Bronchial Artery Embolization

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Pre-Procedure

Indications:
• First-line treatment for massive life-threatening hemoptysis
• Moderate or mild hemoptysis resistant to conservative therapy
• Often bronchial artery embolization performed for less severe bleeding particularly in patients with poor lung function

Massive hemoptysis:
• Literature has many definitions of what constitutes massive hemoptysis
• Cystic fibrosis foundation uses >240 mL within 24 hours
• Commonly caused by hypertrophy of bronchial arteries secondary to underlying inflammatory process. Then, inflammatory erosion into the bronchial arteries causes bleeding
• Risk is not blood loss, but blood filling alveoli and asphyxiation
Moderate hemoptysis: > 100 mL/day x 3 days

Preprocedural Evaluation:
• H&P - details of bleeding volume, underlying pulmonary disorders, coagulopathies etc.
• Preprocedural neurologic evaluation
• Prior imaging - CTA of the chest
Review anatomy
• Bronchial and non-bronchial arteries
• Non-bronchial arterial source - can be source of hemoptysis; need to select and embolize

Role of bronchoscopy is limited: often times difficult to identify site, side or offer endobronchial therapy
• Can delay treatment with limited utility
• May vary with institution and operator experience
Airway status- any need for intubation/ventilation protection

Etiologies of hemoptysis:
• Airway: COPD, lung cancer, bronchiectasis
• Parenchymal: Cystic fibrosis, sarcoid, lung abscess or mycetoma
• Traumatic or infectious pseudoaneurysm
• Pulmonary AVM
• Vascular: AVM, Behcet's, Wegener's
Rarely are pulmonary arteries source of bleeding

Procedure

Antibiotic prophylaxis:
• No consensus

Femoral access - radial access can be difficult for BAE
Sheath placement
• Longer sheath can help stabilize catheter in the aorta

Most operators will try and select bronchial arteries without flush aortogram
• Recent CTA extremely helpful to identify bronchial and nonbronchial system arteries which may contribute to hemoptysis.

Select bronchial artery (BA)
• Approximately 2/3rds of bronchial arteries will arise between T5-T6 from the descending thoracic aorta.
• Left main stem bronchus is helpful landmark for approximate location of bronchial arteries
• Catheter choice will depend on operator: Mikaelson commonly used
• Direct catheter lateral or anterolateral for right BA
• Direct catheter anterior or anterolateral for left BA

Angiogram of BA
• BA and branches will track with mainstem bronchi
• Abnormal vessel classically described as enlarged (>3 mm), hypervascular, tortuous, parenchymal staining and systemic-pulmonary artery shunting.
• Unlikely to see active extravasation
Careful review of angiogram to identify anterior spinal artery.
• Anterior spinal artery is small with "hairpin" loop
• More commonly seen on right side. Left rarely supplies anterior spinal cord

Once seated in bronchial artery, use microcatheter for more distal positioning
• Advance microcatheter at least a few centimeters distal to BA origin
• Reduces chance of reflux
• Advance microcatheter beyond takeoff of anterior spinal artery

Particle size
• At least 350 μm particles
• 500-700 or 700-900 μm Microspheres
• PVA 350-500 μm
• Liquid embolics
• Endpoint: near stasis
Avoid coils
Post embolization angiogram to confirm stasis
Remove catheters
Hold pressure vs. closure device

Post-Procedure

Outcomes:
Success rate:
• Up to 99% successful in immediately resolving acute bleed
• Recurrence rate: between 10-55%

Early recurrence may be secondary to incomplete embolization
Late recurrence
• Collateralization or parasitization of new vasculature
• Progression of underlying lung disease
• Recanalization of previously embolized vessels

Potential complications:
• Paralysis, transverse myelitis, stroke from non-target embolization - uncommon but potentially devastating
• Post embolization syndrome: fever, chest pain, dysphagia (less common with superselective microcatheter embolization)
• Bronchial artery dissection or perforation
• Access site hematoma or pseudoaneurysm
• Bronchial necrosis
• Pulmonary infarction

Postoperative care:
• Depends largely on patient acuity
• Postprocedural neurologic check with comparison to baseline

Related Procedures

No related procedures.

 

References

[1] Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307‐317. doi:10.5152/dir.2017.16454
[2] Sopko DR, Smith TP. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2011;28(1):48‐62. doi:10.1055/s-0031-1273940
[3] Sidhu M, Wieseler K, Burdick TR, Shaw DW. Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 2008;25(3):310‐318. doi:10.1055/s-0028-1085931
[4] Burke, C. T., & Mauro, M. A. (2004). Bronchial artery embolization. Seminars in Interventional Radiology, 21(1), 43–48. http://doi.org/10.1055/s-2004-831404
[5] https://www.cff.org/Care/Clinical-Care-Guidelines/Respiratory-Clinical-Care-Guidelines/Pneumothorax-and-Hemoptysis-Clinical-Care-Guidelines/

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Bronchial Artery Embolization

Dr. Timothy P. Maroney walks through a case of massive hemoptysis treated with bronchial artery embolization.

 

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Seminars in Interventional Radiology (Mar 2004)

Bronchial Artery Embolization

Patients with chronic inflammatory lung diseases may experience massive hemoptysis. Surgical intervention is hazardous and often impossible in these patients, however endovascular management of hemoptysis with bronchial artery embolization is effective and well tolerated by these patients.

Seminars in Interventional Radiology (Mar 2011)

Bronchial Artery Embolization for Hemoptysis

The aim of this article is to summarize the etiologies, pathophysiology, and the diagnostic and management strategies of hemoptysis as related to bronchial artery embolization. In addition, the techniques of arteriography and embolization as well as associated procedural outcomes and complications are delineated.

Seminars in Interventional Radiology (Sep 2008)

Bronchial Artery Embolization for Hemoptysis

Relevant anatomy and pathophysiology, pre-procedure evaluation with radiographic imaging, and endovascular technique for bronchial artery embolization is reviewed.

 

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