Isolated bronchial hemangioma causing recurrent hemoptysis: A case report

RATIONAL

The development of bronchial hemangioma in adults is rare, and massive hemoptysis due to diffuse vascular proliferation of bronchial hemangioma is fatal.

PATIENT CONCERNS

A case of a 29-year-old woman kept massive hemoptysis even after being underwent repeated interventional embolization for recurrent massive hemoptysis. Eventually, the patient was performed the operation of right upper lung lobectomy and bronchial hemangioma with extracorporeal membrane oxygenation support and was followed up for 4 years without recurrent hemoptysis.

DIAGNOSES

Bronchial hemangioma.

CONCLUSION

For patients with bronchial angiomas bonded with bronchial artery-pulmonary arteriovenous fistulae, the early surgical resection is recommended if bronchial artery embolization (BAE) is considered ineffective.

[Endovascular Treatment of a Ruptured Mediastinal Bronchial Artery Aneurysm]

Case 1:A 73-year-old man was transported to our hospital for evaluation of sudden onset of chest pain, back pain, and dyspnea. We initially misdiagnosed him with advanced esophageal cancer accompanied by mediastinal metastasis;however, subsequent multi-detector row computed tomography (MDR-CT) confirmed the diagnosis. We performed coil embolization of a bronchial artery aneurysm and thoracic endovascular aortic repair( TEVAR) to seal the root of the bronchial artery. Case 2:An 81-year-old woman with a one-week history of fever and cervical pain was diagnosed with a ruptured infected thoracic aneurysm. She underwent the same treatment as described in Case 1. Physicians should consider it as a differential diagnosis of mediastinal hematoma.

[Racemose Hemangioma of the Bronchial Artery with Pulmonary Artery Fistula]

A 55-year-old woman was suspected of having hilar lymph node enlargement on a routine examination of the chest computed tomography( CT) scan at our hospital. On further examination, thoracic contrast CT and bronchial arteriography showed prominent dilation and meandering of the right bronchial artery with an aneurysm which formed a fistula to the pulmonary artery A7 at its distal end. Diagnosed as racemose hemangioma of bronchial artery with pulmonary artery fistula, we performed a surgical resection by open thoracotomy on the second day following bronchial artery embolization( BAE). No recurrence was observed in the five years of follow-up period after surgery. Therefore, surgical resection for asymptomatic racemose hemangioma of bronchial artery with bronchial artery-pulmonary artery fistula can be considered an effective method for the long-term prevention of bleeding.

A Ruptured Mediastinal Bronchial Artery Aneurysm Treated with Urgent Thoracic Endovascular Aortic Repair

Bronchial artery aneurysms (BAA) are a rare but potentially life-threatening complications because of the massive hemothorax or hemoptysis that occurs with ruptures. A 79-year-old woman was transferred to our hospital because of the sudden onset of back pain, syncope, and subsequent hypotension. Computed tomography showed a left BAA with bilateral hemothorax and hemomediastinum. Transcatheter bronchial artery embolization failed because of the anatomical location, and she went into cardiopulmonary arrest. Cardiopulmonary resuscitation was performed with successful revival. Urgent thoracic endovascular aortic repair to cover the root of the left bronchial artery was successful, and she survived without any neurological deficits.

Dieulafoy disease of the bronchus involving bilateral arteries: A case report and literature review

RATIONALE

Dieulafoy disease of the bronchus is a rare vascular deformity. To the best of our knowledge, reports of these involving both lung vascular are hitherto absent.

PATIENT CONCERNS

A 67-year-old male was admitted to our department due to agnogenic hemoptysis.

DIAGNOSES

Bronchoscopy was performed and some smooth, pulsatile nodular lesions were found in the middle and lower lobes, Computed tomography angiography of the bronchial artery confirmed a left bronchial artery arising from the aortic arch at T4 level, and both bronchial arteries were dilated and tortuous.

INTERVENTIONS

Bronchial artery embolization was performed successfully.

OUTCOMES

The patient was discharged with no hemoptysis. In addition, patient is under follow-up until today without any further incidents.

LESSONS

This case reminds us that Dieulafoy disease of the bronchus could be a potential etiology for unexplained hemoptysis. The clinician should be aware of this disease when bronchoscopy revealed multiple some smooth, pulsatile nodular lesions, thereafter, bronchoscope biopsy should be avoided, as it could lead to fatal hemoptysis.

Endovascular treatment of ectopic bronchial artery aneurysm with brachiocephalic artery stent placement and coil embolization: A case report and literature review

BACKGROUND

Bronchial artery aneurysm (BAA) is an uncommon but potentially life-threatening disease, and multiple BAAs are even rarer. Clinically, the tortuous and short neck of a BAA may present significant challenges for invasive intervention.

METHODS

This report describes the detailed process of diagnosis and treatment and includes a literature review of the etiology, clinical presentation, and therapeutic management of BAA.

RESULTS

A rare case of multiple BAAs, with one having an inflow artery arising from the brachiocephalic trunk, was referred to our hospital. The patient was successfully treated with coil embolization and brachiocephalic artery stent placement. In addition, we conducted a literature review involving 63 cases of BAA. BAA was most commonly associated with bronchiectasis and was located predominantly in the mediastinum. There was no significant difference between the diameters of the ruptured aneurysms and those of the nonruptured aneurysms (P = 0.115). Transcatheter arterial embolization was the most commonly adopted technique to treat BAA, while thoracic aortic endovascular repair was selected if the neck between the aneurysm and the aorta was short. Subgroup analysis suggested that patients with > 1 BAA were significantly more likely to be female than male (χ test, P = 0.034).

