB can deliver high concentrations of the drug over time. The in vitro release from IBU-BB was markedly slower compared to IBU solution. Increasing the concentration of loaded IBU from 10 to 100 mg/mL decreased the rate of release. IBU release from the T apparatus was slower than the release in the beaker. In vivo, the release of the drug was progressive, without the early peak observed with IBU solution. A high level of correlation was obtained between in vivo and in vitro (T apparatus) results. Theoretically, IBU-BB could sustainably release high concentrations of IBU at the site of the uterine fibroids, which makes it a promising approach for the control of post-embolization pain.

Microcatheter placement through a side hole created in a 5-F catheter into proximal subclavian arterial branches causing hemoptysis

Five patients with moderate to massive hemoptysis who had a bronchial artery of anomalous origin or a nonbronchial systemic artery originating from the proximal subclavian artery underwent microcatheter placement through a created side hole of a 5-F catheter. All patients had pulmonary tuberculosis and had undergone bronchial artery embolization for hemoptysis. The side holes were made in the lesser (n = 2) or greater curvature sides (n = 3) of 5-F nonbraided Headhunter catheters. A microcatheter was passed through the side hole of the 5-F catheter into the target artery for embolization. Polyvinyl alcohol particles were used as the embolic material. The technical success rate was 100%, and immediate control of hemoptysis was achieved in all patients without complication.

Prediction of Recurrent Hemoptysis With MDCT Angiography

OBJECTIVE

To identify the computed tomography (CT) findings to predict recurrent bleeding in patients with massive hemoptysis.

METHODS

Fifty-eight patients with massive hemoptysis underwent both CT and conventional bronchial angiography for bronchial artery embolization. Retrospective analysis was done to analyze the statistical differences in the initial CT findings between the nonrecurrent and recurrent hemoptysis groups using the Mann-Whitney U test and the chi or Fisher exact test. Stepwise logistic regression analysis was used to find predictive variables for the recurrence of hemoptysis.

RESULTS

After embolization, recurrence of hemoptysis was observed in 15 of 58 patients (26%). The diameter of bronchial (P = 0.001) and nonbronchial systemic arteries (P < 0.05), total number of dilated bronchial and nonbronchial systemic arteries (P = 0.001), pleural thickening (P = 0.01), extrapleural fat thickening (P = 0.004), and enhancing vascular structures within the extrapleural fat layer (P = 0.04) were significantly different in the nonrecurrent and recurrent hemoptysis groups. Stepwise logistic regression analysis showed that the total number of dilated bronchial and nonbronchial systemic arteries (odds ratio, 3.540; 95% confidence interval: 1.175, 10.662; P = 0.025) was a significant CT variable associated with the recurrence of hemoptysis.

CONCLUSIONS

CT bronchial angiography may help in the prediction of recurrent bleeding in patients with massive hemoptysis.

Eisenmenger syndrome: medical prevention and management strategies

The original definition of Eisenmenger syndrome refers to an unrestrictive post-tricuspid valve congenital systemic-to-pulmonary shunt. When the pulmonary arterial systolic pressure becomes equal to the systemic arterial systolic pressure, the direction of the shunt becomes pulmonary-to-systemic. The latter leads to progressive cyanosis, and exercise intolerance is initially proportional to the degree of hypoxaemia. Later, congestive heart failure may occur . The management principle is to avoid any factors that destabilise this delicately balanced physiology. Until recently, this could only be achieved by symptomatic therapy; however, when patients are severely incapacitated, transplantation is needed. At present, new drugs, which are more selective pulmonary vasodilators, are available to interfere with the ongoing disease process to improve functional capacity and delay the decision for transplantation.

Bronchial arterial imaging using helical computed tomography

The bronchial arteries, which provide the systemic arterial supply to the lungs, are involved in a variety of disease processes in humans, including congenital disorders, infection, and pulmonary thromboembolism. In these conditions, the bronchial arteries hypertrophy and bronchial blood flow increases. Consequently, in many disorders, such as bronchiectasis, the bronchial arteries are a frequent source of haemoptysis, which may be massive and life-threatening. Evaluation of the bronchial circulation has typically required invasive imaging with angiography to determine the location of bleeding. Non-invasive assessment of bronchial arterial anatomy and morphology is currently being investigated with the use of helical computed tomography (CT). We evaluated eight patients with various lung diseases with helical CT (GE Medical Systems, LS16, Milwaukee, WI) to determine the imaging features of the bronchial circulation. Non-ionic contrast medium (iopromide) was injected intravenously (80-1000ml/30s) and scanning was triggered once contrast material was present in the pulmonary artery (average delay=15s) or ascending aorta (average delay=20s). Detector collimation (16-row unit) was 10mm. Imaging parameters included a section thickness of 0.6mm, kilovolt peak of 120, 150-440mA, pitch factor of 1.375, matrix of 512x512, and tube rotation time of 0.8s. The images were reconstructed and scanned isotropically (Advantage Workstation 4.1,GE Medical Systems). We conclude that helical computed tomography may provide a non-invasive means of evaluating the bronchial arteries and their role in pulmonary disease processes.

