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BackTable / VI / Topic / Procedure
Bronchial Artery Embolization Procedure
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Pre-Procedure Prep
Bronchial Artery Embolization 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
Pre-Procedural 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
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
Bronchial Artery Embolization Podcasts
Listen to leading physicians discuss bronchial artery embolization on the BackTable VI Podcast. Get tips, tricks, and expert guidance from your peers and level up your practice.
Procedure Steps
Antibiotic Prophylaxis
• No consensus
Femoral Access vs. Radial Access
Recommend 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
Distal Positioning with Microcatheter
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
Bronchial Artery Embolization 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
Post-Operative Care
• Depends largely on patient acuity
• Postprocedural neurologic check with comparison to baseline
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] Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002 Nov-Dec;22(6):1395-409. doi: 10.1148/rg.226015180. PMID: 12432111.
[6] https://www.cff.org/Care/Clinical-Care-Guidelines/Respiratory-Clinical-Care-Guidelines/Pneumothorax-and-Hemoptysis-Clinical-Care-Guidelines/
Disclaimer: The Materials available on https://www.BackTable.com/ are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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