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S. Kumar and A. Mukherjee
Fig. 18.14 DSA images showing stent-graft deployment in
TEVAR.First image (left) showing angiographic run delineating the
anatomy and aortic branch vessels. Second image (middle) showing
an undeployed device positioned in the aorta. The marker (arrow)
• An angiogram is obtained in LAO 45°-60°for full visualization of the arch, branch vessels, and the proximal
landing area.
• Arterial access is obtained at the stent insertion site.
• The device is prepared as per the manufacturer’s
instructions.
• The device is advanced into the aorta over a stiff 0.035″
inch guidewire (e.g., Lunderquist).
• Markers on the screen may be drawn to demarcate the
landing target as a guide for deployment. Care must be
made not to move DSA machine/patient.
• After conrming positioning, the device is deployed
under continuous uoroscopic monitoring. Radio-opaque
markers on the device are used to conrm positioning.
• Post deployment of stent-graft, the delivery catheter is
then withdrawn carefully under uoroscopic guidance.
• A post-deployment angiogram is done with the pigtail
catheter positioned proximal to the deployed graft.
• Surgical closure of device insertion access site is performed if arteriotomy was performed. A vascular closure
device may also be used to close the defect in the vessel
wall. The access site used for angiography is manually
compressed after sheath removal.
18.5.3 Post-Procedure Care
Patients are monitored by a multi-disciplinary team in the
ICU for 12–24hours post-procedure. Mean arterial pressure
is kept over 100mm of Hg after device deployment. Patient
is monitored for hemodynamic functions, stroke, symptoms
of paraplegia, and bleeding/hematoma at access sites.
indicates the covered portion of the graft placed distal to the ostium
of the bovine trunk. Third image (left) showing angiographic after
complete device deployment with the exclusion of the DTA
aneurysm
18.5.4 Follow-Up Imaging
A radiograph is obtained after procedure completion. This
serves as a baseline image for surveillance regarding device
migration and graft integrity. Follow-up imaging maybe performed at 1 month, 6 months, 12 months, and thereafter
annually. However, followup and surveillance should be
individualized for patients. CT/MR angiography maybe performed for imaging follow-up.
18.6 Complications ofEndovascular
Intervention
Complications may be considered under device-related complications or systemic complications:
18.6.1 Device-Related Complications
• Stent migration: This is dened as displacement of the
graft by more than 5–10mm from its original position.
The most common cause is progressive aneurysm neck
dilatation. Other causes are aortic tortuosity, degeneration
of aortic wall after device placement, and incorrect sizing
of graft (over or undersizing). Migration can lead to
endoleaks, sac expansion, and possible rupture [17].
• Graft infection: Can occur in 0.5 to 3% in endovascular
repair of abdominal aorta. They have high mortality rates
of up to 50% secondary to septic shock. Infections may
occur due to intraprocedural complications or late infections from distant site of infection elsewhere in the body.
18 Interventions oftheAorta
203
They usually need surgical removal of the graft and placement of antibiotic-coated graft.
• Limb Kinking or occlusion: Can occur in 2 to 4% of cases
in EVAR.They occur due to a progressive decrease in size
of the residual aneurysm sac, an excessive angulation of
the neck, or a reduced diameter of the distal aortic neck.
This may lead to migration of the graft or development of
endoleaks (Type I/Type III). Kinking is managed with
reinforcing stents or additional graft limbs. Occlusion
may be managed by angioplasty with or without additional endograft placements. Surgical bypass may be used
in failed cases.
• Graft collapse: They may occur very rarely due to excessive device over-sizing (> 20%) or in the highly angulated
aortic arch (> 50 degrees). It usually occurs within the
rst month after the procedure.
• Endoleaks: Dened as persistent leakage of blood into an
excluded aneurysm sac after placement of endovascular
stent-graft. Discussed below.
18.6.2 Systemic Complications
• Post-implantation syndrome: Can be seen in 13–60% of
patients post EVR. This presents as a u-like illness
(fever, leukocytosis, and elevated inammatory markers),
pleural effusions. It is self-limiting and usually resolves
within a week.
• Ischemia: Incidence is 9% following EVAR. May cause
limb ischemia, renal ischemia, bowel ischemia, or pelvic
ischemia. Ischemia to the bowel may require surgical
resection.