CONCLUSION

Transcatheter coil embolization combined with stent placement could be a reasonable treatment option for BAAs with a tortuous and short neck. According to our literature review, patients with multiple BAAs display distinctive clinical characteristics compared with patients with a single BAA.

[APPLICATIONS ENDOVASCULAR HEMOSTASIS TREATMENT OF PULMONARY HEMORRHAGE]

Rentgenoendovascular embolization of bronchial arteries was performed in 222 patients about pulmonary hemorrhage (PH) of different nature. Resistant hemostasis was achieved in 198 (89.9%) patients. The possibility of endovascular hemostasis in patients in advanced lung cancer complicated by PH. Hemostasis was ineffective in 24 (10.8%) patients. Died 5 (2.2%) patients due to unresectable lung cancer. The reasons for ineffective hemostasis were analysed.

[Incidentally detected bronchial artery aneurysm with combined operation for mitral regurgitation;report of a case]

A 77-year-old woman was admitted to the hospital for heart failure with orthopnea. Echocardiography revealed massive mitral regurgitation. During preoperative cardiac catheterization, an aneurysm was indentified incidentally just below the tracheal carina. Three dimensional computed tomography showed three bronchial artery aneurysms behind the pulmonary artery and the left atrium. The proximal aneurysm was the largest and was 22 mm in diameter. It was resected by retracting the ascending aorta to the left, the superior vana cava to the right and right pulmonary artery cranially under cardiopulmonary bypass, and mitral valve plasty was performed. We believed that resection of the proximal aneurysm would cause thrombotic occlusion of the other 2 aneurysms. Bronchial artery aneurysm is a rare entity that is observed in fewer than 1% of those who undergo selective bronchial arteriography. In addition, because bronchial artery aneurysm is a potentially life-threatening lesion, it should be treated promptly when diagnosed.

[Bronchial artery ligation for the management of hemoptysis]

Hemoptysis is defined by the expectoration of blood from infra-glottal airway. Massive hemoptysis can be a life-threatening intrathoracic disease that requires urgent investigations and management. The chest radiography and the computed tomography (CT) are useful to localize the bleeding site and to identify the cause of hemoptysis. Bronchial artery embolization is the most effective nonsurgical treatment in the management of massive and recurrent hemoptysis. This article reviews the role of radiology in the diagnosis and treatment of hemoptysis.

Congenital systemic and coronary-to-pulmonary artery fistulas

Congenital systemic-to-pulmonary artery fistulas are very rare, with the exception of congenital heart disease and pulmonary sequestration. We describe the first reported case of left internal mammary and bronchial artery to pulmonary artery fistulas associated with bilateral coronary arteries to pulmonary artery fistulas.

Management of tracheobronchial ulceration induced by high-dose brachytherapy

The most severe complication of high-dose endobronchial brachytherapy is fatal hemoptysis. Intractable tracheobronchial ulceration due to high-dose endobronchial brachytherapy often develops into tracheobronchial necrosis and fatal hemoptysis. Our experience demonstrated that when bleeding from tracheobronchial ulcer, after high-dose endobronchial brachytherapy occurs, blocking the blood supply to the tracheobronchial ulcer alone is ineffective. Prophylactic tracheobronchial wrapping using the omentum should be added before the occurrence of fatal hemoptysis. This is the first report that describes an effective management for preventing fatal hemoptysis.

[Successful treatment of a primary racemose hemangioma using ligation and transection of the bronchial artery decided on the basis of the intra-operative arterial pressure]

An 80-year-old woman presented with hemoptysis. Fiberoptic bronchoscopy revealed a blue, non-pulsatile, polypoid lesion at the orifice of the left upper division bronchus. Bronchial arteriography demonstrated convolution, dilatation, and pooling of contrast material in the left upper lobe. Since the bronchial arterial pressure decreased to the predicted pulmonary artery pressure after transient interruption between the aorta and proximal bronchial artery, the racemose hemangioma was presumed to be supplied mainly from the bronchial artery. She underwent ligation and transaction of the left bronchial artery, and had no further hemoptysis. Measurement of the bronchial arterial pressure is important for determining how to treat racemose hemangioma.

Coronary-to-bronchial anastomosis: an unusual cause of hemoptysis

Coronary-to-bronchial anastomosis (CBA) is a rare anomaly. This vascular abnormality may be subclinical or be responsible for several pathophysiological events and symptoms involving the respiratory and/or the coronary system. We report the case of a patient with hemoptysis caused by this anomalous coronary-to-bronchial communication, who was concomitantly affected by aortic stenosis and coronary artery disease requiring surgical treatment. A coronary angiogram clearly demonstrated the abnormal vascular connection between the proximal right coronary artery and the bronchial arteries of the left inferior right lobe. The coronary branch was intra-operatively identified and ligated, in association with aortic valve replacement and coronary artery bypass, with an uneventful postoperative course and resolution of the respiratory symptoms. This case presents an unusual cause of hemoptysis due to CBA in patients with other cardiac comorbidities, which required surgical treatment, allowing direct ligation of the CBA. A review of the clinical and therapeutic characteristics of such a peculiar vascular abnormality is also provided.