Bronchial and nonbronchial systemic arteries in patients with hemoptysis: depiction on MDCT angiography

OBJECTIVE

In this pictorial essay, we show the usefulness of MDCT angiography for visualization of the bronchial and nonbronchial systemic feeder vessels responsible for hemoptysis.

CONCLUSION

By providing thin-section transaxial, multiplanar reconstruction, and 3D images, CT angiography using MDCT allows comparable or better images than conventional angiography with respect to the depiction of bronchial or nonbronchial systemic arteries. CT angiography is particularly useful for visualizing the ectopic origin of bronchial arteries and nonbronchial systemic collateral arteries.

Multi-detector row CT of hemoptysis

Hemoptysis is symptomatic of a potentially life-threatening condition and warrants urgent and comprehensive evaluation of the lung parenchyma, airways, and thoracic vasculature. Multi-detector row computed tomographic (CT) angiography is a very useful noninvasive imaging modality for initial assessment of hemoptysis. The combined use of thin-section axial scans and more complex reformatted images allows clear depiction of the origins and trajectories of abnormally dilated systemic arteries that may be the source of hemorrhage and that may require embolization. Conditions such as bronchiectasis, chronic bronchitis, lung malignancy, tuberculosis, and chronic fungal infection are some of the most common underlying causes of hemoptysis and are easily detected with CT. "Cryptogenic" hemoptysis is common among smokers and warrants subsequent follow-up imaging to exclude possible underlying malignancy. The bronchial arteries are the source of bleeding in most cases of hemoptysis. Contributions from the non-bronchial systemic arterial system represent an important cause of recurrent hemoptysis following apparently successful bronchial artery embolization. Vascular anomalies such as pulmonary arteriovenous malformations and bronchial artery aneurysms are other important causes of hemoptysis. Multi-detector row CT angiography permits noninvasive, rapid, and accurate assessment of the cause and consequences of hemorrhage into the airways and helps guide subsequent management.

Treatment of SVC syndrome and hemoptysis in a patient with mediastinal fibrosis

Mediastinal fibrosis can present with a multitude of symptoms, most commonly cough, dyspnea and hemoptysis. We describe a case of mediastinal fibrosis secondary to histoplasmosis, which presented with both superior vena cava syndrome (SVCS) and hemoptysis. Our patient was successfully treated with bronchial artery embolization followed by SVC stent placement during a brief hospital stay.

Endovascular Treatment of Massive Hemoptysis by Bronchial Artery Embolization: Short-Term and Long-Term Follow-Up Over a 15-Year Period

OBJECTIVE

To present our experience of using arterial embolization for the endovascular treatment of massive hemoptysis along with the results of follow-up over a 15-year period.

PATIENTS AND METHODS

A total of 401 patients with hemoptysis were referred to the minimally invasive surgery unit of the Hospital Universitario Lozano Blesa de Zaragoza between April 1989 and September 2004 for diagnosis and possible endovascular treatment. Of those patients, 314 met criteria for massive hemoptysis and treatment was attempted using embolization in 287 (91.4%). The most common cause of hemoptysis was bronchiectasis (n=99, 31.5%), followed by lesions due to tuberculosis (n=57, 18.1%) and chronic bronchitis (n=47, 14.9%).

RESULTS

Angiography of the bronchial arteries provided evidence to account for the hemoptysis in 287 patients (91.4%). The affected arteries were satisfactorily embolized in 281 (97.9%). Endovascular treatment was clinically successful in 256 of those patients (91.1%). Embolization had to be repeated during the hospital stay in 19 patients (6.7%) and was effective in 52.6% of those cases. The 6 patients in whom embolization was not satisfactory underwent thoracotomy. The mean follow-up in 201 patients (71.5%) was 2372.5 days (range, 61-5475 days). Eighty patients (28.4%) were lost to follow-up for various reasons and at different points. Recurrence of hemoptysis occurred on 1 or more occasions in 45 patients (22.3%) but only 21 (10.4%) required repeat embolization. Minor complications that did not require treatment were observed in 88 patients (28.0%).