• Spinal ischemia: Can be seen in 2–3% of cases after thoracic stent-graft repair [18]. This is due to interruption of
the blood supply to the spinal cord, potentially from direct
coverage of the arterial supply by the stent. Larger aortic
coverage—coverage of 2/4 vascular territories (LSCA,
intercoastals, lumbar, and hypogastric) increases the risk
of spinal ischemia. Symptoms are seen usually within
24hours of the procedure. Prevention of high intrathecal
pressure through the use of lumbar drains and avoidance
of high central venous pressures (lumbar CSF pressure<12mm Hg intraoperatively) is protective.
• Cerebrovascular accident: Associated with atherosclerotic plaques, proximal aortic position, emergency procedures, PAU, and LSCA coverage with an incidence of
1.2–6.9% (comparable to open surgery).
18.7 Endoleaks
An endoleak is dened as leakage of blood in to an excluded
aneurysm sac after the placement of stent-graft. They are
called primary endoleaks when they occur within 30days of
stent-graft placement and considered as secondary/delayed
endoleaks when they appear after 30days of graft placement
with at least one negative imaging nding post-procedure.
Incidence: Incidence of endoleak after TEVAR is 5–20%.
This is similar to that after endovascular abdominal aortic
aneurysm repair (EVAR).
Endoleaks are classied into ve types:
Type I endoleak can occur when there is inappropriate anat-
omy or malpositioning of the stent-graft. Primary Type I
endoleaks may occur due to inadequate zone(s) of the
stent-graft in conditions such as increased angulation of
neck, plaque or calcication at the landing zone(s), or
under-dilation of the stent-graft. Secondary Type I
endoleak can result from aneurysm re-modeling, gradual
dilatation of neck of aneurysm. Properties of graft can also
determine risk of endoleak, such as devices whose xation
depends upon radial force have more propensity for caudal
migration and endoleaks than graft devices with hooks.
Type II results from retrograde lling of the aneurysm sac
mainly from other arteries such as the IMA or lumbar arter-
ies, and rarely from sources such as the accessory renal
artery, gonadal, or sacral artery. In TEVAR, Type II endole-
aks can be caused by LSCA, intercostal, and occasionally
bronchial arteries. Compared to Type I and III endoleaks,
the risk for expansion of the aneurysm and rupture is lower
in Type II endoleak (0.5% versus 3.4%). Spontaneous seal
is reported in approximately 40% of Type II endoleak.
Type III endoleak is caused by junctional separation of
modular components, holes, or tears in the graft fabric.
This type of endoleak is dangerous because it results in an
acute expansion and increased pressure in the sac.
Type IV endoleak is said to occur due to the porosity of the
fabric used in graft and is usually noted at the time of
device placement. They appear as a faint contrast blush on
the post-procedure angiogram images.
Type V endoleak, sometimes also called endotension, is
characterized by aneurysm expansion without the pres-
ence of a conrmed endoleak. Endotension has been
reported up to 18% and is more commonly reported with
ePTFE grafts, thought to be due to ultra-ltration through
pores of the graft material.
18.7.1 Imaging inEndoleak
Patients who undergo endovascular aortic imaging may
require lifelong surveillance through imaging. However,
there is no exact determination of the ideal frequency of
post-procedural imaging.
Radiograph [19]:
• Anteroposterior and oblique projections.
• Can be used to assess the mechanical structure.
204
S. Kumar and A. Mukherjee
• Possible mechanical defects such as stent-graft migration,
kinking, dilation, fracture, and module or branch disconnection may be detected. However, endoleaks cannot be
directly visualized using this method and it is no longer
used for their detection.
CT angiography:
• CT angiography is a useful tool for endoleak detection,
having higher sensitivity (~92%). Endoleaks can occur at
variable times after contrast material injection and have
variable ow rates.
• A multiphasic CT angiogram protocol is recommended,
including pre-contrast imaging to detect calcication in
the sac, imaging in the arterial phase, and in the postcontrast delayed phase. Delayed phase imaging (60seconds after the end of arterial phase) is particularly
important as it may show endoleaks that may not be
apparent during the early phase. Post-procedural imaging
surveillance by CT angiography may be recommended at
1, 6, 12months, and then annually.
