Bronchial artery embolization for hemoptysis: a retrospective observational study of 344 patients

Biopsy and interventional therapy of subglottic lesions with flexible bronchoscope under protection of endotracheal intubation

Subglottic lesions represent a complex and challenging clinical entity, often associated with high procedural risks due to their anatomical location and vascularity. While a laryngeal mask airway (LMA) is commonly employed for airway management in such cases, it has notable limitations, particularly in scenarios involving significant bleeding or the need for extended intervention. This article presents an alternative and effective approach for the biopsy and interventional treatment of subglottic lesions using a flexible bronchoscope under the protection of an endotracheal tube (ETT). By inserting the bronchoscope through the space between the ETT and the tracheal wall, various procedures-including biopsy, argon plasma coagulation (APC), and CO₂ cryotherapy-can be performed with relative safety. This method provides a feasible option for airway protection, bleeding control, and lesion management, offering new possibilities in clinical practice.

High risk and low incidence diseases: Massive hemoptysis

BACKGROUND

Massive hemoptysis (MH) is a serious condition that carries with it a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of massive hemoptysis, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence.

DISCUSSION

MH is a rare but deadly condition. It is defined clinically as any bleeding from the tracheobronchial tree that compromises respiratory or circulatory function. The bronchial artery system is the primary source in the majority of cases of MH. The most common cause is tuberculosis worldwide, but bronchiectasis, bronchogenic carcinoma, and mycetoma are more common causes in the U.S. Patients with MH require rapid assessment and management, as decompensation can be rapid. Patients with altered mental status, inability to clear their sections, respiratory distress, or hemodynamic compromise require emergent airway intervention. The imaging modality of choice is computed tomography angiography with pulmonary arterial phase contrast. A reasonable order or sequence of management includes initial stabilization; assessment for the need for airway intervention; reversal of any coagulopathy; advanced imaging; and emergent consultation of pulmonary, cardiothoracic surgery, and interventional radiology. Ongoing resuscitation including blood products may be required in some patients with MH until definitive hemostasis is achieved.

CONCLUSIONS

An understanding of MH can assist emergency clinicians in diagnosing and managing this dangerous disease. Providing a prompt evaluation, obtaining intravenous access, pursuing advanced imaging, providing reversal of coagulopathy, supporting hemodynamics, and appropriate consultation are key interventions in MH.

Added Value of Computed Tomography Angiography Prior to Bronchial Artery Embolization for Hemoptysis: A Retrospective Two-Center Study

Objectives

The aim of this retrospective study was to evaluate the added value of pre-procedural computed tomography angiography (CTA) prior to bronchial artery embolization for patients presenting with hemoptysis.

Materials and Methods

In this retrospective study, we evaluated patients admitted for hemoptysis from 2010 to 2021 and treated by catheter-directed embolization. After establishing quality criteria for pre-procedural computed tomography (CT), patients were divided into two groups depending on their pre-procedural imaging assessment: Quality CT-angiography (QCTA group) and suboptimal pre-procedural imaging (suboptimal CTA, unenhanced or no CT evaluation; control group). Groups were compared based on radiological success, procedure-related complications, and clinical success, including cessation of hemoptysis, recurrence rates, and overall mortality.

Results

We included 31 patients in the QCTA group, and 35 in the control group. Clinical success was n = 24/31 (77.4%) in the QCTA group and n = 27/35 (77.1%) in the control group (p = 0.979). Technical success was n = 37/42 (88.1%) in the QCTA group and n = 39/42 (92.86%) in the control group (p = 0.820). Overall recurrence was 10.6%. Minor complications occurred in 27.3%, and one major complication was reported.The concordance between the affected bleeding lung and the identification of pathological arteries during angiography was better in the QCTA group (p = 0.045).The average number of culprit arteries (bronchial, non-bronchial systemic arteries [NBSA] or pulmonary) in the QCTA group was not significantly higher than that in the control group.

Conclusions

Preprocedural QCTA better identifies the affected bleeding lung and bleeding vessels compared to direct angiography. No difference in clinical success, complications, recurrence rates, or mortality was observed.

Acute Hemoptysis Caused by Eroding Spinal Fusion Hardware Into the Left Lower Lobe of the Lung

Hemoptysis can occur in rare cases as a late complication of anterior approach spinal rod surgery in the spine. Our patient presented with hemoptysis. At age 14, he underwent an anterior approach spine surgery for scoliosis. He underwent bronchoscopy, and a round serrated metal object was visible in the left lower lobe. Multiple attempts were unsuccessful in retrieving the metal object. A review of the imaging did not show obvious penetration of the spinal instrumentation into the lung; however, the metallic object was believed to be a round serrated metal object from the fusion spinal hardware. Due to low lung function and the risk of injuring the surrounding tissue, the patient was not deemed a candidate for lobectomy or removal of the hardware. Instead, the patient underwent a left bronchial arterial embolization (BAE) procedure, which successfully stopped the hemoptysis.