CONCLUSIONS

Embolization of bronchial arteries is a nonsurgical treatment that is safe and effective in patients with massive hemoptysis.

L’hémoptysie massive : prise en charge et traitement Quelle est la place de la chirurgie ?

OBJECTIVE

To define the role of interventional radiology and surgery respectively, in the treatment of massive haemoptysis. GENERAL CONSIDERATIONS: For the management of massive haemoptysis in non-terminal pathologies an intensive care facility and a multi-disciplinary team are necessary. It is of paramount importance to identify rapidly the pulmonary or bronchial source of the bleeding. CT scanning and bronchoscopy are essential to localise the bleeding and determine its cause. Initial management. An attempt to control the initial bleeding to allow localisation of its origin and determine the treatment.

TREATMENT

Bronchial or systemic embolisation and surgery are the only effective medium and long-term treatments. Embolisation achieves excellent results in bleeding from bronchial or parietal systemic arteries prior to surgery and may be the only technique possible in the presence of major co-morbidity. Surgery is necessary in the case of failure, in certain specific conditions, and in the case pulmonary artery haemorrhage from a proximal lesion. Various surgical techniques are available depending on the type of lesion encountered and the facilities for post-operative care. Emergency surgery carries a high risk and deferred surgery gives better results.

CONCLUSION

The management of massive haemoptysis should be multi-disciplinary. Intensive care, respiratory and radiological diagnosis, Surgical management and interventional radiology should be combined to improve the prognosis of this grave condition. Pulmonary arterial haemorrhage from a necrotic tumour constitutes a surgical emergency and should be operated on without delay.

Bronchial Artery Embolization for Life-Threatening Hemoptysis Using Tris-Acryl Microspheres: Short-Term Result

A prospective study of 70 patients with life-threatening hemoptysis who had bronchial and systemic artery embolization with tris-acryl linked microspheres was performed over 15 months. The procedure was technically successful in 90% of patients and at 24 hr after the procedure (87%). Recurrent hemoptysis occurred in 13% of patients within the first week. Chest pain was experienced following embolization in 7% of patients. The mortality was 10% due to the inclusion of patients with pulmonary metastases. Bronchial artery embolization using microspheres is an effective and well-tolerated treatment for patients with life-threatening hemoptysis who are not surgical candidates.

Severe hemoptysis from dilated systemic aberrant arteries supplying normal lung segments

Hemoptysis is an uncommon presentation in children. It can be caused by several systemic and pulmonary disorders. Bleeding from an anomalous arterial supply to normal lung segments with no underlying pulmonary or cardiovascular disorders was widely reported in adults but is extremely rare in the pediatric age group. Here we describe 4 previously normal children and one girl with chronic lung disease, secondary to bronchopumonary dysplasia, with acute and significant hemoptysis of variable severity. Extensive clinical and laboratory investigations did not identify any reasonable causes for their symptoms. Cardiac catheterization showed dilated anomalous systemic arteries that supplied a pulmonary arteriovenous malformation in one case and normal basal lung segments in the other 4 cases. Embolization of the anomalous arterial collaterals led to occlusion of these arteries and the cessation of further hemoptysis.

Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT

PURPOSE

To retrospectively evaluate 16-detector row computed tomography (CT) compared with conventional angiography in depiction of bronchial and nonbronchial systemic arteries in patients with hemoptysis.

MATERIALS AND METHODS

Institutional review board approval was obtained, and informed consent was not required. Sixteen-detector row helical CT and conventional angiography of the thorax were performed in 22 patients (16 men, six women; age range, 18-75 years; mean age, 50 years) with hemoptysis. Three observers in consensus analyzed retrospectively transverse, multiplanar reconstruction, or three-dimensional CT images for visibility, traceability of bronchial arteries from their origin at the aorta or aortic branches to the hilum, and presence of nonbronchial systemic arteries. CT and angiographic findings of bronchial and nonbronchial systemic arteries causing hemoptysis were compared by two radiologists in consensus. Differences in visibility, traceability, and diameter of bronchial arteries causing and those not causing hemoptysis were tested by using generalized estimating equation method or the mixed model.

