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EMBOLIZATION OF BRONCHIAL ARTERIES FOR THE TREATMENT OF

HEMOPTYSIS . Update and literature review.

Marcelo Langleib , MD

Interventional Radiologist. IDITE (Instituto de intervencionismo y Terapia Endovascular). Centro Cardiovascular, Casa de Galicia, Montevideo, Uruguay.

Neuroangioradiologist. CASMU IAMPP Montevideo, Uruguay

Summary: Massive hemoptysis is an emergency. It was formerly assessed by means of chest X-Ray, fibrobronchoscopy and CT. In the last few years multislice tomography has achieved good results in localization of the hemorrhage and in the identification of arterial anatomy.

The embolization of bronchial arteries and non-bronchial systemic arteries, a minimally invasive technique, is a safe and effective treatment. This article reviews and updates this technique.

Key words: Hemoptysis, Arterial Embolization, Interventional Vascular Radiology

1- Introduction. morbimortality being very high. It consists in total or segmentary Hemoptysis is a life-threatening lobectomy if the lesion is identified and emergency requiring prompt diagnosis localized (1-2). Percentages of mortality and treatment. in elective surgery were about 18% and Conservative medical treatment of around 40% for emergency surgery. massive hemoptysis used to consist in In this context the embolization of local and peripheral vasopressin bronchial arteries, pioneered by Remy in infusion, and such local measures as 1974 in France and published bronchial instillation of vasopressin, internationally 3 years later (5) appeared balloon obstruction of the involved as a minimally invasive but highly bronchus or selective intubation of the effective treatment for immediate non-involved lung so that it would not be control of bleeding. It has become inundated with blood (1-3). This established as the method of choice for treatment had a morbimortality of the treatment of massive hemoptysis around 50% (4). ever since (6). Surgical treatment, if performed at the acute stage, also shows bad results,

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For this study we reviewed the mammary arteries, for example), which technique, its indications, its restrictions may originate hemoptysis. and its complications, its early and long- term outcomes. We also reviewed Pulmonary circulation may be special situations that can arise in clinical compromised in several conditions practice. leading to vasoconstriction on account of hypoxia, vasculitis and thrombosis. In 2- Pathophyisiology and etiology of those circumstances bronchial arteries hemoptysis. enlarge gradually and replace the main blood supply either at the lesion or Arterial pulmonary circulation is dual: throughout the lung. This chronic pulmonary arteries plus bronchial inflammation not only enlarges the arteries. (2) bronchial arteries: concomitantly Pulmonary arteries provide 99% of the arteriovenous shunts between both arterial supply and are responsible for circuits enlarge as well. In those gas exchange. circumstances inflammation mediators and angiogenetic growth mediators are Bronchial arteries, which provide only released; neovascularization appears 1% of arterial supply, operate as nutrient with engagement of systemic vessels that vessels for the walls of the commonly are not included in the arterial tracheobronchial tree and as vasa supply to the lung (3). vasorum for pulmonary arteries and pulmonary veins; they also provide small These new vessels have thin walls, bronchopulmonary branches for lung where aneurysms and pseudoaneurysms parenchyma. develop. Exposure to systemic pressure and inflammation further weaken their Both systems, the pulmonary arterial thin walls and bring about their rupture. system and the bronchial arterial system, This is followed by blood extravasation intercommunicate by small anastomoses into the airways, which produces what is at bronchial and parenchymal level, known as hemoptysis (2-3). which constitute a physiological right- left shunt. Numerous conditions can lead to this process; the most frequent ones include This circulation is observed in the bronchiectases, tuberculous cavities, respiratory system under completely aspergillomas, pyogenic abscesses and normal conditions. tumors. Rasmussen’s aneurysms, caused by erosion of pulmonary arteries, may No other arterial vessels are involved in originate a small percentage of pulmonary circulation under normal hemoptysis (10%) and may even be conditions. visualized angiographically, by the In pathological situations we shall opacification of bronchial arteries or review later on there may be other systemic arteries (intercostal or systemic branches involved (the internal vertebral) on account of the abnormal communication between both systems in

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Fig. 1- Secuelar Aspergiloma Cavern. HIV 36 old patient. Severe hemoptisis in the last 24 hours. a) Thorax radiography shows a secuelar cavity in the left pulmonary apex. b y c) Aortography in early and late phase shows a pathologic al circulation in the periphery of the cavern. An arteriovenous shunt is observed with left pulmonary vein opacification. d) Selective catheterization of the left internal mammary artery shows the anomalous vascularization in the periphery of the cavern. A nodular image compatible with a Rasmussen aneurysm is observed. e) Post embolization result with 300-500 and 700-900 micres of trysacaryl.

the aforementioned conditions. (Figure idea of risks, benefits, indication and 1) timing of this procedure. It is likewise important to stress that we are a 3-Massive hemoptysis: definition multidisciplinary team where every step