An integrated approach to diagnosis and management of severe haemoptysis in patients admitted to the intensive care unit: a case series from a referral centre

Background

Limited data are available concerning patients admitted to the intensive care unit (ICU) for severe haemoptysis. We reviewed a large series of patients managed in a uniform way to describe the clinical spectrum and outcome of haemoptysis in this setting, and better define the indications for bronchial artery embolisation (BAE).

Methods

A retrospective chart review of 196 patients referred for severe haemoptysis to a respiratory intermediate care ward and ICU between January 1999 and December 2001. A follow-up by telephone interview or a visit.

Results

Patients (148 males) were aged 51 (± sd, 16) years, with a median cumulated amount of bleeding averaging 200 ml on admission. Bronchiectasis, lung cancer, tuberculosis and mycetoma were the main underlying causes. In 21 patients (11%), no cause was identified. A first-line bronchial arteriography was attempted in 147 patients (75%), whereas 46 (23%) received conservative treatment. Patients who underwent BAE had a higher respiratory rate, greater amount of bleeding, persistent bloody sputum and/or evidence of active bleeding on fiberoptic bronchoscopy. When completed (n = 131/147), BAE controlled haemoptysis in 80% of patients, both in the short and long (> 30 days) terms. Surgery was mostly performed when bronchial arteriography had failed and/or bleeding recurred early after completed BAE. Bleeding was controlled by conservative measures alone in 44 patients. The ICU mortality rate was low (4%).

Conclusion

Patients with evidence of more severe or persistent haemoptysis were more likely to receive BAE rather than conservative management. The procedure was effective and safe in most patients with severe haemoptysis, and surgery was mostly reserved to failure of arteriography and/or early recurrences after BAE.

An Adult Case of Bilateral True Tracheal Bronchi Associated With Hemoptysis

The term tracheal bronchus encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe, and a true tracheal bronchus is any bronchus originating from the trachea. In most cases, it is found incidentally during bronchoscopy or tomography. It is often unilateral, and bilateral true tracheal bronchi are very rare. We report a case of a 54-year-old woman who had bilateral true tracheal bronchi associated with hemoptysis.

Dieulafoy's disease: a cause of massive hemoptysis that is probably underdiagnosed

Dieulafoy's disease is a vascular anomaly characterized by the presence of a tortuous dysplastic artery in the submucosa. The condition was first described as a cause of gastrointestinal bleeding in the stomach. Recently, there have been a few reports of Dieulafoy's disease involving the respiratory tract. Herein, we report 2 patients with massive hemoptysis who were treated with surgical resection and later diagnosed with bronchial Dieulafoy's disease.

Airway vascular changes after lung transplant: potential contribution to the pathophysiology of bronchiolitis obliterans syndrome

BACKGROUND

Bronchiolitis obliterans syndrome (BOS) remains the primary factor limiting successful lung transplantation. In asthma and lung transplantation BOS-increased sub-mucosal vascularity has been shown to contribute to airflow limitation. Vascularity has 2 components: sprouting angiogenesis (more vessels) and microvascular enlargement (larger vessels). We hypothesized that the lack of a reanastomosed bronchial arterial blood supply at the time of transplant might stimulate angiogenesis and be a risk factor for subsequent BOS.

METHODS

Twenty-seven initially stable lung transplant recipients (BOS 0) were recruited at 148 +/- 80 days post-transplant and underwent clinical and bronchoscopic longitudinal follow-up for at least 3 years. Eight remained stable and BOS developed in 19. Nine normal controls were also recruited. Airway vasculature was examined immunohistochemically in endobronchial biopsy (EBB) specimens with collagen IV antibody, quantified by computer image analysis, and expressed as average vessel size, vessel number, and overall vascularity. The effects of demographic, clinical, bronchoalveolar lavage (BAL), and EBB variables on airway vasculature were analyzed in a multivariate model.

RESULTS

No significant differences in airway vascularity were found between stable and BOS lung transplant recipients cross-sectionally or longitudinally. However, both lung transplant groups at baseline showed significantly greater airway vascularity compared with normal controls (p < .05). Multivariate analysis suggested that the percentage of BAL CD3+ cells and acute rejection are the most influential variables on airway vasculature.

CONCLUSIONS

This study suggests early and persistent airway vasculature changes occur in lung transplant recipients, mainly manifested as microvascular enlargement. Potentially this baseline change contributes to airway obstruction and also puts all lung transplant recipients at risk for further exponential loss of airway caliber with any subsequent airway inflammatory insult.