RESULTS

Fifty-two (30 right and 22 left) bronchial arteries and 33 nonbronchial systemic arteries were visible at CT. Thirty-four (20 right and 14 left) of 52 bronchial arteries were traceable from their origins to the hilum. Thirty-one (16 right and 15 left) of 46 (27 right and 19 left) bronchial arteries and 26 of 64 nonbronchial systemic arteries evaluated at angiography were causing hemoptysis. Forty (87%, 23 right and 17 left) of 46 bronchial arteries seen at angiography were also detected at CT. All 31 bronchial arteries and sixteen (62%) of 26 nonbronchial systemic arteries causing hemoptysis were detected at CT. Twenty-three (74%) of 31 bronchial arteries causing hemoptysis were traceable from their origins to the hilum, and one (11%) of nine bronchial arteries not causing hemoptysis was traceable (P = .002).

CONCLUSION

Sixteen-detector row CT provides depiction and traceability of the bronchial arteries in patients with hemoptysis, and in most patients it enables detection of the bronchial and nonbronchial arteries causing hemoptysis.

Reperfusion of Complex Pulmonary Arteriovenous Malformations After Embolization: Report of Three Cases

The purpose of this report is to discuss the different mechanisms of reperfusion of pulmonary arteriovenous malformations (PAVMs) after embolization. Transcatheter embolotherapy is currently the first-line treatment of PAVMs to prevent neurologic complications or pulmonary hemorrhage. Initial good results can be expected but we report three cases of reperfusion of complex large PAVMs after coil embolization. After adequate embolization, reperfusion of PAVMs may occur by several mechanisms including recanalization of embolized arteries, recruitment of normal arterial branches, growth or enlargement and development of a systemic arterial supply.

Embolic agents used for bronchial artery embolisation in massive haemoptysis

Massive haemoptysis is a life-threatening disorder that is associated with a high mortality rate. It is mostly caused by bleeding from bronchial circulation. Bronchial artery embolisation is now considered to be the treatment of choice for acute massive haemoptysis. The safety and effectiveness of bronchial artery embolisation for massive haemoptysis has been proved since its first use in 1973. Currently, polyvinyl alcohol (PVA) particles are the most commonly used embolic agent for bronchial artery embolisation worldwide. PVA particles are biocompatible and nonbiodegradable and are considered to be a permanent embolic agent. Gelatin sponge is a temporary embolic agent and can be used as a supplementary agent after initial embolisation with PVA particles. Stainless steel coils are not recommended for embolisation of bronchial artery, although they may be used in the embolisation of internal mammary artery to preserve the normal vascular territory. Recently, the interest in the use of new embolic agents for bronchial artery embolisation is emerging because of inherent limitations of PVA particles as an intravascular embolic agent. Tris-acryl gelatin microspheres are a new embolic agent that is increasingly used for uterine fibroid embolisation. Tris-acryl gelatin microspheres have characteristics that make it an attractive alternative to PVA particles for bronchial artery embolisation. Clinical trials and experimental studies should be performed to explore the safety and efficacy of microspheres for bronchial artery embolisation.

Use of endoscopic fibrinogen-thrombin in the treatment of severe hemoptysis

Bronchial artery embolization (BAE) is the treatment of choice in the majority of patients with severe hemoptysis. However, this procedure may be unavailable and even fail or be counterindicated in 4-13% of cases. In these cases, the efficacy of fibrinogen-thrombin (FT) instilled endoscopically as treatment for massive hemoptysis was assessed. Between August 1993 and February 1996 a prospective clinical study was performed. FT instillation was indicated in all patients with severe hemoptysis (> 150 ml/12 h) in whom BAE had failed, was counterindicated or not available. FT was instilled endoscopically. Patients were followed up until June 2001. Eleven of 101 patients (11%) with hemoptysis > 150 ml/12 h in whom BAE was not possible or proved ineffective were included. The severe hemoptysis was controlled immediately in all cases. During the follow-up period (mean: 39.4 months), early relapse of the severe hemoptysis occurred in two patients (18%) and a long-time relapse in one. Mean procedure duration was 3 min and no attributable complications were observed in any case. In conclusion, these results suggest that topical treatment with FT could be considered in the initial endoscopic evaluation of patients with severe hemoptysis while awaiting BAE or surgery, or as alternative treatment to arterial embolization when the latter is not available, has proved ineffective or is counterindicated.