A Comparison of Clinical and Radiographic Signs of Nontuberculous Mycobacterial Pulmonary Disease, Destructive Drug-Resistant Pulmonary Tuberculosis and a Combination of Nontuberculous Mycobacterium Pulmonary Disease and Pulmonary Tuberculosis

A misdiagnosis of isolated pulmonary tuberculosis (pTB) is highly likely when a patient has nontuberculous mycobacterial pulmonary disease (NTMPD) or a combination of nontuberculous mycobacterium pulmonary disease and pulmonary tuberculosis. Frequently, bacterial excretion is absent or only Mycobacteria tuberculosis (MBT) is found. This often results in an incorrect diagnosis and subsequent misinformed treatment regimes. In order to determine possible clinical and radiographic differences between patients with NTMPD (Group 1), destructive drug-resistant pulmonary tuberculosis (Group 3) and a combination of NTMPD and pTB (Group 2) we compare clinical and radiographic signs for these three patient groups. When comparing with Group 3 (2.5%), Groups 1 (25%) and 2 (17.4%) have a substantially higher incidence of pulmonary haemorrhages. Thus, upon clinically observing the combination of pTB and NTMPD, there are no pathognomonic clinical and radiographic detected symptoms. However, the presence of an indolent course, hemoptysis and bronchiectasis in the presence of acid-fast bacteria (or identified MBT) in the sputum makes it possible to suspect not simple pTB, but a combination of pTB and NTMPD. To clarify this necessitated in-depth bacteriological examination.

Bronchial Artery Embolization in Management of Hemoptysis in a Developing Country: An Initial Experience

Purpose This article evaluates the immediate success, recurrence rate, complications, and the culprit vessel of bronchial artery embolization (BAE) in patients presenting with hemoptysis.

Methods and Materials All patients who underwent BAE from July 1, 2018 to August 31, 2021 were included. BAE was done for moderate to severe hemoptysis or for mild hemoptysis which was recurrent and not controlled by medical management. Patients referred for surgical intervention and hemoptysis controlled on medical management were excluded.

Results One hundred and thirty patients underwent BAE in the study period. Mean age was 41.5 years and majority (73.1%) was male. Forty-three (33.1%) patients had mild, 46 (35.4%) had moderate, and 41 (31.5%) with the duration of symptoms ranging from 3 days to 25 years. Most common culprit vessel was posterior intercostal artery closely followed by the intercostobronchial artery. Hypervascularity was the most common angiographic abnormality encountered. On an average, 2.75 vessels were embolized per BAE with a wide range of 1 to 8 vessels. Hemoptysis control was seen in 96.1% patients immediately, 90.7 % at 1 month, 82.3 % at 3 months, and 66.9 % at 6 months. Overall recurrence was seen in 43 patients (33.1%). Chest pain was the most common minor side effect occurring in 77.1% cases.

Conclusion BAE is a safe and effective procedure that can be performed routinely in patients presenting with moderate to massive hemoptysis or with mild hemoptysis refractory to medical management.

Catastrophic pulmonary haemorrhage after endobronchial biopsy of necrotic lung mass

Flexible bronchoscopy (FB) is instrumental in the diagnosis and treatment of respiratory illness, with low rates of bleeding post-procedure but unpredictable degrees of severity. Although exceedingly rare, massive pulmonary haemorrhage after FB is often catastrophic. We present a case of massive pulmonary haemorrhage after endobronchial biopsy of a 67-year-old patient with a prior diagnosis of right upper lobe (RUL) necrotic lung mass. Imaging revealed possible lymphangitic carcinomatosis and tumour invasion into the lymphatics and vasculature. Significant RUL tumour burden was visualized during the procedure, however, routine endobronchial biopsy resulted in massive pulmonary haemorrhage leading to pulseless electrical activity. Prevention of massive pulmonary haemorrhage may be possible with identification of known risk factors. Catastrophic outcomes from massive pulmonary haemorrhage remain high despite current therapies. Further studies identifying modifiable risk factors, treatment protocols, and the formulation of a multi-disciplinary action plan could prove lifesaving.

A retrospective analysis of risk factors for massive hemoptysis in patients with bronchiectasis

BACKGROUND

Massive hemoptysis is a common and fatal complication of bronchiectasis. However, the risk factors for massive hemoptysis in patients with bronchiectasis have not yet been reported. This study investigated the potential risk factors for massive hemoptysis in patients with bronchiectasis.

METHODS

This retrospective study included patients with bronchiectasis and their data were obtained from medical records. The risk factors for massive hemoptysis were evaluated by multivariate analysis of patient characteristics, medical history, and computed tomography imaging data, including the number of lesions, lesion location, and laboratory findings.

