Utility of intra-procedural cone-beam computed tomography imaging for the determination of the artery of Adamkiewicz suspected by angiography during transarterial embolization for hemoptysis

Improving culprit artery identification with intraprocedural cone-beam CT aortography and its clinical impact in bronchial artery embolization

OBJECTIVE

To evaluate the impact of intraprocedural cone-beam CT (CBCT) aortography on culprit artery identification and clinical outcomes in patients undergoing bronchial artery embolization (BAE).

MATERIALS AND METHODS

Two hundred eighty-two patients with 317 BAE procedures were retrospectively reviewed. Patients who underwent preprocedural chest CT angiography (CTA) without intraprocedural CBCT aortography were categorized as Group A (n = 177). Patients who underwent both preprocedural chest CTA and intraprocedural CBCT aortography were categorized as Group B (n = 105). Whether CBCT can provide improved culprit artery identification and whether this improvement has a clinical impact were evaluated by comparing the two Groups.

RESULTS

In Group B, CBCT aortography detected more culprit non-bronchial systemic arteries originating from the subclavian arteries compared to chest CTA (16 vs 3, p = 0.026), and the average number of embolized vessels was significantly higher than in Group A (2.47 ± 1.61 vs 2.03 ± 1.17, p = 0.016), while the procedure time was shorter (37.4 ± 22.0 vs 43.6 ± 22.7 min, p = 0.024). The recurrent hemoptysis rate was lower in Group B (17.5% vs 8.7%, p = 0.041), and the proportion of patients requiring subsequent procedures was significantly lower (12.4% vs 4.8%, p = 0.035). The changes in estimated glomerular filtration rate before and 3 days after the procedure (0.1 ± 12.8 vs 0.3 ± 11.0 mL/min/1.73 m2, p = 0.909) and total dose area product (DAP, 6119.5 ± 5725.7 vs 6906.2 ± 5978.6 uGym2, p = 0.279) were not significantly different between the two groups.

CONCLUSION

BAE with intraprocedural CBCT aortography enabled the embolization of more culprit arteries, leading to lower recurrent hemoptysis rates without increasing the risk of renal deterioration and radiation hazards when compared to procedures without it.

KEY POINTS

Question Does intraprocedural CBCT aortography improve culprit artery detection and clinical outcomes in BAE for hemoptysis? Findings CBCT aortography significantly improved the detection of additional culprit arteries, especially from non-bronchial systemic arteries, increasing the number of vessels treated during BAE. Clinical relevance Using CBCT aortography during BAE results in better long-term outcomes by reducing recurrent hemoptysis and the need for additional procedures, without increasing the risk of renal impairment.

Anatomy Insights and Key Pearls for Bronchial Artery Embolization

Although bronchial artery embolization (BAE) initially emerged as a critical minimally invasive image-guided procedure to manage massive hemoptysis regardless of underlying etiologies, there has been a growing interest in BAE to treat pulmonary malignancies within recent years. This article provides an in-depth exploration of bronchial artery anatomy, pathologies, imaging modalities in guiding effective BAE, and procedural pearls for successful intervention. The complexity of bronchial artery anatomy, including its variations and potential complications during embolization, necessitates thorough understanding and precise procedural techniques to optimize patient outcomes and minimize risks.

Non-emergent hemoptysis in patients with primary or metastatic lung tumors: The role of transarterial embolization

PURPOSE

To evaluate the role of systemic arterial embolization for the management of non-emergent hemoptysis in patients with primary or metastatic lung tumors.

MATERIALS AND METHODS

This is a retrospective single center study of consecutive patients who underwent systemic arterial embolization for non-emergent hemoptysis between 2011 and 2023. Study endpoints included technical success, clinical success (partial or complete resolution of hemoptysis) and overall survival. Hemoptysis-free and overall survival were estimated using the Kaplan-Meier method. Predictive factors for hemoptysis-free survival and overall survival were evaluated using univariate analysis (Cox regression). Post-procedural 30-day adverse events were recorded in line with Common Terminology Criteria for Adverse Events (CTCAE) v5.0.

RESULTS

A total of 30 patients were identified. Technical success was achieved in 24/30 (80 %) patients. Clinical success following embolization was achieved in 23/30 (76.7 %) patients. Median length of hospitalization was 5 days (Range: 1 to 16 days). Median overall survival was 194 days (95 % CI: 89 to 258). Median hemoptysis-free survival was 286 days (95 % CI: 42 to not reached). No significant clinical or procedural predictors of hemoptysis-free survival or overall survival were identified. Serious adverse events (CTCAE Grade > 3) occurred in 1 patient (3.4 % - fatal respiratory failure).