The interventional radiologist must of diagnosis, treatment and follow-up of know not only the technique to be the patient must be discussed first. performed in order to stop a hemoptysis, he must also have a clear knowledge of On account of the aforementioned it this symptom, its severity, its possible becomes necessary to revise some causes and the assessment to be done clinical concepts. before angiography and embolization are performed. He must also have a clear

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Hemoptysis is defined as the expulsion Studies in hemoptysis patients must aim of blood from the part of the respiratory at a quick localization of the hemorrhage tract that lies under the glottis. site and if possible, the etiology of this hemorrhage. It is important to know According to expectorated volume whether the patient is taking hemoptysis falls into several categories: anticoagulants and to confirm it as soon small quantities of expectorated blood, as possible by means of coagulation blood-streaked sputum, mild hemoptysis studies. At the same time other studies when the volume is less than 150cc in 24 must be undertaken to determine the site hours, moderate or severe when it and the etiology of the hemorrhage. The amounts to 150-500cc a day, and site or the region must be identified as massive when it exceeds 600cc a day. accurately as possible, and it must be This classification is not always useful in determined, if at all possible, if the clinical practice; it has been questioned condition is one-sided (a residual by some authors and need not be taken tuberculous cavity or a tumor, for into account before embolization if the example) or if it is bilateral and wide- indication has been discussed by the spread as is the case with bronchiectases. multidisciplinary group (3). Three studies are available for the In many cases embolization is the first determination of the hemorrhage site: therapeutic procedure. It is intended as a plain chest X-ray, fibrobronchoscopy palliative therapy, not as a curative and computed tomography (7-10). treatment, and as such precedes surgery. The last few years have brought an Our experience includes the addition to this group: multitdetector embolization of patients with persistent computed tomographic angiography (11) blood-streaked sputum related to a whose role and results more will be neoplasic pulmonary nodule; although mentioned in the next item. the daily volume of sputum was not considerable, persistency of the In emergency situations plain chest X- hemorrhage and a tendency to increase ray is a low yield study that contributes were viewed as a hemoptysis threat. diagnostic data only in 50% of the cases (7, 8). These findings may be tumors, Therapeutic decision must be taken by a cavities, images compatible with multidisciplinary team whose members bronchiectases. must always keep in mind that hemoptysis is life-threatening on A few years ago fibrobronchoscopy was account of the functional compromise of the first study to be performed (1-2). Its the airway and not because of role exceeds the scope of this review, we hypovolemia (2). will merely point out that nowadays its use has become controversial and some 4 Diagnostic studies before reviews state that it may be unnecessary arteriography when lesions have been well localized by imaging studies (9). Some studies have

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demonstrated that fibrobronchoscopy, if Computed tomography can contribute performed at an early stage, indicates the important information for the hemorrhage site in 91% of the cases, localization of hemorrhage, it can even while in the case of ongoing hemorrhage localize it by itself in 63%-100% of the of some duration, according to other cases (7). The percentage may be higher authors, it contributed to diagnosis only if CT is combined with in 3 out of 29 cases (10). A recently fibrobronchoscopy. The combination of published study (11) shows that fibrobronchoscopy and CT is the most visualization of active hemorrhage was effective algorithm to use for a first achieved in 84.2% out of 111 patients assessment (8). while in the same series visualization after cessation of hemorrhage was It should be clearly understood that possible only in 19.1%. bronchoscopy and CT do not compete, they are complementary. If we had to Both CT and the aforementioned choose between them, we would opt for multislice CT contribute a wealth of CT because we think it is the most useful localization and etiology data. one, as Galli E et al have affirmed (9).

TABLE 1 Comparison of the main series published in the period 1977 - 2013

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Anyway this depends on the clinical tuberculous cavities and involvement of status of the patient, it should not be pulmonary arteries with tumors (12, 13 forgotten that hemoptysis patients die and 14). These aneurysms may be because of airway compromise, not on evidenced by catheterization of account of hypovolemia; this must be bronchial or systemic arteries, because remembered if aspiration becomes arterial shunts between both systems necessary. hypertrophy in pathological situations (15). No bronchial artery embolization should be undertaken without the orientation of 4b-Angiographic study of pulmonary previous studies, otherwise treatment arteries will be more difficult (8, 9). In a minor percentage of patients, hemoptysis may originate in the pulmonary arteries. In such cases, 4ª- Multislice computed tomographic bleeding begins as a result of eroded angiography for the study of bronchial pseudoaneurysms associated with arteries (12-14) aspergillomas, tuberculous cavities or Angiotomography with 16-detector pyogenic abscesses (10, 15-17). multislice equipment has proved to be Plain chest X-ray usually shows quite effective for the identification of suggestive findings such as necrotic bronchial and non-bronchial arteries in cavities or cavitary lesions near the cases of hemoptysis (12); in a central pulmonary artery (Figure 1a) comparative retrospective study of (10). conventional angiography and angio CT an agreement of 86% was observed In 1984 Remy et al (15) published a regarding their identification. Recently series of 72 patients. Six of them had published prospective studies (14) have recurrent bleeding; the findings were demonstrated that angio CT identified eroded pseudoaneuryms in five cases, 100% of the arteries causing hemoptysis aspergilloma in one case, tuberculous (which were embolized); the same study cavities in two cases and pyogenic reports that 2 hypertrophic non- abscesses in two cases. bronchial arteries were identified in CT and not during the arteriography that was Further on, in 1987, Rabkin (16) performed later. published one of the most numerous series; it included 306 patients who This technique allows simultaneous underwent embolization of bronchial study of both arterial circuits and arteries. In 93% (26/28) of the patients therefore the identification of bronchial whose hemorrhage did not cease arteries as the cause of bleeding, the immediately, the cause was found to be a involvement of systemic non-bronchial lesion of the pulmonary artery. More arteries and also the participation of recently published series have found up pulmonary arteries including to 10% of cases (8/76) with bleeding Rasmussen’s aneurysms related to

