Embolization Therapy: Principles and Clinical Applications, 1 Ed.

Hemoptysis

Miguel A. De Gregorio • Alicia Laborda

Massive hemoptysis, also known as life-threatening hemoptysis, is a serious, critical condition that necessitates urgent assessment and treatment of the patient. Despite advances in the treatment of massive hemoptysis, it still imposes a high-risk condition. According to published data, in any given year, 28% of pulmonologists witness a case of death due to massive hemoptysis.1

The lungs receive blood from the pulmonary artery and bronchial systems under normal conditions. In pathologic situations, systemic arteries can penetrate into the lung and irrigate contained injuries. The low-pressure pulmonary system tends to produce small-volume hemoptysis, whereas bleeding from the bronchial system, which shares systemic pressure, tends to be profuse.2

Conservative medical treatment of patients with expectoration of 300 to 600 mL of blood per day is associated with mortality in 50% to 100% of the patients affected,3 with asphyxia rather than hemorrhage commonly being the cause of death.4 Although surgical treatment of massive hemoptysis is associated with mortality rates between 7.1% and 18.2%, it can reach up to 40% when surgery is performed urgently.5

Since embolization of the bronchial artery was first described by Remy et al.6 in 1973, it has become the main option for the treatment of massive hemoptysis, either at first presentation or in case of recurrence. Various studies have demonstrated its effectiveness, safety, and usefulness.715 However, surgery plays an important role in the treatment of massive hemoptysis caused by certain diseases, such as pulmonary hydatidosis, bronchial adenoma, and aspergilloma that is refractory to other treatments.16 In such cases, prior urgent bronchial artery embolization facilitates surgical treatment and improves results because it allows scheduled rather than urgent surgery to be undertaken.5Surgery also represents the treatment of choice when bronchial artery embolization fails repeatedly or is insufficient to control massive life-threatening hemorrhage.17

Currently, when embolization of the bronchial artery fails, the use of endoscopically implanted thrombin preparations has been proposed on the basis of its high success rate.18

CLINICAL BACKGROUND AND PHYSICAL EXAMINATION

Most hemoptysis are generally small, do not require urgent action, and can be treated medically. It is crucial to differentiate hematemesis from hemoptysis. Before assuming a lower respiratory source of the bleeding, it is important to consider whether the blood may be coming from a nonpulmonary source, such as the upper airway or the gastrointestinal tract. Alkaline pH, foaminess, or the presence of pus may sometimes suggest the lungs as the primary source of bleeding rather than the stomach.

Other data such as age, nutritional status, and comorbidities may assist to the diagnosis and management of hemoptysis.

Epistaxis or expectoration without cough suggests that the source of bleeding is in the upper respiratory tract, whereas expectoration accompanied by cough indicates bleeding from the lower bronchial tree.19

It is difficult to quantify the amount of blood expectorated. In general, patients tend to overestimate, and besides, it is difficult to quantify the amount of blood retained in the alveolar space and the bronchial tree.

Clinical symptoms depend on several factors such as the underlying disease and causes of hemoptysis and the importance and amount of bleeding. Fever, hypoxia, tachycardia, and tachypnea are going to be the most important symptoms that may accompany a hemoptysis. The final cause of death in hemoptysis is not hypovolemia due to blood loss but asphyxiation by drowning.

ETIOLOGY

There are many causes of hemoptysis. Their frequency has varied with time. In the past, lung tuberculosis was the first and main cause, but the main cause nowadays is bronchiectasis. Salajka20 has summarized the main hemoptysis causes in the acronym BATTLE CAMP (Table 18.1).

Hemoptysis, which can be life threatening, complicates the course of 50% to 85% of patients with an aspergilloma.21 Tuberculosis can cause massive hemoptysis through multiple mechanisms: active cavitary or noncavitary lung disease can cause small or large amounts of bleeding. Active disease can cause sudden rupture of a Rasmussen aneurysm (aneurysm of the pulmonary artery that slowly expands into an adjacent cavity because of inflammatory erosion of the external vessel wall until it bursts).21

Many inflammatory or immune disorders can produce hemoptysis, such as Goodpasture syndrome, idiopathic pulmonary hemosiderosis, lupus pneumonitis, and Wegener granulomatosis. Other clinical situations can also explain a hemoptysis: coagulopathy, thrombocytopenia, or use of anticoagulants.