CONCLUSION

Embolization of non-emergent hemoptysis in patients with lung malignancies is safe and effective. Recurrence is however high in this patient population, likely due to the nature of the underlying disease.

Preoperative Embolization in the Management of Giant Thoracic Tumors: A Case Series

Objectives: The aim of this paper is to describe our experience in the embolization of hypervascular giant thoracic tumors before surgical excision. Methods: A single-center retrospective review of five trans-arterial preoperative embolization procedures executed between October 2020 and July 2024. Patients' demographics, anatomical aspects, feasibility, technique, and outcomes were reviewed. Results: In all cases, accurate targeting and safe embolization was achieved, with satisfactory devascularization evaluated with post-procedural angiography and with minimal blood loss during subsequent surgical operation. Conclusions: In our experience, preoperative embolization of giant thoracic masses has been technically feasible, safe, and effective in reducing tumor vascularization, thus facilitating surgical treatment. This approach should be evaluated as an option, especially in patients with hypervascular thoracic tumors.

Unraveling the enigma of Adamkiewicz: exploring the prevalence, anatomical variability, and clinical impact in spinal embolization procedures for bone metastases

BACKGROUND

The artery of Adamkiewicz (AKA) is vital for spinal cord blood supply. Its role in embolization procedures for bone metastases can cause serious complications. We explored its prevalence, anatomical variation, and effect on spinal embolization using N-butyl cyanoacrylate (NBCA) in patients with bone metastases.

PURPOSE

To understand the impact and variability of AKA in spinal embolizations in cases of bone metastases to reduce complications and improve patient outcomes.

MATERIAL AND METHODS

We examined data from 454 patients who underwent spinal embolization with NBCA between 2009 and 2018. The presence, anastomoses, and tumor features of AKA were assessed via pre-procedure imaging and angiography. Complications were classified per the CIRSE Classification System.

RESULTS

AKA was found in 22.8% of patients, predominantly left-sided and originating from T8 to L1. Direct and indirect anastomoses were present in 66.6% and 33.4% of patients, respectively. Extra-compartmental invasion was linked with direct anastomosis (P = 0.004). High-grade complications were rare but included one instance of bilateral lower limb paralysis. Partial embolization was necessary in 22.8% of cases due to AKA.

CONCLUSION

The study underscores the need for rigorous preoperative evaluation of AKA origin and anastomoses in patients undergoing spinal embolization for bone metastases. Given the significant presence of AKA and related anastomoses, especially with renal extra-compartmental tumors, caution is advised to reduce complications and optimize patient outcomes. Further research is required for best practice guidelines involving bone metastases and AKA.

Perspectives of Cone-beam Computed Tomography in Interventional Radiology: Techniques for Planning, Guidance, and Monitoring

Cone-beam computed tomography (CBCT) has emerged as a prominent imaging modality in interventional radiology that offers real-time visualization and precise guidance in various procedures. This article aims to provide an overview of the techniques used to guide and monitor interventions that use CBCT. It discusses the advantages of CBCT, its current applications, and potential future CBCT-related developments in the field of interventional radiology.

Endovascular Management of Life-Threatening Hemoptysis in Primary Lung Cancer: A Retrospective Study

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of endovascular treatment of hemoptysis caused by primary lung cancer.

METHODS

We conducted a single-center retrospective study (2005-2021), including patients who underwent thoracic embolization for life-threatening hemoptysis complication of lung cancer. Exclusion criteria were hemoptysis caused by a benign lung tumor or by a lung metastasis of a primary non-lung tumor. Depending on the origin of the bleeding, determined by CT-angiography, systemic arteries were treated with microspheres or coils, and pulmonary arteries with coils, plugs or covered stents. Outcomes were assessed from patients' medical records in April 2022. Primary endpoints were clinical success at one month and at one year. Secondary endpoints were incidence of complications, 1 year overall survival, and relative risk of recurrence of hemoptysis. Survival was compared with a log-rank test.

RESULTS

Sixty-two patients underwent 68 systemic artery embolizations and 14 pulmonary artery procedures. Clinical success defined as cessation of hemoptysis without any recurrence was 81% at one month and 74% at one year. Three major complications occurred: spinal cord ischemia, stroke, and acute pancreatitis. 5% of patient died from hemoptysis. One-year overall survival was 29% and was significantly higher in patients without hemoptysis recurrence when compared to patients with recurring hemoptysis (p = 0.021). In univariate analysis, recurrence of hemoptysis at one year was associated with massive hemoptysis (RR = 2.50; p = 0.044) and with tumor cavitation (RR = 2.51; p = 0.033).

CONCLUSION

Endovascular treatment for primary lung cancer-related hemoptysis is effective but not uneventful.