[Successful surgical ligation and transection of racemose hemangioma of bronchial artery]

We report two cases of bilateral racemose hemangioma in patients with hemoptysis. Case 1 was a 62-year-old woman who visited a local clinic complaining of hemoptysis. Bronchoscopy revealed multiple pulsating tumorous lesions and she was referred to our department. Chest Multidetector CT (MDCT) disclosed bilateral enlarged and convoluted, abnormal bronchial arteries and primary racemose hemangioma was diagnosed. Bronchial artery embolization was selected, but not conducted because of concern regarding the arteriovenous shunt and escape into the greater circulation. In combination with thoracoscopic mini-thoracotomy, ligation and separation of the bronchial artery were performed. Case 2 was a 68-year-old man who was transferred to our department with a chief complaint of hemoptysis. MDCT revealed bilateral bronchiectasis and a convoluted and enlarged, abnormal bronchial artery along the mediastinum. He was diagnosed as having secondary racemose hemangioma. First, bronchial artery embolization was conducted, but hemostasis was difficult, thus surgical ligation was conducted. In both cases, MDCT was effective for diagnosis and surgical ligation is very important as a therapeutic option for racemose hemangioma.

Bronchial artery revascularization restores peribronchial tissue oxygenation after lung transplantation

With the interruption of the bronchial arteries after lung transplantation, nutritive support is dependent on collateral flow by the pulmonary arteries with desaturated venous blood. Consequently, oxygen deficiency of the peribronchial and dependent lung tissue may occur. Using a canine model for left lung transplantation, we investigated hypoxic peribronchial tissue after conventional lung transplantation and demonstrated restitution of tissue oxygenation after transplantation with bronchial artery revascularization (BAR) (BAR group: Po2 120.4 +/- 28.7 mm Hg; control group Po2 6.8 +/- 2.8; p < 0.001). BAR in lung transplantation protects peribronchial tissue of the transplanted graft from hypoxia in the early phase after reperfusion.

[Bronchial arteries: anatomical and clinical studies and strategies in surgical approach]

One of the most important and controversial aspects of thoracic surgery is due to the topographical and surgical anatomy of the vascular structures involving the mediastinum. The knowledge of the so-called "vascular time", in fact, allows to face more complicated surgical situations, typical of the most specialistic thoracic surgery. The bronchial arteries represent a paradigm of what we have just stated. The study of their anatomy (number, position, origin, distribution and relationships with the mediastinal structures) is of relevant importance, not only for the interest the bronchial vascular tree arises in tracheo-bronchial surgery and in pulmonary transplantology, but also for the knowledge of the pathogenesis of some processes regarding pulmonary and pleural pathologies. The aim of this paper is to evaluate the real clinical interest of bronchial arteries, with an analytic study of the anatomy of vessels, and with the possibility to show the most frequent and characteristic anomalies involving the origin and course of these arteries.

[Castleman's disease of left interloblar lymph node; report of a case]

A 21-year-old man developed an abnormal shadow of left hilum of the lung, discovered in an annual X-ray examination. The tumor grew 3 times in size as large as it had been 1 year before. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed a homogenous mass lesion at the left interloblar portion of the left lung. CT revealed that the left pulmonary artery was markedly compressed by the tumor of left hilum. Surgical operation was performed under usual thoracotomy. The ligation of the branches of the left bronchial artery before tumor resection was very helpful to control bleeding from the tumor. We showed that a tumor of Castleman's disease may be resected without lobectomy of the lung or further procedures.

Giant mediastinal bronchial artery aneurysm mimicking benign esophageal tumor: a case report and review of 26 cases from literature

Mediastinal bronchial artery aneurysm is rare but potentially life-threatening, and requires prompt treatment to avert rupture with catastrophic results. A 78-year-old man was referred to our hospital with a benign esophageal tumor, which appeared as an extrinsic, extramucosal filling defect on an esophagogram. Chest computed tomography and selective bronchial arteriography led to a definitive diagnosis of mediastinal bronchial artery aneurysm. Aneurysmectomy and closure of the ostia of both the afferent and efferent bronchial arteries was performed via standard posterolateral thoracotomy. Postoperative course was uneventful, and the patient was discharged on the seventh postoperative day.

[A case of bronchial arterial aneurysm associated with recurrent massive hemoptysis]

A 69-year-old man was admitted to our hospital because of massive hemoptysis. Bronchial arteriography showed no abnormal findings. Bronchoscopic findings revealed a small, reddish elevated lesion on the posterior surface of the left upper lobe bronchus. Since the patient developed massive hemoptysis four times in a month, he underwent ligation and transection of the left bronchial artery, and bronchoplasty. Histopathologically, the resected tissue showed a bronchial arterial aneurysm without any inflammatory changes. We concluded that the aneurysm had developed in a malformed vessel.

Added benefit of thoracic aortography after transarterial embolization in patients with hemoptysis

OBJECTIVE

The purpose of this study was to examine the usefulness of thoracic aortography performed after transarterial embolization in identifying additional arteries responsible for causing hemoptysis.

SUBJECTS AND METHODS

Between March 2000 and November 2001, we prospectively performed thoracic aortography after transarterial embolization in 76 patients with hemoptysis. Underlying diseases included tuberculosis (n = 34), bronchiectasis (n = 30), emphysema (n = 4), bronchitis (n = 4), aspergillosis (n = 3), and lung cancer (n = 1). Initially, angiography of bronchial and other systemic arteries possibly contributing to hemoptysis was performed with embolization. After completion of the embolization, thoracic aortography was performed, with the tip of the catheter located just distal to the origin of the left subclavian artery.