Iatrogenic etiology, especially due to either percutaneous or transbronchial lung biopsy, is a cause of hemoptysis, which is usually minor and transient and occurs in 5% to 10% of percutaneous lung biopsies, but massive hemorrhage and death have also been reported. Hemoptysis has been described in 6% of habitual smokers of free-base cocaine (“crack”) and has been associated with diffuse alveolar hemorrhage.

When hemoptysis is recurrent and coincident with menstruation, it can be caused by intrathoracic endometriosis, usually involving the pulmonary parenchyma but occasionally affecting the airways.21

As it has already been commented previously, blood can come from the pulmonary artery. The main causes of pulmonary origin are as follows: pulmonary embolism; pulmonary arteriovenous malformation, either with or without underlying Rendu-Osler-Weber syndrome; and elevated pulmonary capillary pressure (mitral stenosis, significant left ventricular failure, congenital heart disease, severe pulmonary hypertension). Pulmonary artery perforation from a Swan-Ganz catheter can also produce hemoptysis.

Depending on the study, up to 30% of patients with hemoptysis have no cause identified even after careful evaluation. In a series of 67 patients with cryptogenic hemoptysis, prognosis was generally good, and most patients had resolution of bleeding within 6 months of evaluation.22

In our series23 of 314 patients, the most frequent causes of massive hemoptysis were bronchiectasis (31.5%), followed by acute tuberculosis or scar tissue caused by tuberculosis (18.1%) and chronic bronchitis (14.9%). Other causes are shown in Table 18.2.

Multislice computed tomography (CT) represents the technique of choice for the etiologic diagnosis of nonmassive hemoptysis. Together with fiber bronchoscopy, they can settle down a very high percentage of the most important and severe causes of hemoptysis. Nevertheless, the use of the CT and the fiber bronchoscopy is discussed in acute massive hemoptysis, where arteriography can establish the diagnosis with good precision and, at the same time, contribute to its treatment.

BRONCHIAL ANATOMY

Bronchial arteries provide oxygen and nutritional elements to different pulmonary structures and also some adjacent mediastinal structures. They supply the trachea, bronchi, visceral pleura, and esophagus and the vasa vasorum of the aorta, pulmonary artery, and vein.24

Although there are many variations, there are usually two bronchial arteries that run in the right lung and one in the left lung. Bronchial arteries originally measure about 1 to 1.5 mm diameter. Above this diameter, they must be considered pathologic.25 The most common source of hemoptysis is located in the bronchial arteries (90%), and only in 5% of cases the pulmonary circulation is the origin of the bleeding.26

The remaining 5% of pulmonary bleeding originates directly from the aorta or systemic intrathoracic or extrathoracic branches.2729 In over 70% of the general population, the bronchial arteries arise directly from the descending thoracic aorta, most commonly between the levels of T5 and T6.30 When the bronchial arteries arise at these levels, they are called orthotopic, and when the source is outside these levels, their name is ectopic (8% to 35%). These ectopic bronchial arteries may originate from the aortic arch, brachiocephalic artery, subclavian artery, internal mammary artery, thyrocervical trunk, coronary arteries, costocervical trunk, pericardiacophrenic artery, inferior phrenic artery, or abdominal aorta31 (Fig. 18.1).

According to the classification of Morita et al.,32 the main right bronchial artery arises from the intercostobronchial trunk in more than 50% of the cases, and in the rest, it comes from a common trunk (right and left bronchial arteries) from the subclavian artery or directly from the aorta. Left bronchial artery, on the other hand, arises from a bronchial common trunk (right-left) in over 95% of the cases. Referencing the axial division of the aorta into eight segments, the right intercostobronchial artery ostium is usually located in the medial segment or anteromedial, whereas the origin of the bronchial common trunk (right-left) arises from the anterolateral segment (>70%)33 (Fig. 18.2).

Cauldwell et al.34 reported four classic bronchial artery branching patterns: type I, one intercostobronchial trunk on the right and two bronchial arteries on the left (40%); type II, one intercostobronchial trunk on the right and one on the left (21%); type III, two branches on the right (one intercostobronchial trunk and one bronchial artery) and two bronchial arteries on the left (20%); and type IV, two on the right (one intercostobronchial trunk and one bronchial artery) and one bronchial artery on the left (9.7%) (Fig. 18.3).

