Bronchial artery embolization to control hemoptysis in patients with Mycobacterium avium complex

FEASIBILITY STUDY OF LOW TUBE VOLTAGE COMPUTER TOMOGRAPHY ANGIOGRAPHY (CTA) FOR BRONCHIAL ARTERY IMAGING IN PATIENTS WITH HEMOPTYSIS

OBJECTIVE

To investigate the application of low tube voltage computer tomography angiography (CTA) in bronchial artery (BA) imaging in hemoptysis patients.

METHODS

Between January 2017 and December 2021, 119 patients were studied, including 31 in the 80-kV group, 39 in the 100-kV group and 49 in the control group (120 kV). The CT dose index-volume (CTDIvol) (mGy) and effective dose (ED) (mSv) of each group were comparatively analysed. Image quality evaluation included the signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and subjective 5-scores.

RESULTS

Statistically significant differences were noted in CTDIvol, ED, SNR, CNR and image quality scores of the groups (P < 0.05). Comparative analysis showed no statistical difference in CTDIvol, ED and image quality scores between the 80- and 100-kV groups.

CONCLUSION

Low tube voltage CTA is useful in BA imaging for hemoptysis patients. Tube voltages of 100 kV have better image quality and lower radiation dose.

Prevalence of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization

OBJECTIVES

To identify the prevalence of non-bronchial systemic culprit arteries and their relationship to bleeding lobes in patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization (BAE).

METHODS

Data of 83 consecutive patients with bronchiectasis and chronic pulmonary infection (non-tuberculous mycobacteriosis, aspergillosis, and tuberculosis) who underwent de novo BAE between January 2019 and December 2020 were retrospectively reviewed. The prevalence of culprit arteries was investigated.

RESULTS

Fifty-five patients (66%) had 172 non-bronchial systemic culprit arteries. The bleeding lobes were the right upper, right middle, right lower, left upper, and left lower lobes in 14 (17%), 20 (24%), 7 (8%), 31 (37%), and 11 (13%) patients, respectively. The internal thoracic (49%; n = 41), intercostal (28%; n = 23), and inferior phrenic (28%; n = 23) arteries were the top three non-bronchial systemic culprit arteries, which were involved in all five types of bleeding lobes. The costocervical trunk and thoracoacromial and lateral thoracic arteries were predominant in patients with upper lobe bleeding. Ligament arteries were predominant in patients with left lower lobe bleeding.

CONCLUSIONS

These findings will better ensure the identification of non-bronchial systemic culprit arteries in patients with hemoptysis with bronchiectasis and chronic pulmonary infection. All systemic arteries, especially those which are adjacent to the lung lesions, should be evaluated carefully using MDCT; the internal thoracic, intercostal, and inferior phrenic arteries should be proactively assessed using angiography.

KEY POINTS

• Non-bronchial systemic culprit arteries were identified in 66% of patients with hemoptysis with bronchiectasis and chronic pulmonary infection who underwent de novo bronchial artery embolization. • The internal thoracic (49%), intercostal (28%), and inferior phrenic (28%) arteries were the top three arteries, which were involved in all five types of bleeding lobes. • The costocervical trunk and thoracoacromial and lateral thoracic arteries were prominent in patients with upper lobe bleeding, and the ligament artery was prominent in patients with left lower lobe bleeding.

Management of life-threatening hemoptysis in the ICU

Life-threatening hemoptysis is commonly encountered in the ICU and its management can be challenging even for experienced clinicians. Depending on the etiology and severity, one can tailor the treatment modality and therapeutic intervention(s). The grading of severity of hemoptysis varies greatly in the literature; however, unlike hemorrhage in other scenarios, small amounts of blood can significantly impair oxygenation and ventilation leading to cardiovascular collapse. Importantly, the initial evaluation and management should focus on airway and hemodynamic stabilization along with maintenance of oxygenation and ventilation. In this review, we discuss commonly encountered etiologies, vascular anatomy, diagnostic evaluation, and therapeutic interventions. We examine the evolving trends in etiologies of life-threating hemoptysis over the years. The role of flexible and rigid bronchoscopy as both a diagnostic and therapeutic modality is explored, as well as the use and indications of several bronchoscopic techniques, such as topical hemostatic agents, endobronchial tamponade, and tranexamic acid (TXA). In addition, we assess the use of multi-row detector computed tomography as the initial rapid diagnostic method of choice and its use in planning for definitive treatment. The efficacy and long-term results of bronchial artery embolization (BAE) are evaluated, as well as indications for surgical intervention. Furthermore, the importance of a multidisciplinary approach is emphasized. The necessary interplay between intensivists, consultative services, and radiologists is described in detail and an algorithmic management strategy incorporating the above is outlined. Given the complexity in management of life-threatening hemoptysis, this paper aims to summarize the available diagnostic and therapeutic methods and provide a standardized approach for the management of patients with this often difficult to treat condition.