RESULTS

Among 379 patients, 61 (16.09%) experienced severe hemoptysis. Multivariate analysis revealed that diabetes (odds ratio (OR) 2.885; 95% confidence interval (CI) 1.009-8.247), lesions involving two lobes (OR 4.347; 95% CI 1.960-9.638) and three lobes (OR 2.787; 95% CI 1.055-7.363) were significant predictors of severe hemoptysis. However, a disease course between 1 and 5 years (OR 0.300; 95% CI 0.112-0.801) and involvement of the left lower lobe (OR 0.394; 95% CI 0.196-0.793) were protective factors for the prevention of massive hemoptysis. Lesions in the right upper lobe were more likely to cause massive hemoptysis (OR 1.458) than involvement of other lobes.

CONCLUSIONS

Diabetes and lesions involving two and three lobes, were risk factors for massive hemoptysis in patients with bronchiectasis. Disease duration between 1 and 5 years and involvement of the left lower lobe were protective factors, while lesions in the right upper lobe had a stronger relationship with massive hemoptysis in patients with bronchiectasis.

Role of computed tomography angiography in the evaluation of haemoptysis in children: Decoding the abnormal vessels

BACKGROUND & OBJECTIVES

Haemoptysis in children is potentially life-threatening. In most cases, the bleeding arises from the systemic circulation, and in 5-10 per cent of cases, it arises from the pulmonary circulation. The role of computed tomography angiography (CTA) in this setting is important. This study was undertaken (i) to study the role of single-phase split-bolus dual energy contrast-enhanced multidetector row CTA (DECTA) in the evaluation of haemoptysis in children; (ii) to analyze the patterns of abnormal vascular supply in the various aetiologies encountered.

METHODS

A retrospective study of 86 patients who underwent split bolus DECTA for the evaluation of haemoptysis was performed. Final diagnoses were categorized as normal computed tomography, active tuberculosis (TB), post-infectious sequelae, non-TB active infection, cystic fibrosis (CF), non-CF bronchiectasis, congenital heart disease (CHD), interstitial lung disease, vasculitis, pulmonary thromboembolism and idiopathic pulmonary haemosiderosis. Abnormal bronchial arteries (BAs) and non-bronchial systemic collateral arteries (NBSCs) were assessed for number and site and their correlation with underlying aetiologies.

RESULTS

A total of 86 patients (45 males, age from 0.3 to 18 yr, mean 13.88 yr) were included in the study; among these only two patients were less than five years of age. The most common cause of haemoptysis was active infection (n=30), followed by bronchiectasis (n=18), post-infectious sequelae (n=17) and CHD (n=7). One hundred and sixty five abnormal arteries were identified (108 BA and 57 NBSC), and were more marked in bronchiectasis group.

INTERPRETATION & CONCLUSIONS

Active infections and bronchiectasis are the most common causes of haemoptysis in children. While post-infectious sequelae are less common, in patients with haemoptysis, the presence of any abnormal arteries correlates with a more frequent diagnosis of bronchiectasis. NBSCs are more common in post-infectious sequelae and CHD.

Bronchial artery embolization for hemoptysis: A systematic review and meta-analysis

Objective

To assess the safety and efficacy of bronchial artery embolization (BAE) for hemoptysis.

Methods and materials

Databases with articles published in English, including Pubmed, Embase, Web of science and Chochrane library, were comprehensively searched to get accurate, up-to-date and sufficient literature about BAE for hemoptysis until March 2020. The technical success rates, immediate control rates, recurrence rates, mortality rates, and total complication rates (minor and major complication rates) extracted from the articles were pooled to estimate and assess the efficacy and safety of BAE using random-effect and fixed-effect models.

Results

21 articles published between 2008 and 2019, which include a total of 2511 patients, were studied to evaluate the safety and efficacy of BAE. The technical success and immediate control rates are 99.9% (95%CI: 99%–100%) and 99.5% (95%CI: 97.8%–99.2%), respectively. This study showed hemoptysis recurrence in 23.7% (95%CI: 18.5%–28.9%) with a mortality rate of 2% (95%CI: 0–3%). Additionally, the assessment of complications revealed a total complication rate of 13.4% (95% CI: 7.6–19.2%), in which 0.2% (95% CI: 0.2–0.4%) were major complications and 10% (95% CI: 4.7–9.6%) were minor complications.

Conclusion

BAE is an effective, safe, and feasible procedure with a low complication rate for hemoptysis patients. However, recurrence of hemoptysis is still at high risk after BAE due to different underlying diseases.

Feasibility and outcomes of bronchial artery embolization in patients with non-massive hemoptysis

Purpose

To evaluate the safety, efficacy, and long-term outcome of bronchial artery embolization (BAE) in the treatment of non-massive hemoptysis and the prognostic factors associated with recurrent bleeding.