The right intercostobronchial trunk is the most consistently seen vessel at angiography (80% of individuals) (Fig. 18.4). It usually arises from the right posterolateral aspect of the thoracic aorta, whereas the normal right and left bronchial arteries arise from the anterolateral aspect of the aorta. Right and left bronchial arteries that arise from the aorta as a common trunk are not uncommon at angiography (Fig. 18.5). The true prevalence of a common bronchial artery trunk is unknown.

Of particular relevance is the anatomy of the nearby spinal arteries. During bronchial angiography, we can observe two types of spinal arteries that must always be avoided: the dorsal and ventral radicular arteries, which supply the dorsal and ventral nerve root and which emerge from the intercostal arteries, and the anterior medullary arteries. An average of eight arteries supply the spinal cord from its anterior side. In 5% to 10% of cases, they can be observed during bronchial angiography, usually arising from the intercostal artery of the right intercostobronchial trunk. Adamkiewicz artery or great anterior radiculomedullary artery is the most important artery in terms of medullary irrigation. This artery arises from the left side of the aorta, from T9 to L1, in 75% of cases. Anterior medullary arteries have a characteristic “hairpin” configuration at angiography35 (Fig. 18.6).

Often, spinal arteries cannot be observed initially in the angiography. They only become visible when the distal vessels are embolized, as recalled by Brown and Ray36 (Fig. 18.7).

WORKUP

Initial priorities are ensuring adequate airway protection, ventilation, and cardiovascular function. Patients with poor gas exchange, rapid ongoing hemoptysis, hemodynamic instability, or severe shortness of breath should be orally intubated with a large-bore endotracheal tube (size 8.0 or greater).15,17 Coagulation disorders should be rapidly reversed.

If the location or site of bleeding is known, placing the bleeding lung in a dependent position may prevent blood spillage into the nonbleeding lung. An alternative strategy involves placement of a typical, single lumen endotracheal tube into either the right or the left mainstem bronchus. The approach of selective intubation is less practical when the right lung is bleeding because selective intubation of the left mainstem bronchus may be difficult. A third alternative is the placement of a double lumen endotracheal tube specially designed for selective intubation of the right or left mainstem bronchi. 21,37

The evaluation should begin with the initial history and physical examination supplemented by chest radiograph. Important features of the history include age, smoking history, duration of hemoptysis, and association with symptoms of acute bronchitis or an acute exacerbation of chronic bronchitis.21

Vital signs including pulse oximetry levels and blood gases, temperature, heart rate, and breathing should be recorded and fever, tachycardia, tachypnea, and hypoxia corrected.

In a survey of respiratory physicians during the 1998 American College of Chest Physicians (ACCP) Annual International Scientific Assembly, more than 50% of these clinicians favored the use of interventional angiography even in surgical patients, which was a substantial change from 1988 when only 23% had favored this approach.1

Location of Bleeding: Computed Tomography versus Bronchoscopy

Diagnostic examination in massive hemoptysis should focus on etiology and identification of the site of bleeding. Such examination commonly involves chest radiography, fiberoptic bronchoscopy, and chest CT.38

Despite the fact that chest radiography is a standard procedure and is always available, it rarely provides clear information on the site of bleeding.

Various studies have reported that fiberoptic bronchoscopy can help to locate the site of the hemorrhage in between 49% and 92.9% of cases.21,23 Fiberoptic bronchoscopy is often considered in patients with hemoptysis and a normal or nonlocalizing chest X-ray to rule out endobronchial malignancy. Performed early in the evaluation, while the patient is actively bleeding, provides the highest performance for locating the bleeding site.1

Many experts advocate the use of fiberoptic bronchoscopy as the primary method of localizing the site of bleeding in massive hemoptysis,39,40 but many studies have downplayed this technique and even set it aside just as an aid to the location of the bleeding before arterial embolization.41

Instead, an early chest CT has been advocated to help localize the bleeding site and diagnose the cause of hemoptysis.42 The advantage of CT is that it may define one of several diagnoses such as bronchiectasis, lung abscess, and mass lesions, including cancer, mycetomas, and arteriovenous malformations. CT can localize the site of bleeding in 63% to 100% of cases. Specifically, CT can aid in diagnosing nonbronchial systemic supply in 80% of cases, with the lowest success in visualizing internal mammary supply.43 Knowledge of nonbronchial supply in advance has the potential for increasing the success rate of initial embolization.21,41 It may also help in acute cases to guide arteriography or bronchoscopy to the regions of highest yield.