Spinal Cord Infarction after Bronchial Artery Embolization for Hemoptysis: A Nationwide Observational Study in Japan

Background The most serious complication of bronchial artery embolization (BAE) for hemoptysis is spinal cord infarction. However, because it is rare, previous reports from single institutions have been insufficient to determine the actual prevalence of spinal cord infarction after BAE. Purpose To investigate the actual prevalence of spinal cord infarction as a complication of BAE using a nationally representative inpatient database. Materials and Methods This retrospective study was performed using data from the Japanese Diagnosis Procedure Combination database between July 2010 and March 2018. The authors identified patients who were diagnosed with hemoptysis and underwent BAE during hospitalization. The overall prevalence of spinal cord infarction after BAE was determined. The authors also compared the prevalence of spinal cord infarction using the Fisher exact test according to the embolic agent used for BAE: coils, gelatin sponge (GS) particles, and N-butyl-2-cyanoacrylate (NBCA). Results During the study period, 8563 patients (mean age ± standard deviation, 68 years ± 13; 5103 men) met the inclusion criteria. Among these 8563 patients, 1577 (18%), 6561 (77%), and 425 (5%) underwent BAE with coils, GS particles, and NBCA, respectively. The overall prevalence of spinal cord infarction as a complication of BAE was 0.19% (16 of 8563 patients). The prevalence of spinal cord infarction after BAE with coils, GS particles, and NBCA was 0.06% (one of 1577 patients), 0.18% (12 of 6561 patients), and 0.71% (three of 425 patients), respectively (P = .04). Conclusion With use of a nationwide real-world inpatient database, the results of this study demonstrated that the actual prevalence of spinal cord infarction as a complication of bronchial artery embolization (BAE) for hemoptysis was 0.19%. Patients who underwent BAE with coils had a lower prevalence of spinal cord infarction than patients who underwent BAE with gelatin sponge particles or N-butyl-2-cyanoacrylate. © RSNA, 2021.

Long-Term Outcomes of Bronchial Artery Embolization for Patients with Non-Mycobacterial Non-Fungal Infection Bronchiectasis

BACKGROUND

There is no study on the predictive factors of recurrent haemoptysis after bronchial artery embolization (BAE) with the long-term outcomes in patients with bronchiectasis (BE).

OBJECTIVES

To evaluate the long-term outcomes of BAE in BE patients without accompanying refractory active infection of mycobacteriosis and aspergillosis with analysis for the predictive factors of recurrent haemoptysis.

METHODS

Data of 106 patients with BE who underwent BAE using coils between January 2011 and December 2018 were retrospectively reviewed. The cumulative haemoptysis control rate was estimated using Kaplan-Meier methods with log-rank tests to analyze differences in recurrence-free rate between groups based on technical success and failure, bacterial colonization status, number of BE lesions, and vessels embolized to bronchial arteries (BAs) or BAs + non-bronchial systemic arteries (NBSAs).

RESULTS

Bacterial colonization was detected in approximately 60% of patients. Computed tomography showed bronchiectatic lesions with 2.9 ± 1.4 lobes. In the first series of BAE, embolization was performed in the BAs alone and BAs + NBSAs in 65.1 and 34.9% of patients, respectively, with 2.4 ± 1.4 embolized vessels in total. The median follow-up period was 1,000 (7-2,790) days. The cumulative haemoptysis control rates were 91.3, 84.2, 81.5, and 78.9% at 1, 2, 3, and 5 years, respectively. The haemoptysis control rates were higher in the technical success group than in the technical failure group (p = 0.029).

CONCLUSIONS

High haemoptysis control rates for long-term periods were obtained by embolization for all visualized abnormal arteries, regardless of the colonization status, number of bronchiectatic lobes, and target vessels, irrespective of NBSAs.