RESULTS

A total of 200 arteries (52 right bronchial, 40 left bronchial, six common bronchial, 76 intercostal, 11 inferior phrenic, six thoracodorsal, eight internal mammary, and one thyrocervical) were identified either at the initial embolization or on thoracic aortography as being responsible for causing hemoptysis. Among them, 29 arteries (14.5%) that were not included on the initial selection for embolization were later identified on postembolization thoracic aortography. There were two right bronchial, three left bronchial, eight inferior phrenic, and 16 intercostal arteries.

CONCLUSION

The inferior phrenic and intercostal arteries were often missed on routine transarterial embolization in patients with hemoptysis. Postembolization thoracic aortography is useful for monitoring the effectiveness of embolization and for improving the detection of arteries contributing to hemoptysis.

Mediastinal bronchial artery aneurysm treated with a stent-graft

PURPOSE

To report a rare case of mediastinal bronchial artery aneurysm successfully treated with an endovascular stent-graft.

CASE REPORT

A 79-year-old man with a history of tuberculosis was admitted to our hospital complaining of worsening hoarseness. Examination revealed a large mediastinal bronchial artery aneurysm located near the origin of the artery. Since neither surgical intervention nor transcatheter embolization was feasible, an endovascular stent-graft repair was performed using a newly developed stent-graft constructed from a nitinol stent and a thin membrane of polyester. Postprocedural angiography showed satisfactory exclusion of the aneurysm. The patient made an uneventful recovery. The 18-month computed tomographic scan documented continued exclusion of the aneurysm, with no evidence of endoleak, graft thrombosis, or migration.

CONCLUSIONS

When conventional procedures are too complicated for bronchial artery aneurysms, endovascular stent-graft repair can be a useful approach.

[Successful transection of racemose hemangioma of bronchial artery; report of a case]

A 52-year-old female was admitted to the hospital because of increasing hemoptysis for twenty years. Chest computed tomography (CT) on admission showed bronchoectasia with dilated bronchial arteries in the left lower lung field. Bronchial arteriogram showed racemose hemangioma of bronchial arteries draining to left lower pulmonary arteries. Transresection of bronchial artery and partial lung resection was performed. The cut surface of the resected specimen showed bronchoectasia with dilated bronchial arteries (8 mm in diameter). She is well 15 months following the treatment with no evidence of hemoptysis.

Bronchial artery aneurysm disguised as a leiomyoma of the esophagus

Bronchial artery aneurysm (BAA) is a rare entity with potentially fatal hemorrhagic complications. It is usually diagnosed using a computed tomography scan or angiography in emergency situations (clinical picture of aortic dissection or massive hemoptysis). We report a case of bronchial artery aneurysm where dysphagia was the predominant symptom. Thoracic computed tomography and endoscopic ultrasound seemed to indicate leiomyoma of the esophagus. The final diagnosis revealed a bronchial artery aneurysm.

Bronchial artery revascularization affects graft recovery after lung transplantation

Restitution of bronchial artery circulation might alter ischemia- reperfusion injury and improve organ function after lung transplantation. Weight-matched dogs underwent a left lung allotransplantation either with bronchial artery revascularization (BAR; n = 6) or as conventional lung transplantation (LTX; n = 6), to evaluate effects of BAR on lung cell function over a period of 5 h postischemically. Lactate dehydrogenase (LDH) and marker enzymes for pneumocytes type I (carboxypeptidase M [CPM], pneumocytes type II (alkaline phosphatase [AP]), and pulmonary endothelium (angiotensin-converting-enzyme [ACE]) were determined from bronchoalveolar lavage fluid. Donor lungs were preserved with Euro-Collins solution. Total ischemic time was kept at 6 h. CPM and LDH activities were significantly higher in both groups at 2 h and 4 h of reperfusion compared with control dogs (p < 0.01). AP and ACE activities in lavage after 2 h of reperfusion were significantly elevated in animals that underwent LTX (AP: 60 +/- 28 IU/L; ACE: 1.39 +/- 1.13 IU/L) compared with animals with BAR (AP: 33 +/- 29 IU/L; ACE: 0.35 +/- 0.6 IU/L; p < 0.05) and with control animals (AP: 13.58 +/- 11.0 IU/L; ACE: 0.06 +/- 0.14 IU/L; p < 0.01). According to these results, BAR protects pulmonary endothelium and type II pneumocytes in the early phase after lung transplantation and might have consequences for lung tissue in the long term.

Primary racemose hemangioma of the bronchial artery

A 44-year-old woman was admitted to our hospital for repeated hemoptysis. Selective angiography of the bilateral bronchial arteries showed them to be enlarged and convoluted, and revealed shunts between the bronchial and pulmonary arteries. The patient was diagnosed as having racemose hemangioma of the bronchial artery. Although embolization of the bronchial artery with gelatin sponges was performed, hemoptysis emerged again about one year later. Finally, segmentectomy of the right lower lung was performed and primary racemose hemangioma of the bronchial artery was histopathologically confirmed.

Deleterious effects of telescoped bronchial anastomosis in single and bilateral lung transplantation

PURPOSE

To compare complication rates of telescoped versus end-to-end bronchial anastomoses in single and bilateral lung transplantation.

METHODS

One hundred and thirty adult lung transplant recipients were evaluated during a seven-year period for the presence of three types of major bronchial anastomotic complications (ischemia, dehiscence, and severe stenosis). Surgical technique, clinical course, and mortality in all patients were reviewed retrospectively.