Revel and coworkers38 wondered if CT could replace bronchoscopy in the detection of the site and cause of bleeding in patients with large or massive hemoptysis. The disadvantage of chest CT is that it may require temporary movement of an unstable patient away from intensive care.

Nowadays with the availability of multislice CT, the use of the fibrobronchoscopy and the arteriography has been questioned for the location and diagnosis of the bleeding. Undoubtedly, the quality of the images, their precision, and the speed and readiness cause CT to play an important role in the diagnosis of the hemoptysis. It has several potential interests, including anatomic workup of bronchial and systemic arterial anatomy to the lung and diagnosis of uncommon sources of bleeding such as pulmonary artery43,44 (Fig. 18.8).

Bronchial and Systemic Angiography

The main objective of a severe hemoptysis diagnosis is the design of an appropriate treatment approach. It is unquestionable that embolization stands out as the optimal treatment. Every embolization requires a previous angiographic study, which is the gold standard for diagnosis of hemoptysis. However, although CT might delay the intervention, it may be very helpful to understand the etiology, the mechanism of bleeding, and the origin of aberrant bronchial or systemic arteries and to plan a successful procedure.45

If the patient continues bleeding and the source is still unknown, then arteriography should be performed next because it may be useful for therapy as well as for diagnosis. Because most massive bleedings arise from the bronchial circulation, bronchial arteriography has a higher performance than arteriography of the pulmonary or systemic arterial beds.

Knowledge of the anatomy of the bronchial arteries is crucial for their location and examination. The bronchial arteries exhibit several anatomic variations in terms of both their origin and their various branches.32,34

When the pulmonary arterial circulation is the source, the most common underlying conditions are pulmonary arteriovenous malformations, Rasmussen aneurysms, or iatrogenic pulmonary artery tears. A recent study observed that 8 (10.5%) in a series of 76 patients undergoing bronchial angiography for hemoptysis had visible pulmonary artery pseudoaneurysms.46 In our series,23 the pulmonary artery was the origin of pulmonary bleeding in 6 patients (2%) with different causes. In only one case a Rasmussen aneurysm was diagnosed (Fig. 18.9).

Occasionally, other systemic arteries of the chest or in the vicinity are the cause of bleeding or are involved together with the bronchial arteries. Nonbronchial systemic collateral arteries differ from anomalous bronchial arteries because they are not congenital but developed through several pulmonary diseases.47

Systemic collateral arteries may include a wide spectrum of arteries within or near the thorax, such as the thyrocervical trunk, intercostal, internal mammary, thoracodorsal, and lateral thoracic arteries and other branches from the subclavian artery. Intra-abdominal arteries, including the inferior phrenic arteries, may also provide nonbronchial collateral supplies for the lung lesions that cause hemoptysis4851 (see Fig. 18.1).

The nonbronchial systemic collateral arteries are common in the presence of pleural thickening and adhesion, in chronic inflammatory lung disease, or pulmonary malignancies, thereby facilitating transpleural systemic pulmonary anastomosis.47

Angiographic Signs

The diagnosis of bleeding by arteriography is simple but controversial. When direct signs such as extravasation, aneurysms, or pseudoaneurysms are observed, diagnosis is easy and the cause of hemoptysis is clear. However, extravasation of contrast agent is observed in only 3.6% to 10.7% of cases41 (Fig. 18.10).

Angiographic indirect findings in hemoptysis include hypertrophic and tortuous bronchial arteries, areas of hypervascularity and neovascularity, and shunting of blood into pulmonary artery or vein52 (Fig. 18.11).

In our series,23 bronchial angiography revealed abnormalities that would account for hemoptysis in 287 patients (91.4%). Of those, 58 (20.2%) presented direct signs of hemorrhage (extravasation and/or aneurysm). The remainder only showed indirect signs that were more or less intense (Table 18.3).

INDICATIONS AND CONTRAINDICATIONS

Not every hemoptysis requires either embolization of bronchial, systemic, or pulmonary arteries. Most small entity hemoptysis require only a correct diagnosis and conservative medical treatment. Massive hemoptysis is the most important indication for invasive treatment by surgery or embolization. There is no agreement in the definition proposed for the term massive hemoptysis, being the most commonly used for a blood expectoration greater than 300 to 600 mL in 24 hours. Furthermore, the reliability of patient measurement and reporting of volume of expectorated blood may be limited in real life, therefore a more reasonable practical definition would be any amount of hemoptysis that is life threatening28,43 (Fig. 18.12).