Materials and methods

From March 2005 to September 2014, BAE was performed in 233 patients with non-massive hemoptysis. All patients had a history of persistent or recurrent hemoptysis despite conservative medical treatment. We assessed the technical and clinical success, recurrence, prognostic factors related to recurrent bleeding, recurrence-free survival rate, additional treatment, and major complications in all the patients.

Results

Technical success was achieved in 224 patients (96.1%), and clinical success was obtained in 219 (94.0%) of the 233 patients. In addition, 64 patients (27.5%) presented hemoptysis recurrence with median time of 197 days after embolization. Tuberculosis sequelae and presence of aberrant bronchial artery or non-bronchial systemic collaterals were significantly related to recurrent bleeding (p < 0.05). The use of Histoacryl-based embolic materials significantly reduced the recurrent bleeding rate (p < 0.05). Patient who had a tuberculosis sequelae showed a significantly lower recurrence-free survival rate (p = 0.013). Presence of aberrant bronchial artery or non-bronchial systemic collaterals showed a statistically significant correlation with recurrence-free survival rate (p = 0.021). No patients had major complications during follow-up.

Conclusions

BAE is a safe and effective treatment to manage non-massive hemoptysis. The procedure may offer a better long-term control of recurrent hemoptysis and quality of life than conservative therapy alone.

Surgical Treatment of Pulmonary Aspergilloma: A 13-year Experience from a Single Clinical Center

BACKGROUND

Pulmonary aspergilloma is chronic and invasive, potentially leading to life-threatening massive hemoptysis. The role of surgery for treating pulmonary aspergilloma and its effect on long-term survival need more study.

METHODS

We reviewed 166 patients with aspergillomas treated at Shanghai Pulmonary Hospital from 2004 to 2017. Surgery indications included destroyed lung parenchyma, recurrent hemoptysis despite appropriate medical treatment and isolated pulmonary nodules suspected to be aspergilloma. Pulmonary aspergillomas are classified as simple (in an isolated thin-walled cavity, ≤3 mm) or complex (a thick-walled cyst, >3 mm) based on CT scan findings.

RESULTS

Aspergilloma was complex in 100 (60.2%) patients and simple in 66 (39.8%) patients. The median size of complex aspergillomas (2.5 [0.3-8.0] cm) was larger than that (2.0 [0.2-6.0] cm) of simple types (p<0.001). Hemoptysis occurred in 72 (72%) patients with complex disease and 35 (53%) with simple disease (p=0.014). Video-assisted thoracoscopic surgeries were performed in 42 (63.6%) simple aspergillomas, while 75 (75%) of complex aspergillomas patients underwent thoracotomy. Prolonged air leakage (>7d) was the most (17, [10.2%]) common postoperative complication. One (0.6%) patient had postoperative bronchopleural fistula. One (0.6%) patient died within 30 days postoperatively due to respiratory failure. Two (1.2%) patients experienced recurrence during follow-up. The overall 10-year survival rates of complex and simple aspergillomas were 87.7% and 94.97% (p=0.478). Diabetes (12, [7.2%], HR [95% CI] = 13.15(1.12-154.46)) was associated with a worse prognosis.

CONCLUSIONS

The perioperative morbidity and mortality of pulmonary aspergillomas are acceptable. Overall survival rates of simple and complex types are comparable.

The emergency department evaluation and management of massive hemoptysis

INTRODUCTION

Massive hemoptysis is a life-threatening emergency that requires rapid evaluation and management. Recognition of this deadly condition, knowledge of the initial resuscitation and diagnostic evaluation, and communication with consultants capable of definitive management are key to successful treatment.

OBJECTIVE

The objective of this narrative review is to provide an evidence-based review on the management of massive hemoptysis for the emergency clinician.

DISCUSSION

Rapid diagnosis and management of life-threatening hemoptysis is key to patient survival. The majority of cases arise from the bronchial arterial system, which is under systemic blood pressure. Initial management includes patient and airway stabilization, reversal of coagulopathy, and identification of the source of bleeding using computed tomography angiogram. Bronchial artery embolization with interventional radiology has become the mainstay of treatment; however, unstable patients may require advanced bronchoscopic procedures to treat or temporize while additional information and treatment can be directed at the underlying pathology.

CONCLUSION

Massive hemoptysis is a life-threatening condition that emergency clinicians must be prepared to manage. Emergency clinicians should focus their management on immediate resuscitation, airway preservation often including intubation and isolation of the non-bleeding lung, and coordination of definitive management with available consultants including interventional radiology, interventional pulmonology, and thoracic surgery.