Detection of Shunting Into Pulmonary Artery on Multidetector Row Computed Tomography Arteriography Before Bronchial Arterial Embolization: A Preliminary Study

OBJECTIVE

The aim of this study was to investigate the diagnostic performance of detecting systemic arterial pulmonary circulation shunts on multidetector row computed tomography arteriography (MDCTA).

METHODS

Thirty-five consecutive bronchial artery embolization sessions with preprocedural MDCTA were performed for 32 patients and 35 sessions. The MDCTA studies with computed tomography value of pulmonary trunk visually lower than that of ascending aorta were defined as "diagnostic MDCTA." Angiographic studies and "diagnostic MDCTA" were evaluated, respectively, for shunting into pulmonary artery. Based on the results of angiographic studies, diagnostic performance of "diagnostic MDCTA" was evaluated.

RESULTS

The rate of diagnostic MDCTA was 63% (23 of 35). On "diagnostic MDCTA," sensitivity, specificity, and positive and negative predictive values for detecting shunts were 83% 100%, 100%, 94%, respectively.

CONCLUSIONS

Systemic arterial pulmonary circulation shunts were detected on "diagnostic MDCTA" with high sensitivity and specificity.

ACR Appropriateness Criteria® Hemoptysis

Hemoptysis, the expectoration of blood, ranges in severity from nonmassive to massive. This publication reviews the literature on the imaging and treatment of hemoptysis. Based on the literature, the imaging recommendations for massive hemoptysis are both a chest radiograph and CT with contrast or CTA with contrast. Bronchial artery embolization is also recommended in the majority of cases. In nonmassive hemoptysis, both a chest radiograph and CT with contrast or CTA with contrast is recommended. Bronchial artery embolization is becoming more commonly utilized, typically in the setting of failed medical therapy. Recurrent hemoptysis, defined as hemoptysis that recurs following initially successful cessation of hemoptysis, is best reassessed with a chest radiograph and either CT with contrast or CTA with contrast. Bronchial artery embolization is increasingly becoming the treatment of choice in recurrent hemoptysis, with the exception of infectious causes such as in cystic fibrosis. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Erratic coil migration in the bronchus after bronchial artery embolization

Herein, we report two cases of erratic coil migration from the bronchial artery to the bronchus after bronchial artery embolization (BAE). Neither patient exhibited haemoptysis recurrence, but chest radiographs revealed that part of the coil had disappeared. In Case 1, the patient coughed up the coil 4.5 years after BAE. We performed repeat BAE to minimize the possibility of haemoptysis considering bronchoscopic and angiographic findings. In Case 2, the patient had severe dry cough 2 years after BAE. Chest radiography showed migrated coils in the trachea; bronchoscopy revealed a migrated fragment of the coil protruding from the elevated mucosa. We used a loop cutter to split the coil and then removed it using forceps. Coil migration to the bronchus is an infrequent late-stage complication of super-selective bronchial artery coil embolization, and only one other case has been reported. Accordingly, we propose treatment strategies and speculate on the mechanism of fistula formation.

Exacerbation of chronic pulmonary aspergillosis was associated with a high rebleeding rate after bronchial artery embolization

BACKGROUND

Hemoptysis is a common symptom associated with chronic pulmonary aspergillosis (CPA). While surgery is the primary choice to manage hemoptysis, it is often avoided because patients with CPA are more likely to have complications such as respiratory insufficiency and low pulmonary function. Bronchial artery embolization (BAE) may be considered one of the treatments of massive and persistent hemoptysis for such patients.

METHODS

We retrospectively reviewed medical records of 41 patients, admitted to National Hospital Organization Tokyo National Hospital, Tokyo, Japan with hemoptysis arising from CPA between January 2011 to December 2016, who were considered inoperable and had undergone BAE.

RESULTS

Out of the 41 cases analyzed in this study, 21 (51.2%) developed rebleeding after BAE within the mean follow-up duration of 24 months. The non-rebleeding rate of patients after BAE was 92.7% within a month and 65.8% within a year. Patients who developed rebleeding had significantly more non-bronchial systemic arteries responsible for the bleeding compared with patients who did not develop rebleeding (mean of 2.55 vs. 4.86, respectively, P = 0.011). Patients with stable or improved radiological findings demonstrated significantly lower rebleeding rates than those with radiological deterioration (P < 0.001). The non-rebleeding patients had significantly better survival than those with rebleeding (79.7% vs. 39.9% over 5 years, P = 0.046).