The main indications for embolization treatment are outlined in Table 18.4.

The only real contraindications for bronchial or nonbronchial artery embolization are the usual contraindications for angiography, including intractable coagulopathy, renal dysfunction, and severe contrast allergy. The presence of medullary artery with insurmountable embolization risk, such as a bronchial artery that is too small to be selectivized or a medullary artery that cannot be occluded with a proximal coil, would also contraindicate the technique,. Likewise, inexperience or inability to safely catheterize selectively or embolize the bleeding branches should contraindicate the intervention due to the high risk of embolic agent migration to other territories.43

TECHNIQUE

Bronchial and nonbronchial artery embolization requires a thorough detailed examination to discover angiographic pathologic vessels. Both diagnosis and treatment should be performed in a vascular interventional operating room equipped with the best possible imaging technology and the means of constant monitoring and appropriate resuscitation to solve any unexpected issue. The operator must be familiar with the anatomy of thoracic and bronchial arteries as well as the technical considerations and materials of embolization. It can use different arterial access, but perhaps the most used is the right femoral artery. In all cases, an angiogram of thoracic aorta is recommended to demonstrate bronchial artery anatomy and to identify other systemic collateral vessels (Fig. 18.13).

The initial aortogram shows hypertrophied arteries and denotes possible aberrant origins of ectopic arteries that reach the pulmonary parenchyma.21,53 A methodical selective catheterization of the major bronchial arteries is mandatory even if the aortogram did not show any pathologic bronchial artery.21 Although 4-Fr to 5-Fr cobra-type curved catheters are the most commonly used for catheterization, several different configurations (e.g., Simmons 1, Headhunter, Michaelson, Yashiro-type, Sos-Omni catheters, etc.) should be available for optimal selection of bronchial arteries.

Most of the authors recommend the routine use of coaxial microcatheters for superselective bronchial artery catheterization. Superselective catheterization allows a safe position and allows the blood flow necessary to achieve distal embolization1,54,55 (Fig. 18.14).

The use of microcatheters is of particular importance when embolizing the right intercostobronchial trunk to avoid the occlusion of intercostal branches shunting directly to the anterior spinal artery.56

To identify the bleeding bronchial artery, it is necessary to selectively catheterize each of the bronchial artery independently and slowly inject small quantities of contrast manually. If all explored bronchial arteries are normal, then the systemic arteries that surround the thorax (internal mammary, lateral thoracic, intercostals, etc.) have to be methodically explored bilaterally; if they are also normal, then we should study the pulmonary arteries. When pleural thickening, peripheral tumors, or peripheral lung scars are detected, it is mandatory to study the systemic vascularization anyway.21

It has been established that embolization should always be the most distal possible to prevent recurrences by collateral vessels. The rationale for this approach is that the distal embolization of the bronchopulmonary pathologic anastomosis slows the flow in the smaller vessels, making it easier to occlude them. In fact, several authors contraindicate the use of coils in hemoptysis embolization because they produce a more proximal occlusion and, in case of recurrence, they can complicate the access to the diseased arteries.52

In our experience, the proximal occlusion, after distal embolization, reinforces decreasing the bronchial artery flow and ensures its occlusion (Fig. 18.15). In case of recurrence by collaterals, that new collaterals are the ones to be closed. With this technique in 15-year follow-up, we observed a lower rate of recurrence (10.4%) than most authors (10% to 55%).23,57

Several embolic materials are available for bronchial artery embolization. The use of embolization agents smaller than 300 μm should be avoided. Pump58 and Bernard et al.59 have demonstrated that bronchopulmonary anastomoses could allow the flow of particles smaller than this size, so they can produce pulmonary infarction (bronchial artery shunt to pulmonary artery) or systemic embolization (bronchial artery shunt to pulmonary vein).

The main embolic agents used for hemoptysis treatment are absorbable gelatin sponge, polyvinyl alcohol, trisacryl microspheres, N-butyl cyanoacrylate, ethylene vinyl alcohol, and metal coils60 (Table 18.5).