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secondary to pulmonary possible anatomical variants. pseudoaneurysms (7, 16) (Table 1). That leaves 10% of variants outside this classification. Another known cause of pulmonary artery hemorrhage, albeit infrequent, is Type 1- Two bronchial arteries on the arteriovenous malformation, which can left and one intercostobronchial trunk on be treated successfully with coils (16). the right (40.6%).

The conclusion of all the above findings Type 2- A single bronchial artery on the is as follows: pulmonary arteries must be left and one intercostobronchial trunk on examined whenever the study of the right (21.3%). bronchial arteries did not find the cause of hemoptysis and also in those patients Type 3- Two bronchial arteries on the who present with recurrent hemoptysis left and two on the right, one of them (7). being an intercostobronchial trunk (20.6%). 5 – Anatomy of the bronchial arteries Type 4- A single bronchial artery on the It is essential to know the anatomy of the left and two on the right, one of them bronchial arteries in order to achieve presenting as intercostobronchial trunk adequate embolization in hemoptysis (9.7%). patients. This classification omits to mention the Bronchial arteries are subject to great case of both bronchial arteries anatomical variation regarding origin, originating in a common trunk. number, and route. They originate directly from the anterolateral surface of b) Botenga’s classification (18) the descending aorta at T5-T6 level. Botenga proposes, like Uflaker, 10 Several classifications are available: different pattern types.

Cauldwell reports 4 classic patterns for Type 1- Two bronchial arteries on the bronchial arteries, which are perhaps the left and one intercostobronchial trunk on most accepted ones. Some authors the right (27.7%). describe more, up to 10 patterns. Type 2- A single bronchial artery on the We will describe in this study the three left and one intercostobronchial trunk on classifications outlined in Uflaker’s the right (17.0%). Atlas of Angiographic Anatomy (15): Type 3- A single bronchial artery on the Cauldwell’s classification, Botenga’s left, one intercostobronchial trunk on the and Uflaker’s own (18). right and a common trunk as the origin a) Cauldwell’s classification (7, 8, of a single right bronchial artery and a single left one (17.0 %). 9, 10 and 18): This author uses only 4 groups because he Type 4 – Two bronchial arteries on the considers they include 90% of all left, one intercostobronchial trunk and a

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single bronchial artery on the right (10.7 Pattern 5- A single left bronchial artery, %). an intercostobronchial trunk on the right and a common trunk from which arise Type 5- Two bronchial arteries on the one right bronchial artery and one left right and a single bronchial artery on the bronchial artery (8.3%). left (8.5 %). Pattern 6- Right intercostobronchial Type 6- Intercostobronchial trunk on the trunk, single left bronchial artery and a right and a common trunk from which common trunk in caudal position (4.2%). arise both right and left bronchial arteries (8.5%). Pattern 7- Common bronchial trunk (2.8 %). Type 7- Common bronchial trunk (4. 3%). Pattern 8- Right intercostobronchial from which arises one left bronchial Type 8- Intercostobronchial trunk and artery, and another single bronchial single bronchial artery on the right, three artery on the left (2.8%). bronchial arteries on the left (2. 1 %). Pattern 9- Two common trunks giving Type 9- Intercostobronchial trunk and origin to bronchial arteries on the right two bronchial arteries on the right and a and on the left (1.4%). single bronchial artery on the left (2.1%). Pattern 10- Right intercostobronchial Type 10- A common bronchial trunk trunk, single right bronchial artery and with one right bronchial artery and one common trunk giving origin to a branch left bronchial artery, and a single left on each side (1.4%). bronchial artery (2.1 %). Some remarks should be added c) Uflaker’s classification (6,18) concerning this variety in classification:

Pattern 1- A single bronchial artery on Cauldwell’s classification, the oldest the left and an intercostobronchial trunk one, is the one most often mentioned in on the right (30.5%). review studies (7-10). It was done in Pattern 2- One intercostobronchial trunk cadavers. It is perhaps the briefest one on the right and a common trunk from and therefore the most practical one but which arise both right and left bronchial it does not take into account the arteries (25.0 %). existence of a single trunk giving origin to arteries for both sides, as we Pattern 3- Two left bronchial arteries and mentioned before. one intercostobronchial trunk on the right (12. 5%). When this common trunk gives origin to arteries on both sides, as will be Pattern 4- Right intercostobronchial illustrated with some examples below, it trunk, single right bronchial artery and can make selective catheterization to single left bronchial artery (11%). both sides difficult on account of its brevity and direction. This increases the

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probability of complications. The real Non-bronchial systemic arteries- prevalence of the common trunk is Chronic inflammatory processes tend to unknown (8). recruit vessels from the systemic circuit transpleurally. These vessels have been A right intercostobronchial trunk is quite noted to originate from very diverse frequent, in our experience it is one of sites: subclavian arteries, internal the most frequently embolized vessels, mammary arteries, thyrocervical trunk, perhaps on account of right apex lesions phrenic arteries and intercostal arteries. being so frequent. They characteristically do not run Bronchial arteries provide blood supply parallel to the bronchi. The radiologist to the trachea, to the airways within and must look for them systematically in without the pleura, to connective tissue, order to avoid recurrences. They can be nerves, regional lymph nodes, visceral localized with angio CT (12) and pleura and esophagus, and also to the panoramic aortography, the latter being vasa vasorum of aorta, pulmonary artery performed during the interventional and pulmonary veins (8). procedure (Figure 1b,c) (7,8).

Bronchial arteries originating above or Artery of Adamkiewicz- During the below vertebral bodies T5-T6 are catheterization of intercostal arteries and considered anomalous or ectopic. Some bronchial arteries the radiologist may see authors have reported their prevalence as the arteries supplying the spinal cord, ranging from 16.7 to 30% (7), others which deserve careful attention. These estimate prevalence in a range of 8.3% to are the two posterior spinal arteries, 35% (8). They arise from very different which are parasagittal, and the anterior sites, such as the aortic arch, the internal spinal artery, known as arteria radicularis mammary artery, the subclavian artery, magna of Adamkiewicz, a single median the costocervical trunk, the inferior artery originating from intercostal phrenic artery and the abdominal aorta. branches. The artery of Adamkiewicz Anomalous or ectopic bronchial arteries generally begins between T9 and T12 (8) must be distinguished from non- but variations occur. Sometimes it has a bronchial systemic arteries, bearing in higher origin, at T4-T12 level and mind that bronchial arteries follow the sometimes it arises from a right bronchi along their whole course. Most intercostobronchial trunk, in this latter of the ectopic bronchial arteries originate situation it can be identified on account from the aortic arch. The percentage of of the classic hairpin shape of its upper ectopic bronchial arteries originating end and occluding it must be avoided. elsewhere is unknown (8).

This variety in anatomical origin makes it evident that embolization should be performed with care and perseverance in order to be complete and avoid recurrences.

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6-Technique of bronchial the bronchial arteries and their embolization (Figures 2 and 3) embolization.

a) Catheterization and semiology Once the arterial puncture has been done of pathologic arteries. according to the Seldinger technique, an arterial 5 F sheath is placed and a 5F or Embolization of bronchial arteries 6F multifenestrated pigtail catheter is begins with a diagnostic angiography advanced up to T5 level in order to performed by means of arterial puncture perform a panoramic aortography with a according to the Seldinger technique. volume of 40cc and a flow of 25cc per Most of bronchial angiographies are second. performed by catheterization of the punctured femoral artery. If this access The embolization procedure for proves difficult in the patient, one can hemoptysis patients begins with a decide to puncture the humeral artery; in diagnostic panoramic aortography this case the left humeral artery is the aiming at the visualization of bronchial more practical option since it provides a arteries and non-systemic circulation very comfortable access for catheterizing involved in the pathological process.

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This first arteriography often allows -Hypertrophy of bronchial arteries; their visualization of pathological arteries diameter will exceed 2mm, thus which which are to be catheterized in a makes possible to catheterize them with selective or a superselective manner. But 5F catheters (Figure 3 y Figure 4). in many cases it turns out to be negative. -Hypervascularity (Figure 2a) Normal bronchial arteries measure less than 1.5 mm in diameter at their point of -Systemic-pulmonary fistulae (Figure origin, that it is why not infrequently 1c). they go unseen in a panoramic -Aneurysms or pseudoaneurysms arteriography or cannot be selectively (Figure 1d). catheterized with a 5F catheter (1.6 mm). Arteries are considered hypertrophic if Selective catheterization, which their diameter exceeds 2mm (4-8). permits proximal access to the ostium of the vessel, is linked to increased reflux Pathological lung areas can also be during embolization and also to visualized, depending on the severity of increased risk of complications resulting vascular alterations. from embolization of non-targeted The pigtail catheter is removed and territories. selective catheterization, both of During the last few years superselective bronchial arteries and systemic non- catheterization has been increasingly bronchial arteries that are seen as altered, employed (19-20). The procedure gets under way (Figure 2). consists of inserting a coaxial micro Preferred catheters for selective catheter into the 5F catheter and then bronchial arteriography are Cobra, advancing it as far as possible towards Simmons’s and Mikaelson’s, but other the embolization target by means of a catheters can also prove useful, like the micro guidewire. In this way the internal mammary catheter and the possibilities for complications would multipurpose catheter, for example (6). diminish, as will be discussed further on.