RESULTS

The three major complications, ischemia, dehiscence, and severe stenosis, were observed in 13 (32%), 10 (24%), and 13 (32%), respectively, of 41 telescoped bronchial anastomoses. In contrast, ischemia, dehiscence, and severe stenosis, occurred in 25 (19%), 14 (10%), and 11 (8%) of 135 end-to end anastomoses. These differences were statistically significant for the occurrence of dehiscence and severe stenosis (p=0.0350 and 0.0004, respectively), and not statistically significant for ischemia (p=0.0846). Five (12%) telescoped anastomoses required stent placement as compared with six (4%) end-to end anastomoses (p=0.1313). Early postoperative pneumonia was more common in the telescoped anastomosis group (57%) as compared to the end-to-end group (35%; p=0.0271). There was a trend to shorter survival in the telescoped anastomosis group (mean survival 1172+/-149 d) as compared to the end-to-end group (mean survival 1542+/-126 d), but these differences did not achieve statistical significance (p=0.2400).

CONCLUSION

In single and bilateral lung transplants, telescoped anastomoses are associated with a higher incidence of bronchial anastomotic complications and postoperative pneumonia than end-to-end anastomoses.

Extrapleural bronchial artery ligation for life-threatening hemoptysis in cystic fibrosis--a case report

Hemoptyses are common in cystic fibrosis (CF) patients. They range from massive life-threatening (> 240 mL/24 hours) to recurrent minor streaking. Limited pulmonary reserve, potential concurrent chest infection, and the progressive nature of CF pose a high risk to this subgroup. Conservative management and selective bronchial artery embolization (BAE) control most acute episodes, but the recurrence rate is high. The possible need for lung transplantation in future makes an extrapleural approach for bronchial artery ligation desirable. The aim of this study was to assess the role of extrapleural bronchial artery ligation in the treatment of recurrent hemoptysis in CF patients. This is a retrospective analysis of four patients between 1986 and 1999 treated by extrapleural thoracotomy and ligation of bronchial arteries. Indications, surgical experience, and outcome are presented. Three patients underwent unilateral, and one patient bilateral extrapleural thoracotomy (in two separate sessions) for bronchial artery ligation. There were three men and one woman, with a mean age of 26.6 years (range 19-32 years). Indications were failure to stabilize the bronchial arterial catheter for BAE (three cases), recurrence after BAE previously controlled bleeding (one case), and communication with the right costocervical trunk signifying risk to the spinal circulation (one case). The mean follow-up was 68 months (range 3-144 months). There was one death in this series, a patient who was asphyxiated with hemoptysis, requiring ventilation preoperatively. He underwent successful extrapleural thoracotomy for bronchial artery ligation, with no further bleeding but succumbed to severe chest infection and multiorgan failure a few days later. Two patients had recurrent bleeding 12 and 36 months after surgery. Selective bronchial angiography proved the contralateral bronchial arteries to be the culprit. Extrapleural bronchial artery ligation is an effective method of controlling hemoptysis in CF, when BAE has failed. This approach minimizes pleural adhesions and is, therefore, desirable in the future consideration for lung transplantation. In this experience, muscle-sparing thoracotomy and postoperative epidural analgesia significantly improved the postoperative recovery.

Operative aneurysmectomy and middle lobectomy for asymptomatic bronchial artery aneurysm in young patient

A 33-year-old woman was admitted for investigation of a round right hilar shadow on chest X-ray. A bronchial arteriogram revealed it was a bronchial artery aneurysm. She had no symptoms such as bloody sputum or hemoptysis. Although bronchial arterial embolization (BAE) is a good procedure for controlling hemoptysis, sometimes hemostasis is unsuccessful or bleeding recurs after BAE. Our patient underwent an operative aneurysmectomy and middle lobectomy to eliminate aneurysmal rupture instead of BAE.

Magnetic resonance imaging angiography in patency evaluation of bronchial artery revascularization grafts

In this report we present our experience of non-invasive magnetic resonance imaging (MR) angiography and selective catheter angiography in assessing the patency of bronchial artery revascularization grafts after an en bloc double-lung and heart-lung transplantation. We studied 8 patients who had undergone pulmonary transplantation with direct bronchial artery revascularization. Catheter angiography was performed 10 days to 63 months postoperatively. MR angiography was performed within 24 h of the catheter procedure and the results were compared with the findings from catheter angiography. Catheter angiography showed the bronchial revascularization graft to be patent in 6 patients and occluded in 2. At MR angiography, the patency of bronchial artery revascularization grafts was reliably identified in 7 of the 8 patients. One patient had inadequate image quality because of void artefacts caused by haemostatic clips. It is concluded that MR angiography is a reliable method for assessing the patency of bronchial artery revascularization grafts.