Embolotherapy in Bronchial Hemorrhage

Hemoptysis, defined as bleeding into the tracheobronchial tree, is a serious symptom that can cause asphyxiation if inadequately treated. Massive hemoptysis carries a very high mortality risk, and therefore, a prompt multidisciplinary approach to hemoptysis is highly encouraged. Bronchial artery embolization has evolved as the mainstay of treatment in control of hemoptysis. It is a low-risk procedure that carries high initial clinical success rates. Despite relatively high recurrence rates, it can be repeated until the underlying disease process can be definitively treated.

Bronchial Angioembolization for Management of Hemoptysis Due to Pulmonary Tuberculosis

BACKGROUND

The study aimed to evaluate the effectiveness and safety of BAE in TB patient with massive hemoptysis and evaluate the recurrence rate of hemoptysis after BAE.

MATERIALS AND METHODS

In this prospective study, 68 patients with moderate and severe hemoptysis due to active or old tuberculosis who underwent bronchial arteriography were included. CXR and CT scan were performed in all patients. Selective and nonselective bronchial artery angiography was performed in all patient and 62 patients underwent embolization.

RESULTS

Thirty-two patients (47.1%) had active TB and 36 patients (52.9%) had inactive TB (post-tuberculosis sequelae). Abnormality was detected in a single vessel in 30 (44.1%) patients, in two vessels in 23 (33.8%) and in more than two vessels in 13 (19.1%) patients. Embolization was performed in 62 patients and overall 95 abnormal arteries were embolized. Hemoptysis control rate was 82.3% at one month, 73.5% at three months, 69.1 % at 6 months, 63.2% at one year and 60.3% after two years.

CONCLUSION

No major complication occurred as a result of BAE procedures. BAE is a safe and effective method for the management of hemoptysis in patient with tuberculosis. Only 20.6% of the patients need to repeat BAE during 2 years of follow up.

The impact of bronchial artery embolisation on the quality of life of patients with haemoptysis: a prospective observational study

Objectives

Patients with haemoptysis often experience daily physical and mental impairment. Bronchial artery embolisation is among the first-line treatment options used worldwide; however, no evidence exists regarding the health-related quality of life (HRQoL) after bronchial artery embolisation. Therefore, this study aimed to evaluate the effects of bronchial artery embolisation on the HRQoL of patients with haemoptysis.

Methods

We prospectively enrolled 61 consecutive patients who visited our hospital from July 2017 to August 2018 and received bronchial artery embolisation for haemoptysis. The primary outcome was the HRQoL evaluated using the Short Form Health Survey, which contains physical and mental components, before and after bronchial artery embolisation. The secondary outcomes were procedural success, complications, and recurrence-free survival rate at 6 months.

Results

The mean age of the patients was 69 years (range, 31–87 years). The procedural success rate was 98%. No major complications occurred. The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8% (95% confidence interval, 91.1–92.5%). Compared with the pre-treatment scores, the physical and mental scores were significantly improved at 6 months after bronchial artery embolisation (p < 0.05).

Conclusion

Bronchial artery embolisation improved the HRQoL of patients with haemoptysis.

Key Points

• Bronchial artery embolisation improved the HRQoL of patients with haemoptysis.

• Vessel dilation on computed tomography and systemic artery-pulmonary artery direct shunting on angiography were the most common abnormalities.

• The recurrence-free survival rate estimated using the Kaplan-Meier analysis at 6 months after bronchial artery embolisation was 91.8%.

Clinical applications of digital angiography with the harmonization function in body interventional radiology

Digital subtraction angiography (DSA) is frequently applied in interventional radiology (IR). When DSA is not useful due to misregistration, digital angiography (DA) as an alternative option is used. In DA, the harmonization function (HF) works in real time by harmonizing the distribution of gray steps or reducing the dynamic range; thus, it can compress image gradations, decrease image contrast, and suppress halation artifacts. DA with HF as a good alternative to DSA is clinically advantageous in body IR for generating DSA-like images and simultaneously reducing various motion artifacts and misregistrations caused by patient body motion, poor breath-holding, bowel and ureter peristalsis, and cardiac pulsation as well as halation artifacts often stemming from the lung field. Free-breath DA with HF can improve body IR workflow and decrease the procedure time by reducing the risk of catheter dislocation and using background structures as anatomical landmarks, demonstrating reduced radiation exposure relative to DSA. Thus, HF should be more widely and effectively utilized for appropriate purposes in body IR. This article illustrates the basic facts and principles of HF in DA, and demonstrates clinical advantages and limitations of this function in body IR.

Bronchial artery embolization. What further we can offer?

Introduction

Massive hemoptysis is the most feared of all respiratory emergencies, with many underlying causes. In 90% of cases, the source of hemoptysis is the bronchial circulation. Despite high recurrence rates, bronchial artery embolization (BAE) remains the first-line treatment in management of hemoptysis.