Absorbable gelatin sponge (Gelfoam; Baxter, Deerfield, Illinois) is the most economical agent; it is readily available and easy to use. Delivering the material through microcatheters can be difficult. Moreover, it has the disadvantage of producing temporary arterial occlusion with a high rate of recurrence by recanalization when gelatin is reabsorbed in 15 to 30 days.8,9,54

Polyvinyl alcohol (PVA) is a nonabsorbable particulate agent available in various particulate sizes. The most common particle size for bronchial artery embolization ranges from 250 to 500 μm. 55,6163

Currently used trisacrylic PVA microspheres show a spherical morphology of fairly uniform size, compliant and nonclumping, and easily delivered through microcatheters. There are several companies that sell different types of microspheres with small variations and different characteristics.64

Ethylene vinyl alcohol, known as Onyx (Covidien, Irvine, California), is a copolymer dissolved in dimethyl sulfoxide and suspended in micronized tantalum powder to provide contrast for visualization under fluoroscopy. The embolic agent Onyx is safer and easier to use than other liquid glues (as Histoacryl; B. Braun Medical, Inc., Bethlehem, Pennsylvania) but has the drawback of its high price.65

Histoacryl consists of monomeric N-butyl cyanoacrylate, which polymerizes quickly in contact with tissue fluid. Histoacryl is available in two colors: translucent, especially for facial application, and blue, which enables an easy control over the quantity applied. It solidifies in a few seconds upon contact with blood. Its management requires a lot of expertise because the tip of the microcatheter may quickly become trapped in the glue and can be difficult to retrieve.66,67

The use of metal coils for bronchial artery embolization in the treatment of hemoptysis is controversial. As it has been already said, many authors advise against its use based on the difficulty of treating a recurrence.52,60 Other authors defend embolization using microcoils with acceptable rates of recurrence.68,69

We use the combination of distal embolization with microspheres and detachable microcoils at the proximal end (Fig. 18.16). Long-term follow-up supports the benefits of this technique.2,70

OUTCOMES

Bronchial and nonbronchial systemic artery embolization is the treatment of choice for massive and recurrent hemoptysis. Immediate control of bronchial bleeding is achieved in 73% to 99% of cases23,57,64,71,72 (Table 18.6).

Technical success achieved with new technologies is very high (>90% of cases), whereas clinical success varies depending on the length of the follow-up. It seems that these new technologies have not improved the clinical long-term outcome, but there are no randomized studies with sufficient clinical evidence to categorically state that. At least, calibrated microparticles and microcatheters seem to have improved the efficacy in arterial occlusion and, especially, the safety.

Immediate control of a massive bleeding rate ranges from 80% to 100% using different embolic agents. The Achilles heel of this procedure is a recurrence up to 50% or even 75%, as stated by some authors. It is difficult to establish the true rate of recurrence if there is no consensus of defining recurrence. If we consider small bloody sputum episodes without clinical significance, our recurrence will be high. Some authors only record episodes of hemoptysis requiring medical management (surgery or embolization).57,60,73

Early rebleeding in general is due to incomplete embolization or presence of overlooked collateral vessels. Up to 20% of patients will bleed again in the first month. Late rebleeding (months or years), on the other hand, is due to progression or reactivation of the underlying disease and lesion revascularization by collateral vessels from other bronchial arteries and systemic arteries of the neighborhood.

The main factors for recurrence are improper technique, partial embolization, or embolization of side branches involved in the injury but which are not the origin of the bleeding. Other causes include the use of absorbable embolic agents, acute vascular pathologic processes, or chronic diseases such as tuberculosis, aspergillosis, and cancer.13,74,75 Also, if the primary disease is not adequately treated, such as in tuberculosis and in aspergillosis lung infections, it is expected to have a higher recurrence rate of bleeding.

Chronic or resistant tuberculosis has high rate of recurrence, whereas acute tuberculosis sensitive to antituberculosis therapy has a favorable outcome with low rate of rebleeding after embolization.57,75

Hemoptysis is the most common symptom in aspergilloma; it occurs in 69% to 83% of all patients, and it ranges from mild to life threatening, with a mortality rate ranging from 2% to 50% and with an early and very high recurrence rate.57,76

Patients with lung cancer carry a 10% to 30% risk of developing hemoptysis and are also at risk of recurrence following embolization.14,77

It is important to know that hemoptysis is a symptom that can become fatal in patients suffering from a severe pulmonary disease. Embolization is a symptomatic treatment of hemoptysis. It is necessary to medically or surgically resolve the underlying condition, when possible.52 It is therefore important to identify and embolize all vessels that may be contributing to the abnormal blood supply, including any nonbronchial systemic or pulmonary arteries. The underlying pathology should be treated if possible to achieve long-term hemoptysis control.