Laser Doppler flowmetry detects early risk of tracheal anastomotic complications after lung transplantation

Healing of tracheal anastomosis after en bloc double-lung or heart-lung transplantation was analysed with the aid of endoscopic laser Doppler flowmetry in 7 patients (group I) with successful bronchial artery revascularization (BAR) and in 5 patients (group II) without or with failed BAR. Fifteen patients undergoing coronary surgery served as a control group. Airway anastomotic index (AAI) was used to express the ratio of Doppler flowmetry values between donor and recipient airway. On postoperative day 1 the mean (range) AAI was 1.3 (1.1-1.6) in group I, 0.74 (0.25-1.0) in group II and 0.95 (0.7-1.4) in the controls.The difference was statistically significant between groups I and II (p = 0.01) and also between group I and the control group (p = 0.003). Two group II patients had low AAI (<0.5), and both developed airway anastomotic complications. We conclude that successful BAR increases blood flow in the airway anastomotic region, and that low AAI on the first postoperative day is a strong predictor of late airway anastomotic complications.

[Successful thoracoscopic ligation and transection of racemose hemangioma of bronchial artery]

We used thoracoscopy for the successful ligation and transection of a racemose hemangioma of bronchial artery. The patient was a 61-year-old woman who had been admitted to our hospital because of hemoptysis. Bronchoscopic examination revealed bulging lesions covered with normal bronchial mucosa in the right B5 and B8, and bronchial arteriography revealed a shunt between the right bronchial arteries and pulmonary arteries and veins. Ligation and transection of the right bronchial artery under thoracoscopy was performed. Hemoptysis has not recurred 9 months after the operation. Thoracoscopic ligation and transection of bronchial artery may be an effective and less invasive procedure for the treatment of racemose hemangioma.

Human bronchial artery blood flow after lung Tx with direct bronchial artery revascularization

The inaccuracy of measuring human bronchial artery blood flow has previously been considerable. En bloc double-lung transplantation with bronchial artery revascularization (BAR) using a single conduit offers the unique opportunity of direct measurement of the total bronchial artery blood flow. In eight en bloc double-lung-transplanted patients with complete BAR, the basal blood flow was measured by using a 0.014-in. Doppler guide wire and arteriography. The average peak velocity in the conduit was 12-73 cm/s [+/-2.1 (SD) cm/s], and the conduit diameter was 1.7-3.1 mm [+/-0.10 (SD) mm], giving individual basal flow values between 19 and 67 ml/min [+/-5 (SD) ml/min], or 0.2-1.9% of estimated cardiac output. In three patients basal measurements were followed by injection of nitroglycerin and verapamil into the conduit. This increased the bronchial artery flow to 121-262% of basal values (31-89 ml/min). The measured values appear more physiologically plausible than previous bronchial artery blood flow measurements in humans.

Bronchial artery perfusion scintigraphy to assess bronchial artery blood flow after lung transplantation

The bronchial arterial system is inevitably interrupted in transplanted lungs when removing the organs from the donor, but it can be reestablished by direct bronchial artery revascularization (BAR) during implantation. The purpose of this study was to visualize and quantify the distribution of bronchial artery perfusion after en bloc double lung transplantation with BAR, by injecting radiolabeled macroaggregated albumin directly into the bronchial artery system.

METHODS

BAR was performed using the internal mammary artery as conduit. Patients were imaged 1 mo (n = 13) or 2 y (n = 9) after en bloc double lung transplantation with BAR. Immediately after bronchial arteriography, 100 MBq macroaggregated albumin (45,000 particles) were injected through the arteriographic catheter. Gamma camera studies were then acquired in the anterior position. At the end of imaging, with the patient remaining in exactly the same position, 81mKr-ventilation scintigraphy or conventional intravenous pulmonary perfusion scintigraphy or both were performed. Images were evaluated by visual analysis, and a semiquantitative assessment of the bronchial arterial supply to the peripheral parts of the lungs was obtained with conventional pulmonary scintigraphy.

RESULTS

The bronchial artery scintigraphic images showed that the major part of the bronchial arterial flow supplied central thoracic structures, but bronchial artery perfusion could also be demonstrated in the peripheral parts of the lungs when compared with conventional pulmonary scintigraphy. There were no differences between scintigrams obtained from patients studied 1 mo and 2 y post-transplantation.

CONCLUSION

Total distribution of bronchial artery supply to the human lung has been visualized in lung transplant patients. This study demonstrates that this nutritive flow reaches even the most peripheral parts of the lungs and is present 1 mo as well as 2 y after lung transplantation. The results suggest that bronchial artery revascularization may be of significance for the long-term status of the lung transplant.

Airway epithelium of transplanted lungs with and without direct bronchial artery revascularization

OBJECTIVE

Normal systemic blood flow to the airways and lung parenchyma of transplanted lungs can only be re-established by direct bronchial artery revascularization. The purpose of the present study was to investigate whether such direct bronchial artery revascularization would preserve ciliary function, previously shown to be reduced in lungs transplanted without revascularization.

METHODS

Twenty-five single lung transplanted patients were included in this study. Complete direct bronchial artery revascularization was achieved in eight patients. In 16 patients the procedure had either failed (n = 10) or was not attempted (n = 6). In one patient the result of the revascularization was unknown. Airway epithelium samples were obtained from the native and the transplanted lungs during bronchoscopic examinations. Airway erythema and excessive secretion were registered. The epithelium samples underwent histological examination and ciliary beat frequency was measured in vitro by video recording. Transbronchial biopsies from the transplanted lungs were examined for signs of rejection and bronchitis.

