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Bronchial Artery Embolization

Bronchial Artery Embolization Procedure Prep

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Pre-Procedure Prep

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

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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

• May be secondary to incomplete embolization

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

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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