The equipment of choice is a digital one, When performing a superselective because it enables to reach complete catheterization (19-20) the ratio of the high-quality diagnoses and to decrease micro catheter lumen to the size of the the quantity of contrast agent. embolizing particles must be considered. A lumen of 0.021 or 0.027 is It is very rare to visualize extravasated recommended for use, which does not set contrast as a direct sign of bleeding. any limits to the size of macro particles Therefore attention should focus on (9). other semiologic elements, in order to find out which pathological vessels are to Having reached a diagnosis, treatment be embolized. will follow, in the shape of arterial embolization of affected areas, that is to Those signs are the following (6-10): say, of pathological arteries. We have

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different materials for embolization at and this applies in particular to occlusion our disposal, and we must know the of the arteria radicularis magna of characteristics of each of them. Adamkiewicz. Particles are dissolved in a solution of non-ionic contrast and

b) Embolization materials saline (50-50%) that must be constantly The most frequently used materials are shaken. The solution is loaded in a 20cc embolizable particles: Gelfoam, syringe connected with a three-way luer polyvinyl alcohol (known as PVA), lock and the volume to be embolized in calibrated Trisacryl particles and injected slowly into 1cc syringes. The occasionally glue-like elements like PVA is slowly injected under Histoacryl, and even coils or micro coils fluoroscopic control, watching closely to (4). avoid reflux into the aorta (9). Washing the catheter or the micro catheter with Characteristics, indications and saline is to be recommended, because limitations of each material are analyzed PVA particles tend to clump and thus below. occlude the catheters, which in turn favors reflux (9). Gelfoam or “Espongostan” is well- known: a widely available hemostatic Calibrated particles of Trisacryl sponge used in surgery, it can be cut (Embospheres) are a recent addition. manually in small 1-mm squares, which These non-absorbable particles are are soaked in saline and contrast, perfectly calibrated to a uniform, regular inserted into a syringe and pushed into shape. That would be their best asset the 5F catheter. It was the first material because it would avoid obstruction of the to be used, on account of its being widely catheter or the micro catheter during available and easy to manipulate, besides infusion. Trisacryl particles tend to being low cost. Its greatest drawback is clump less by comparison with PVA that the occlusion lasts only for a few particles. In our experience they also weeks, about 20 days, which is why its tend to occlude more rapidly than PVA use is not recommended. particles. That is why technique must be painstaking; 1cc syringes must be used Calibrated polyvinyl alcohol (PVA) and the injection must be pulsatile, particles are presented in vials; particle watching for slowing of the circulation size ranges from 50 microns to 1000 during embolization and progressive microns. Particles in the 350-500 micron vessel occlusion. If injection is continued range and in the 500-700 one are used for when flow has slowed down markedly, the embolization of bronchial arteries. the risk of unseen reflux into the aorta These non-absorbable particles are the increases (9). most widely used material for embolization of bronchial and systemic Absolute alcohol cannot be arteries round the world for hemoptysis recommended as an embolizing agent in patients. Particles under 350 microns this condition because it necrotizes the should not be used, because in that size bronchial wall (10). range the risk of complications increases,

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N-butyl cyanoacrylate (Histoacryl) hemoptysis patients. This copolymer is combines with lipiodol to change its mainly used in the treatment of polymerization rate and its visibility. intracranial arteriovenous malformations This glue-like material is particularly and dural fistulae. Its components are useful for high-flow fistulae that cannot dimethyl sulfoxide (DMSO) and

Figure 2 Cystic fibrosis. Recurrence . 21 years old patient with Cystic fibrosis and recurrent hemoptysis. She has been embolized in 3 Previous opportunities A) It develops anomalous origin of the right upper lobe bronchial arteries which opacify from a thick collateral of the right mammary artery. B) A distal coil is placed in the mammary artery From where small branches originate. be solved with particles, because they go ethylene-vinyl alcohol (EVOH). The through the shunt. Published animal studies reporting use of this product are studies (21) and recently published quite few. Use is reserved for cases human studies concerning big where pulmonary artery embolization is populations (22, 23) both show that required. We think this is not the ideal against former thinking no risk of tissue product for an emergency situation such damage is involved and damage to lung as ongoing hemoptysis because use of parenchyma or mucosa is infrequent. Its Onyx is time-consuming and requires a use demands very skilled personnel. very experienced operator. Although it is frequently used in Interventional Neuroradiology, its Fibrillar coils, 0.035 in size, are not utilization in peripheral areas is rare. The routinely used because they only permit main indications for the use of this a very proximal occlusion with the material are pulmonary artery aneurysms corresponding phenomena: development and intended occlusion of internal of collaterals and recurrence of the mammary artery and branches of the lesion. Micro coils to be used with 0.018 subclavian artery, a territory where the guidewire may be useful in fistulae use of particles is particularly risky on patients undergoing superselective account of possible reflux into the catheterization (20) with micro catheter, vertebral artery (8). provided the micro coil is placed quite distally to the fistula. Although this Some recent articles (24) have shown the resource is available, it is rarely needed use of Onyx as embolizing agent in and infrequently used. One of the