RESULTS

No differences in ciliary beat frequency nor in the distribution of ciliated/de-ciliated columnar epithelium cells between native lungs and transplanted lungs with or without successful direct bronchial artery revascularization could be demonstrated. In 38% of the transplanted lungs without successful revascularization metaplastic or squamous epithelium was present, while lungs with successful revascularization had only normal columnar epithelium. Ongoing rejection or airway erythema did not influence ciliary beat frequency. Excessive secretion in the airways was the only finding associated with significantly increased ciliary beat frequency.

CONCLUSIONS

Ciliary beat frequency of epithelium cells of transplanted lungs did not differ from that of native lungs and consequently direct bronchial artery revascularization did not have any demonstrable important influence. Excessive secretion in the airways was associated with increased ciliary beat frequency. The histological findings also showed that the abundance of ciliated cells was preserved in transplanted bronchi irrespective of bronchial artery revascularization. However, epithelium metaplasia was only seen in transplanted bronchi without revascularization.

Does bronchial artery revascularization influence results concerning bronchiolitis obliterans syndrome and/or obliterative bronchiolitis after lung transplantation?

OBJECTIVE

To study the frequency of histological obliterative bronchiolitis and clinical bronchiolitis obliterans syndrome after en bloc double lung transplantation with bronchial artery revascularization and bilateral lung transplantation without bronchial artery revascularization.

METHODS

Primary en bloc double lung transplantation with bronchial artery revascularization using the internal mammary artery as conduit was performed in 62 patients. The frequencies of obliterative bronchiolitis and bronchiolitis obliterans syndrome have been established from transbronchial biopsies and lung function measurements. Results have been analyzed in relation to the arteriographic success of bronchial artery revascularization and have been compared to results from Stanford University, obtained through personal communications.

RESULTS

Survival after 1, 2, 3, 4 and 5 years was 85, 81, 69, 69, and 69%, respectively. Fifteen patients developed bronchiolitis obliterans syndrome while seven developed obliterative bronchiolitis. Survival was superior for patients with bronchial artery revascularization classified as complete or incomplete bilateral versus incomplete hemilateral, incomplete poor or failed (P = 0.016, log-rank test). For patients surviving > or = 3 months post-transplant, the post-operative baseline FEV1 was lower for patients who later developed bronchiolitis obliterans syndrome compared to patients who did not (P = 0.007). The development of bronchiolitis obliterans syndrome and obliterative bronchiolitis were both correlated to observation time post-transplant but not to the number of rejections or infections when corrected for observation time.

CONCLUSIONS

In a subgroup of lung transplant patients, a process in the transplanted lungs, eventually leading to bronchiolitis obliterans syndrome diagnosis, seems to start in the donor during the transplantation and/or in the early post-operative cause. A comparison with results after bilateral lung transplantation without bronchial artery revascularization suggests that good direct bronchial artery revascularization may postpone the onset of bronchiolitis obliterans syndrome and obliterative bronchiolitis. The positive trend motivates further use of direct bronchial artery revascularization in lung transplantation.

Coronary to bronchial artery anastomosis in patients with noncyanotic cardiopulmonary disease: report of seven cases

An angiographically visible coronary to bronchial artery anastomosis was found in seven (0.12%) of 6045 patients with noncyanotic cardiopulmonary disease who underwent coronary angiography between 1989 and 1995. Aortitis syndrome was associated with four patients, whereas pulmonary embolism, aortic regurgitation and vasospastic angina were the diagnoses in the others. Coronary stenotic lesions were not observed in any patients. In five of six patients who underwent pulmonary perfusion scintigraphy, perfusion defect was observed in the area supplied by the bronchial artery, which had the anastomosis to the coronary artery. In each patient this anastomosis seemed to function as collateral circulation, compensating for decreased perfusion in either the lung or the heart. When coronary to bronchial artery anastomosis is found, ischemic conditions in either the lung or the heart are likely.

Medium-term patency and anatomic changes after direct bronchial artery revascularization in lung and heart-lung transplantation with the internal thoracic artery conduit

OBJECTIVE

Our purpose was to study the 2-year patency of direct bronchial artery revascularization in lung transplantation. We wanted to clarify whether the revascularized bronchial artery system is functional after 2 years, whether bronchial artery vascularity changes with time, and whether posttransplantation bronchial artery disease is arteriographically evident after 2 years.

METHODS

Bronchial artery revascularization is performed by anastomosing the internal thoracic artery to as many bronchial artery orifices in the donor descending aorta as possible. Twenty-three patients surviving 2 years or more have had internal thoracic artery-bronchial arteriography performed 1 month and 2 years after transplantation. One-month and 2-year arteriograms have been compared.

RESULTS

Two-year patency of the internal thoracic artery conduit was 100%. The appearance of the bronchial arteries was unchanged after 2 years in 11 patients. A unilateral or bilateral increase in vascularity was found in two and seven patients, respectively. In three patients new vessels, not visible on the first arteriogram, had appeared. In four patients one or more small vessels visible on the first arteriogram had disappeared on the second arteriogram. We have found no arteriographic signs of bronchial artery disease, such as stenosis of the bronchial arteries, and no arteriographic evidence of arteriosclerotic disease in the internal thoracic artery.

CONCLUSION

The internal thoracic artery is an excellent conduit for bronchial artery revascularization, with a 2-year patency of 100% in 23 patients. Only minor changes in the bronchial arteriograms have been found.