Aim

To establish pre-procedure and procedural protocols for BAE.

Material and methods

The study included a total of 50 patients referred to the Department of Radiology for complaints of hemoptysis. Pre-procedure computed tomography (CT) angiography for determination of responsible circulation was performed as a regular protocol except in cases presenting with life-threatening hemoptysis. Polyvinyl alcohol (PVA size, 300–500 μm and 500–700 μm) particles combined with gel foam embolization was performed. Successful catheterization and embolization of the targeted vessel was considered technical success and the cessation of hemoptysis to minimal levels was labeled clinical success.

Results

Thirty-two (64%) male and 18 (36%) female subjects comprised the study group. Forty (80%) patients had moderate to severe hemoptysis. Tuberculosis (80%) was the most common etiology. Five patients had severe AV shunting and were embolized with decremental particle size (500–700 μm followed by 300–500 μm) to occlude the bed and then embolize the artery. Technical success was achieved in all the patients, but clinical success was achieved in 40 (80%) patients.

Conclusions

Bronchial artery embolization is a minimally invasive procedure recognized for primary management of hemoptysis. Preprocedure evaluation with CT angiography can add incremental value in management. Usage of decremental particle size is helpful to embolize large AV shunts.

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.

Invasive Tracheobronchial Aspergillosis with Bronchial Ulcers Complicated by Nontuberculous Mycobacterial Disease

Invasive tracheobronchial aspergillosis (ITBA) complicated by nontuberculous mycobacteria (NTM) is rare. An 88-year-old man was admitted for hemoptysis. Bronchoscopy revealed bronchial ulcers, and a tissue biopsy showed Aspergillus fumigatus. He was diagnosed with ITBA, which improved with voriconazole. During treatment, infiltrative shadows appeared in his lungs, and bronchoscopy was performed once again. A non-necrotic epithelioid granuloma and Mycobacterium intracellulare were detected in the biopsy specimen. He was diagnosed with NTM disease. It is important to note that tracheobronchial ulcers may cause hemoptysis and to identify the etiology and treat it appropriately when multiple bacteria are found.

Bronchial Artery Embolisation for Massive Haemoptysis: Immediate and Long-Term Outcomes-A Retrospective Study

Introduction

Bronchial artery embolisation (BAE) is an established treatment method for massive haemoptysis. The aim of this study is to evaluate the impact of BAE on in-hospital outcomes and long-term survival in patients with massive haemoptysis.

Methods

Retrospective review of all cases of acute massive haemoptysis treated by BAE between April 2000 and April 2012 with at least a 5 year follow up of each patient. Targeted BAE was performed in cases with lateralising symptoms, bronchoscopic sites of bleeding or angiographic unilateral abnormal vasculature. In the absence of lateralising symptoms or signs, bilateral BAE was performed.

Results

96 BAEs were performed in 68 patients. The majority (64 cases, 67%) underwent unilateral procedures. 83 (86.5%) procedures resulted in immediate/short term control of haemoptysis which lasted for longer than a month. The mean duration of haemoptysis free period after embolisation was 96 months. There were three major complications (cardio-pulmonary arrest, paraparesis and stroke). 38 (56%) patients were still alive at least 5 years following their BAE. Benign causes were associated with significantly longer haemoptysis free periods, mean survival 108 months compared to 32 months in patients with an underlying malignant cause (p = 0.005). An episode of haemoptysis within a month of the initial embolisation was associated reduced overall survival (p = 0.033).

Conclusion

BAE is effective in controlling massive haemoptysis. Long-term survival depends on the underlying pulmonary pathology. Strategies are required to avoid incomplete initial embolisation, which is associated with ongoing haemoptysis and high mortality despite further BAE.

Efficacy and Safety of Bronchial Artery Embolization on Hemoptysis in Chronic Thromboembolic Pulmonary Hypertension: A Pilot Prospective Cohort Study

Supplemental Digital Content is available in the text.

Objectives:

Managing hemoptysis in chronic thromboembolic pulmonary hypertension can be challenging due to the difficulties in maintaining coagulation homeostasis in affected patients. In this study, we evaluated the efficacy and safety of bronchial artery embolization in treating hemoptysis in chronic thromboembolic pulmonary hypertension patients.

Design:

Pilot, prospective cohort study.

Setting:

A large respiratory medical institute.

Patients:

From January 1, 2012, to December 31, 2017, hospitalized chronic thromboembolic pulmonary hypertension patients were eligible for inclusion. Patients with pulmonary hypertension caused by other conditions, or who failed to participate in the follow-up were excluded.

Interventions:

Hemoptysis in chronic thromboembolic pulmonary hypertension patients was treated with or without bronchial artery embolization based on whether the bleeding could be stopped with medication alone and patient willingness for bronchial artery embolization treatment.