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conditions that may require its use is The first series, including 49 patients, cystic fibrosis, because it usually entails was reported internationally by Remy in the development of very hypertrophic 1977; success rate was 84% and vessels and wide fistulae that cannot be recurrences amounted to 28.6%. effectively occluded by particles (Figure Numerous series followed. Those 2b) (10); in these cases the selected coil publications are summarized in Table 1. must be 15-25% greater in diameter than the vessel in order to avoid a backward Those different series all demonstrate movement of the coil after its that bronchial artery embolization is a detachment. Catheter position must be very effective procedure for the control kept stable. of massive acute hemoptysis, with a success rate at the outset, that is, 9-Results immediate control of hemorrhage, ranging between 73% and 98%. Embolization of bronchial and non- bronchial systemic arteries is accepted as a first-line technique for the treatment of threatening or massive hemoptysis. It has proved to be quite effective from the very first studies that were reported by Remy.

Figure 3 Bronchiectasis A) computed tomography: Bronchiectasis in right hemitorax. B and C) Rx thorax showing Bronchiectasis in a patient with Active hemoptysis of right bronchi. D and E) pre and post embolization arteriography of the inferior right bronchial artery, pathologic vessel occlusion with trysacryl particles.

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The follow-up period ranges from 1 day bronchial systemic collaterals like the to the first post-embolization month. The internal mammary arteries and other aforementioned table shows success branches of the subclavian arteries. If a rates and recurrence rates for different tumor growth is involved, multiple authors in the past 25 years. Reported pedicles supplying the tumor may have recurrence rates are quite dissimilar, and developed. the same applies to the follow-up periods. Some authors report immediate In most of the published series there is recurrence, while others report long-term coincidence concerning illnesses and follow-up starting three months after the their incidence on recurrence. procedure. On that account not all the Bronchiectases and tuberculosis are the series are comparable. conditions that respond better to this treatment, while tumors usually have Recurrence rates, both on long- and poor results (9). medium-term, remain high, ranging from 10% to 55%. That is why, in spite Aspergilloma presents a high risk of of its effectiveness for the immediate recurrence because of its frequent control of hemorrhage, embolization is association with Rasmussen’s aneurysm, still considered in many cases a palliative which necessitates either pulmonary treatment, aiming at stabilizing the artery embolization or surgery. Remy patient with a view to elective surgery or was the first to report a case of pharmacological treatment. In many Rasmussen’s aneurysm embolization in other cases it is the definitive treatment, 1980; it concerned a residual tuberculous according to the condition and the cavity with aspergilloma (25). Aneurysm concomitant diseases of each individual visualization is often possible by means patient (9). of reflux from bronchial arteries into the pulmonary artery through pathological Recurrences depend on several factors: shunts. As a rule, however, embolization the operator’s experience, the materials of bronchial arteries is insufficient as in use, the patient’s clinical condition. definitive treatment for aneurysms and embolization of pulmonary arteries may Recurrent bleeding during the first days prove necessary (16). Sbano reports a or weeks is considered due to incomplete series comprising 66 patients in whom vessel embolization or persistence of embolization of bronchial arteries was disease. It could also be due to performed; during the 9-year follow-up revascularization of occluded vessels (if period, 11% (8 cases) presented absorbable materials like Gelfoam were recurrences due to peripheral pulmonary used) or to the development of collateral aneurysms, which were treated with circulation by non-bronchial vessels (9). coils. In three cases the presence of This latter instance is frequent in case of aneurysms was linked to the existence of extensive pleural affection (9, 10). In aspergilloma and in other two cases, to such cases it becomes necessary to tuberculous cavities as a manifestation of undertake a special examination of reactivated disease. Rabakantan (26), intercostal arteries and also of non- who performed embolization of