POTENTIAL COMPLICATIONS

The most frequent complications of hemoptysis embolization include chest pain (24% to 91%) and dysphagia (1% to 18%). They are temporary symptoms due to ischemic phenomena caused by embolization of intercostal and esophageal branches respectively.13,21,52

It is known that the bronchial arteries supply not only the bronchial artery branches but also provide for the vasa vasorum of the aorta, pulmonary artery wall, esophagus, pleura, and spinal cord.52

To prevent accidental embolization, we have to work in optimal imaging conditions (adequate equipment, high dose, zoom, and collimation) to identify any leakage to an undesired structure and with the adequate materials for microcatheterization. Every injection should be performed under fluoroscopic control with a slow, careful, and precise infusion of the mixture (iodine contrast and embolic agent, choosing an adequate proportion depending on the contrast concentration and the employed agent).

Subintimal dissection of the aorta or the bronchial artery during hemoptysis embolization is another frequent minor complication, with a reported prevalence of 1% to 6.3%. There are usually no symptoms or problems related to it. This complication can be avoided with the use of soft tip diagnostic catheters, microcatheters coaxially, and gentle hand injections15,21 (Fig. 18.17).

Probably the most feared and serious complication is the embolization of the anterior spinal artery, which can be caused by transverse myelitis. The prevalence of spinal cord ischemia after hemoptysis embolization is reported to be 1.4% to 6.5%. When the anterior medullary artery (Adamkiewicz artery) is visualized at angiography, embolization should not be performed. Therefore, good imaging and extensive previous diagnostic angiographies or scans are essential.54,7880

As has been already said, sometimes, the medullary artery cannot be visualized at the beginning of the embolization because it is very thin and bronchial flow is dominant. Therefore, embolization should always be performed meticulously, slowly, and under fluoroscopic guidance to stop on time and avoid its accidental embolization.36

Another serious but infrequent complication is the posterior cerebral circulation stroke because of embolism to the occipital cortex, either via bronchial artery–pulmonary vein shunt or via collateral vessels between bronchial and vertebral arteries.81,82

Other rare complications reported in the literature include aortic and bronchial necrosis, bronchoesophageal fistula, ischemic colitis, and pulmonary infarction.83,84

TIPS AND TRICKS

Tips

• Chest CT angiography previous to embolization shortens the procedure length because it helps to locate the bleeding.

• It is useful to include the entire thoracic aorta in the angiography to get the whole picture of bronchial and intercostal arteries and any other anomalous artery arising from the aorta.

• An adequate equipment and radiographic technique that achieve a high image quality is essential to visualize medullary and esophageal arteries.

• Anterior medullary artery can usually be found in the left hemithorax.

• Always use a microcatheter coaxial to the diagnostic catheter.

• Always use spherical particles greater than 300 μm to avoid leakage to the systemic circulation through shunts.

• Ensure distal embolization.

• Systematically check every bronchial and thoracic systemic artery.

• In case of inflammatory or infectious disease such as tuberculosis, do not forget to also check the pulmonary circulation due to the possibility of shunting .

Tricks

• Do not introduce the diagnostic catheter (4-Fr to 5-Fr) into the bronchial artery to avoid vasospasm.

• If it is not possible to stabilize the microcatheter, try to use a 5-Fr to 6-Fr guiding catheter in the aorta.

• Try to get as distally as possible with the microcatheter gently using a soft tip 0.014-in microwire.

• Use spherical particles greater than 300 μm, ensure a homogenous mix, and deliver them slowly. Take your time.

• Perform control checks gently and slowly to avoid particle lavage to the systemic circulation.

• When a medullary, esophageal, or tracheal artery is visualized, it is possible to close it proximally with a coil to avoid particle embolization.

• Once distal embolization is ensured, some authors recommend proximal coil occlusion. Other authors emphatically advise against it.

SUMMARY

Hemoptysis is a fairly common symptom of a group of respiratory diseases. Fortunately, only a few are massive and/or life threatening. Massive and recurrent hemoptysis are those that require invasive treatment. In the management of hemoptysis, location of the bleeding point is essential. Multidetector CT and bronchoscopy play an important role before angiography. Embolization with nonabsorbable particles is the preferred treatment of massive hemoptysis. Embolization is, in general, a symptomatic treatment: never forget the treatment of the underlying disease, if possible. Surgery is reserved for some difficult cases and embolization failures.

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