Measurements and Main Results:

A total of 328 patients diagnosed with chronic thromboembolic pulmonary hypertension were consecutively collected, 317 patients were completed the follow-up. There were 15 chronic thromboembolic pulmonary hypertension patients with hemoptysis in total, and the occurrence rate of hemoptysis in chronic thromboembolic pulmonary hypertension patients was 4.7%. Among the hemoptysis chronic thromboembolic pulmonary hypertension patients, 10 (67%) underwent bronchial artery embolization, and five (33%) were treated with medication only. The median follow-up period for hemoptysis patients was 7.6 months. In patients underwent bronchial artery embolization treatment, oxygenation index and right heart function showed no significant difference between pre bronchial artery embolization and post bronchial artery embolization. Hemoptysis relapse (20% vs 80%; p = 0.025) and hemoptysis-related mortality (0% vs 40%; p = 0.032) were significantly lower, whereas the overall survival (90% vs 40%; p = 0.040) was higher in patients treated with bronchial artery embolization than in patients treated without bronchial artery embolization.

Conclusions:

Bronchial artery embolization procedure demonstrated effectiveness and safety to treat hemoptysis in chronic thromboembolic pulmonary hypertension patients at our center, but further controlled studies are needed before it can be considered as an effective therapy for these patients.

Spinal Arterial Blood Supply Does Not Arise from the Bronchial Arteries: A Detailed Analysis of Angiographic Studies Performed for Hemoptysis

PURPOSE

To determine the angiographic prevalence of spinal arteries originating directly from the bronchial arteries in the setting of embolization for hemoptysis.

MATERIALS AND METHODS

Over a 14-year interval, 205 patients underwent angiography for hemoptysis. Twenty-five patients were excluded because their bronchial arteries were not visualized. The remaining 180 patients underwent a total of 254 angiographic procedures (range, 1-8 per patient). Images were reviewed jointly by 2 interventional radiologists with formal fellowship training in both peripheral and neurological interventional radiology. All catheterized arteries were evaluated for arterial contribution to the spinal cord. For patients with multiple studies, each unique artery was reported only once. Embolization was performed during at least 1 procedure in 158 patients (88%). Electronic record review was used to assess neurological sequelae after the procedure.

RESULTS

One or 2 bronchial arteries originating from the aorta were identified in 57 patients (32%) on the right and in 75 patients (42%) on the left. Conjoined bronchial arteries were found in 76 patients (42%). Spinal arterial supply was absent in all. A total of 102 patients (57%) had at least 1 right and 11 patients (6%) at least 1 left intercostobronchial artery. Spinal arterial supply from the intercostal portion of an intercostobronchial artery was found in 6 patients (5 right, 1 left). Medical record review revealed no postprocedure symptoms referable to spinal cord injury in any patient.

CONCLUSIONS

Spinal arterial supply does not originate directly from the bronchial artery but can originate from the intercostal portion of an intercostobronchial artery.

Outcomes and Complications of Bronchial Angioembolization in Patients with Massive Hemoptysis

BACKGROUND

Massive hemoptysis is a potentially life threatening medical condition and one major problem for both patients and physicians. Choosing the appropriate treatment for the patients is crucial in order to decrease the complications and increase the success rate. Hence, in this study the outcomes and complications of bronchial angioembolization (BAE) were determined in patients with massive hemoptysis.

MATERIALS AND METHODS

In this prospective cohort, 189 consecutive patients with moderate and severe hemoptysis who had referred to two large cardiovascular centers were enrolled. The Chest X Ray, CT Scan, Fiberoptic Bronchoscopy, Selective and Nonselective Bronchial Angiography were performed in patients. The outcomes with 20-month follow-up were compared.

RESULTS

The immediate success rate was 97.3%. In 79.7% there were no complications. Temporary chest pain, subintimal dissection, temporary dysphagia, and pancreatitis were seen in 12.3, 2.4, 5.1, and 0.5%, respectively, without any major complication. The in-hospital mortality rate was 1.1% and mortality during 20-month follow-up was 9.6%, and recurrence rate was 28.3% on total.

CONCLUSION

Our case series showed that BAE is a safe and effective method in treating patients with hemoptysis. Compared to surgery, the procedure is faster and less invasive and might be used both as first line or bridging therapy. Importantly, no major complications have been detected.