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bronchial arteries in 140 tuberculosis otherwise afflicted. In patients with patients, reports 73% effectiveness and cystic fibrosis recurrence amounted to considerable recurrence in the first 30 38% (42/110), while in other conditions days. All cases were treated with recurrence was observed in 21% espongostan, which explains these (77/367) of cases. results. Poyanli (27), who treated a similar population using polyvinyl As far as materials are concerned, alcohol particles, reports better results recurrence is higher when absorbable with less recurrence. Recently Hwang materials like Gelfoam (10) are used. In (28) has recently published an analysis of the last few years N-butyl cyanoacrylate risk factors for rebleeding in tuberculosis has been used, in vivo as well as in vitro, patients after embolization of bronchial and it was proved that it produces no arteries; he concluded that aspergilloma, lesions in lung parenchyma. Yoo (23) diabetes mellitus and arteriovenous published a numerous series comprising shunts are risk factors. In this series 108 cases in 2011, showing 97% comprising 72 patients and including a effectiveness and 20% long-term retrospective analysis of risk factors recurrence during a 5-year follow-up. In immediate effectiveness amounted to this series aspergillomas have a high 93.1% and overall recurrence after one recurrence incidence, just as with other year was 40.3% (Table 1). materials. The authors conclude that NBCA is a safe and effective means for Repeat embolization is more necessary the embolization of hemoptysis patients. in young patients with prolonged disease . 10-Complications of the procedure (10). This observation is especially true of cystic fibrosis patients in whom The most dreaded complications of embolization of bronchial arteries has embolization of bronchial arteries are: proven effective even if repeat post-embolization paraplegia due to a embolization was required to achieve lesion of the arteria radicularis magna of control. Brinson (28) achieves control in Adamkiewicz and transverse myelitis 15 patients out of 18 in his series in one linked to use of contrast. Although session, but the remaining 3 patients according to literature their incidence required 3, 4 and 7 embolizations each. lies within the 1.4-6.5% range, it is more The causes for this high incidence of of a potential risk nowadays, an reembolization are the important infrequent occurrence that can be development of non-bronchial minimized with the use of non-ionic circulation in this condition and the fact contrast media, the right choice of of the disease being bilateral. particle size and a detailed arteriographic Cornalba(30) has recently published a analysis in order to achieve adequate review of his experience of 31 years; he visualization of the artery, particularly observed a high incidence of cystic when it originates from the right fibrosis (23%) in his population. This intercostobronchial trunk (4, 10). allows a comparison of recurrences in patients with this condition to patients

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Figure 4- Ectopic origin of right bronchial arteries at the staffing level. Aortography and selective arteriography.

The most frequent complication is sound knowledge of anatomy, technique transitory chest pain; prevalence ranges and currently available materials. from 24% to 91% (8). Dysphagia secondary to embolization of esophageal In order to optimize results it is branches is likewise a frequent important to assess the situation complication and disappears adequately with fibrobronchoscopy spontaneously. Subintimal dissection, and/or computed tomography and angio CT before the procedure. another frequent complication, is quite variable as to prevalence but usually Indication has expanded, nowadays the causes no symptoms. method is not only indicated in severe or Bronchoesophageal fistulae secondary to massive hemoptysis but also in moderate necrosis, embolization of peripheral or chronic hemoptysis; it even extends to organs as a consequence of reflux and intermittent episodes (10). transitory cortical blindness (due either to contrast or to embolism as an eventual References consequence of shunts or reflux) have 1) Noseworthy TW, Anderson BJ. all been reported as less frequent Massive hemoptysis CMAJ, November complications (4, 8-10). 15 1986 ; 135(10):1097-9 12. Conclusion 2) Piñeyro Gutiérrez L. Hemoptisis. Rev. Embolization of bronchial and non- Med. Uruguay 1987; 3: 156-170. bronchial systemic arteries is a safe and 3) Jougon J, Ballester M, Delcambre F et effective method of treatment for al. Massive hemoptysis: what place for threatening and massive hemoptysis. medical and surgical treatment. Eur J From the beginning it has shown a high Cardiothorax Surg 2002; 22:345-351. level of efficacy regarding immediate hemorrhage control. Rates of long-term 4) Sopko DR, Smith TP. Bronchial artery recurrence have decreased as the embolization for hemoptysis. Semin technique was perfected and new Intervent Radiol 2011 March; 28(1) 48- materials were developed. 62. Complications can be minimized by a

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5) Remy J, Arnaud A. Fardou H, Giraud http//dx.doi.or/10.1016/j.medcli.2012.0 R, Voisin C. Treatment of hemoptysis by 1.31. embolization of bronchial arteries. Radiology 1977; 122(1):33-37. 12) Remy –Jardim, Bouaziz N, Dumont P. Bronchial and non-bronchial systemic 6) Uflaker R, Kaemmerer A, Picon P, et arteries at multi-detector row CT al. Bronchial Artery embolization in the angiography comparison with management of haemoptysis: tehchnical conventional angiography. Radiology aspects and long-term results. Radiology 2004, 233: 741-749. 1985; 157: 637-644 13) Khalil A, Fartouukh M, Tassart M et 7) Chun JY, Morgan R, Belli AM. al. Role of MDCT in identification of the Radiological management of bleeding site and the vessel causing haemoptysis: a comprehensive review hemoptysis. AJR 2007; 188(2): W117- of diagnostic imaging and bronchial W125. artery embolization. Cardiovasc Intervent Radiol 2010 33: 240-250. 14) Gupta M, Snvaslava DN, Seith S, Sharma S. Clinical impact of 8) Yoon W, Kim JK, Kim YH, et al. multidetector row computed tomography Bronchial and nonbronchial systemic before bronchial artery embolization in artery embolization for lifethreating- patients with hemoptysis. A prospective hemoptysis: a comprehensive review. stydy. Can Assoc radiol J. 2013 Feb, Radiographics, 2002; 22:1395-1409. 64(1) 61-73.