CONCLUSIONS

Bronchial artery embolization was effective in controlling hemoptysis in patients with CPA, especially those who could not undergo surgical resection. However, disease control of CPA was important to prevent rebleeding over the long term and to improve survival after BAE.

Mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation: a single-centre retrospective observational study

Objectives

In recognition of the significant impairment caused by haemoptysis on a patient’s quality of life, bronchial artery embolisation has been introduced worldwide as one of the first-line treatment options. Since little evidence is available on the mechanisms of recurrent haemoptysis after super-selective bronchial artery coil embolisation (ssBACE), the purpose of the present study is to evaluate these.

Methods

We retrospectively evaluated the mechanisms of recurrent haemoptysis using both enhanced computed tomography and cineangiography following ssBACE by reviewing 299 haemoptysis-related arteries (HRAs) in 57 consecutive patients who underwent 2nd series ssBACE for the management of recurrent haemoptysis between April 2010 and December 2015.

Results

Median age of patients was 69 (interquartile range 64–74) years, and 43.9% were men. This study revealed that (1) recanalisation was the most common mechanism (45.2%) followed by development of new HRA (38.5%), bridging collaterals (14.7%) and conventional collaterals (1.7%); (2) these trends could be modified in several situations such as with antiplatelet or anticoagulant medications; (3) relatively large-diameter HRAs were more likely to recanalise compared with small-diameter HRAs and (4) recurrent haemoptysis could be managed by 2nd series ssBACE with a procedural success rate of 97.7% without any major complications.

Conclusions

Recanalisation was the most common mechanism of recurrent haemoptysis after ssBACE. Our results provide interventionists with indispensable insights.

Key Points

• Recanalisation was the most common mechanism of recurrent haemoptysis after super-selective bronchial artery coil embolisation, followed by development of new haemoptysis-related arteries

• These trends could be modified in several situations such as with antiplatelet or anticoagulant medications

• Recurrent haemoptysis could be managed by 2nd series super-selective bronchial artery coil embolisation with a procedural success rate of 97.7% without any major complications.

Efficacy and safety of super selective bronchial artery coil embolisation for haemoptysis: a single-centre retrospective observational study

OBJECTIVES

Evidence on the safety and long-term efficacy of super selective bronchial artery embolisation (ssBAE) using platinum coils in patients with haemoptysis is insufficient. The objective of the present study was to evaluate the safety and the 3-year postprocedure haemoptysis-free survival rate of de novo elective ssBAE using platinum coils rather than particles for the treatment of haemoptysis.

DESIGN

A single-centre retrospective observational study.

SETTING

Hemoptysis and Pulmonary Circulation Center in Japan.

PARTICIPANTS

A total of 489 consecutive patients with massive and non-massive haemoptysis who underwent de novo elective ssBAE without malignancy or haemodialysis.

INTERVENTIONS

ssBAE using platinum coils. All patients underwent CT angiography before the procedure for identifying haemoptysis-related arteries (HRAs) and for procedural planning.

PRIMARY AND SECONDARY OUTCOME MEASURES

The composite of the 3-year recurrence of haemoptysis and mortality from the day of the last ssBAE session. Each component of the primary end point and procedural success defined as successful embolisation of all target HRAs were also evaluated.

RESULTS

The median patient age was 69 years, and 46.4% were men. The total number of target vessels was 4 (quartile 2-7), and the procedural success rate was 93.4%. There were 8 (1.6%) major complications: 1 aortic dissection, 2 symptomatic cerebellar infarctions and 5 mediastinal haematoma cases. The haemoptysis-free survival rates were estimated by the Kaplan-Meier analysis at 86.9% (95% CI 83.7% to 90.2%) at 1 year, 79.4% (74.8% to 84.3%) at 2 years and 57.6% (45.1% to 73.4%) at 3 years. Although not statistically significant by the adjusted analysis of variance with multiple imputation of missing variables, cryptogenic haemoptysis tended to show the most favourable outcome and non-tuberculous mycobacterium showed the worst outcome (adjusted p=0.250).

CONCLUSIONS

We demonstrated the safety and long-term efficacy of elective ssBAE using platinum coils and established that it can be a valuable therapeutic option for treating patients with haemoptysis.