Management of broncholithiasis

Broncholithiasis is a condition in which calcified material has entered the tracheobronchial tree, at times causing airway obstruction and inflammation. Broncholiths generally originate as calcified material in mediastinal lymph nodes that subsequently erode into adjacent airways, often as a result of prior granulomatous infection. Disease manifestations range from asymptomatic stones in the airway to life-threatening complications, including massive hemoptysis and post-obstructive pneumonia. Radiographic imaging, particularly computed tomography scanning of the chest, is integral in the evaluation of suspected broncholithiasis and can be helpful to assess involvement of adjacent structures, including vasculature, prior to any planned intervention. Management strategies largely depend on the severity of disease. Observation is warranted in asymptomatic cases, while therapeutic bronchoscopy and surgical interventions may be necessary for cases involving complications. Bronchoscopic extraction is often feasible in cases in which the broncholith is freely mobile within the airway, whereas partially-embedded broncholiths represent additional challenges. Surgical intervention is indicated for advanced cases deemed not amenable to endoscopic management. Complex cases involving complications such as massive hemoptysis and/or bronchomediastinal fistula formation are best managed with a multidisciplinary approach, utilizing expertise from fields such as pulmonology, radiology, and thoracic surgery.

Approach to Hemoptysis in the Modern Era

Hemoptysis is a frequent manifestation of a wide variety of diseases, with mild to life-threatening presentations. The diagnostic workup and the management of severe hemoptysis are often challenging. Advances in endoscopic techniques have led to different new therapeutic approaches. Cold saline, vasoconstrictive and antifibrinolytic agents, oxidized regenerated cellulose, biocompatible glue, laser photocoagulation, argon plasma coagulation, and endobronchial stents and valves are amongst the tools available to the bronchoscopist. In this article, we review the evidence regarding the definition, etiology, diagnostic modalities, and treatment of severe hemoptysis in the modern era with emphasis on bronchoscopic techniques.

Bronchial artery embolization in hemoptysis: a systematic review

We systematically reviewed the role of bronchial artery embolization (BAE) in hemoptysis. Literature search was done for studies on BAE published between 1976 and 2016. Twenty-two studies published in English, with sample size of at least 50 patients, reporting indications, technique, efficacy, and follow-up were included in the final analysis. Common indications for BAE included tuberculosis (TB), post-tubercular sequelae, bronchiectasis, and aspergillomas. Most common embolizing agent used was polyvinyl alcohol (size, 300-600 μm) with increasing use of glue in recent years. Overall immediate clinical success rate of BAE, defined as complete cessation of hemoptysis, varied from 70%-99%. However, recurrence rate remains high, ranging from 10%-57%, due to incomplete initial embolization, recanalization of previously embolized arteries, and recruitment of new collaterals. Presence of nonbronchial systemic collaterals, bronchopulmonary shunting, aspergillomas, reactivation TB, and multidrug resistant TB were associated with significantly higher recurrence rates (P < 0.05). Rate of major complications remained negligible and stable over time with median incidence of 0.1% (0%-6.6%). Despite high hemoptysis recurrence rates, BAE continues to be the first-line, minimally invasive treatment of hemoptysis in emergency settings, surgically unfit patients, or in patients with diffuse or bilateral lung disease.

Massive Hemoptysis

Hemoptysis, or coughing of blood, oftentimes triggers anxiety and fear for patients. The etiology of hemoptysis will determine the clinical course, which includes watchful waiting or intensive care admission. Any amount of hemoptysis that compromises the patient's respiratory status is considered massive hemoptysis and should be considered a medical emergency. In this article, we review introduction, definition, bronchial circulation anatomy, etiology, and management of massive hemoptysis.

Bronchial artery embolisation in management of hemoptysis--A retrospective analysis in a tertiary university hospital

BACKGROUND

Bronchial artery embolisation (BAE) becomes a mainstay in the treatment of hemoptysis.

OBJECTIVE

To characterise patients with hemoptysis undergoing bronchial artery angiography (BAA) for embolisation, evaluating outcomes.

METHODS

We retrospectively evaluated patients with acute severe or chronic recurrent hemoptysis admitted to the Pulmonology department and submitted to BAA for purpose of embolisation.

RESULTS

A total of 88 patients were submitted to BAA, 47 (53.4%) were male, with a mean age of 61.4 ± 15.8 years. In 64 (72.7%) patients, hemoptysis presented as chronic recurrent episodes. Hemoptysis was considered severe in 40 (45.5%) patients. Bronchiectasis (other than cystic fibrosis) (n=35; 38.0%) and tuberculosis sequelae (n=31; 35.2) were the major aetiology for hemoptysis. The main angiographic abnormality was hypertrophy and tortuosity (n=68; 77.3%). BAE was performed in 67 (76.1%) of the 88 patients submitted to BAA. Immediate success was achieved in 66 (98.5%) patients. Recurrence of hemoptysis occurred in 25 (37.3%) patients, and was related to presence of shunting (p=0.049). The procedure-related complications were self-limited.

CONCLUSION

Our results suggest that BAE is a safe and effective treatment for acute severe and chronic recurrent hemoptysis, supporting the current literature. Besides this, bleeding recurrence was relatively high, and correlated with presence of systemic pulmonary shunting.