9) Galli E, Alcantara R, Sierre S. 15) Remy J, Lemaitre L, Lafitte JJ, Embolización bronquial en el Vilain SO, et al. Massive hemoptysis of tratamiento endovascular de la pulmonary arterial origin: diagnosis and hemoptisis. En: Giménez M Guimarães treatment AJR 1984 Nov 143(5): 963- M, Oleaga J. Manual de técnicas 969. intervencionistas guiadas por imagen. Ed. Journal, 2011: 330-338. 16) Sbano H, Mitchell AW, Idn PW, Jackson JE. Peripheral pulmonary artery 10) Mauro MA, Burke CT, Jaques PF. and massive hemoptysis. AJR April Transcatheter bronchial artery 2005, 184(4): 1253-59. embolization for inflammation (hemoptysis) In: Baum S, Pentecost MJ 17) Rabkin JE, Astafjev VI, Gothman (eds) Abrams Angiography LN, Grigorjev YG. Transcatheter Interventional Radiology. 2nd ed. embolization in the management of Lipincott Williams and Wilkins 2006: pulmonary hemorrhage . Radiology 909-919. 1987 May, 163(2):361-5.

11) Orriols R, Nuñez V, Hernando R, et 18) Atlas de anatomía angiográfica de Uflaker. al. Hemoptisis amenazante: estudio en 154 pacientes. Med Clin Barc (2012). 19)Tanaka N, Yamakado K, Muashima S, Takeda K et al. Superselective

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bronchial artery embolization for 25) Remy J, Smith M, Lemaitre L, hemoptysis with a coaxial micro catheter Marache P, Fournier, E. Treatment of system. J Vasc Interv radiol 1997; 8(1 massive hemoptysis by occlusion of a Pt1): 65-70. Rasmussen aneurysm. AJR, Sep. 1980, 135:605-606. 20)Serasli E., Kalpakidis V, Iatrou K, et al. Percutaneous bronchial artery 26) Ramakantan R , Bandekar VG, embolization in the management of Gandhi MS et al. Massive hemoptysis massive hemoptysis in chronic lung due to pulmonary tuberculosis: control diseases. Immediate and long-term with bronchial artery embolization. outcomes. Int Angiol 2008 Aug 27, (4): Radiology 1996, 200: 691-69. 319-28. 27 ) Poyanly A, Acunas B, Rozanes I, et 21) Tanaka T, Kawai N, Sato M, A al. Endovascular therapy in the management of moderate and massive Ikoma A, et al. Safety of bronchial hemoptysis. BJR 2007, 80:331-336. arterial embolization with n-butyl 28) Brinson JM, Noone PG, Mauro MA cyanoacrylate in a swine model. World J et al. Bronchial artery embolization for Radiol. 2012 December 28; 4(12): 455– the treatment of hemoptysis in patients 461. with cystic fibrosis. Disponible en: http://www.atsjournals.org/doi/pdf/10.1 22) Ikoma A, Kawai N, Sato M. Pathologic Evaluation of Damage to 164/ajrccm.157.6.9708067 Bronchial Artery, Bronchial Wall, and 29) Hwang HG, Lee HS, Choi JS et al. Pulmonary Parenchyma After Bronchial Artery Embolization With N-butyl Risk factor influencing rebleeding after Cyanoacrylate for Massive Hemoptysis. bronchial artery embolization on the JVIR, Aug 2011, 22(8):1212-1215. management of hemoptysis associated with pulmonary tuberculosis. Tuberc 23) Yoo DH, Yoon CJ, Kang SG. Respir Dis (Seoul) 2013 March, Bronchial and non-bronchial systemic 74(3):111-119. artery embolization in patients with major hemoptysis: safety and efficacy of 30) Cornalba GP, Vella A, Barbosa F, et N-Butyl Cyanoacrylate. AJR 2011; 196: al. Bronchial and non-bronchial systemic w199-w204. artery embolization in managing haemoptysis: 31 years of experience. 24) Bommart S, Bourdin A, Giroux MF, Radiol Med 2012. Klein F, et al. Transarterial ethylene vinyl alcohol copolymer visualization 31) Mal H, Rullon I, Mellot F, et al and penetration after embolization of Inmediate and long-term results of life-threatening hemoptysis: technical bronchial artery embolization for life- and clinical outcomes. CVIRJune 2012, threatening hemoptysis. Chest 1999; 35(3):668-675. 115: 996-1001.

32) de Gregorio MA, Medrano J, Mainar A et al. Tratamiento endovascular

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mediante embolización arterial bronquial en la hemoptisis masiva: seguimiento a corto y largo plazo durante 15 años. Arch Bronconeumol 2006, 42:49-56.

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