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1 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, § REVIEW ARTICLE/Dr. Marcelo Langleib 1 1 2 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 2 Rev. Imagenol. 2da Ep. Junio 2013 XVI N (2). 3 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 § REVIEW ARTICLE/Dr. Marcelo Langleib 3 1 4 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 4 Rev. Imagenol. 2da Ep. Junio 2013 XVI N (2). 5 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
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