MR angiography [20]:
To evaluate for endoleaks, the following steps are taken
during endoleak angiography:
• Obtain AP and lateral angiograms at the proximal landing
site using a pigtail catheter to assess for type I endoleaks.
• Reposition the catheter just above the stent-graft ow
divider for another angiogram, being careful so that there is
contrast reux up to the proximal landing zone of the graft.
• Look for Type Ib or Type III endoleaks using this
angiogram.
• Conduct selective arteriography of the SMA and the internal iliac artery to assess for Type II endoleaks.
• Extend the image acquisitions to include the venous phase
to detect delayed Type II endoleaks, and make treatment
decisions based on the DSA ndings.
• According to a study, incorrectly classied endoleaks
were correctly identied with DSA leading to a treatment
change for 11% of study population [23].
18.7.2 Important Points Regarding
Surveillance Image Interpretation
(Figs.18.15, 18.16 and18.17)
• MR angiography (MRA) can be useful for detecting
endoleaks in patients with stent-grafts. Studies have
shown that MRA has sensitivity similar to CTA in detecting endoleaks.
• Newer techniques such as time-resolved MRA can have
utility in improved characterization of endoleak types as
they can show the temporal changes of contrast within the
sac, similar to catheter angiography. However, when
time-of-ight (TOF) MR angiography is used alone, its
sensitivity is lower and can be as low as 54%. Combining
TOF with gadolinium-enhanced MR angiography can
increase sensitivity and provide a concordance of 97%
with angiography for endoleak detection.
• Additionally, newer MR contrast agents, such as
Ferumoxytol, may demonstrate slow-owing endoleaks
that are not apparent on CTA; however, clinical signicance of these slow-ow leaks is yet to be determined [21].
Ultrasound:
• Has multiple advantages being radiation safe, cheap, and
portable, but it is also operator dependent.
• Sensitivity of Doppler US has wide variations, ranging
from 25% to 100%, with specicity of 93–94% in detecting endoleaks, compared to CTA [22].
• Microbubble contrast agents may improve the sensitivity
of US to detect endoleaks and may be potentially used in
suspected endotension.
Endoleak angiography
When interpreting surveillance images for stent-graft repair of
aneurysms, it is important to keep in mind the following points:
• Accurately measure aneurysm size and monitor for signicant changes in dimensions.
• Detect and characterize any endoleaks that may be
present.
• Look for structural integrity of the stent-graft, including
fracture, kink, or migrations.
• Relatively small differences in aneurysm size on follow up may dictate management.
• An enlarging aneurysm may require intervention, while
reduction in size is reassuring.
• Ensure accurate aneurysm measurement by always measuring dimensions in true axial planes.
• Consider using aneurysm volume measurement during
follow-up as it maintains uniformity and has less variations in measurement among different observers.
• Aneurysm volume measurements may detect enlargement of sac 18months prior to measurements using diameters [24].
18.7.3 Management ofEndoleaks
Type IA:
The management of endoleaks depends on the type of
endoleak present. The following management strategies are
typically used for Type IA endoleaks:
ab
ab
ab
18 Interventions oftheAorta
Fig. 18.15 (a and b): Axial
and sagittal oblique CTA
images showing contrast
extravasation from the
proximal end of the aortic
stent-graft—Type Ia endoleak
Fig. 18.16 (a and b) Axial
and coronal oblique CTA
images showing contrast
extravasation from the distal
end of the thoracic aortic
stent-graft—Type Ib endoleak
205
Fig. 18.17 (a and b): Axial
(a) and coronal MIP (b) CTA
showing the focus of contrast
in the aneurysm sac which
was traced to be originating
from a lumbar artery—
suggesting a Type II endoleak.
Patient was kept on follow-up,
and endoleak disappeared on
the 1-month follow-up CTA
• To achieve an adequate seal, a plain balloon angioplasty of
the proximal landing site is the initial treatment. If it is unsuccessful, bare metal stents can then be placed over the affected
site to tightly oppose the stent-graft with the aortic wall.
• Covered extension cuffs can be used to bridge the
endoleak defect.
• Newer devices such as EndoStaples and EndoAnchors
can be used as mechanical attachment anchors for the
stent-graft with the aortic wall. Early studies with these
devices have shown encouraging results for the management of Type IA endoleaks [25].
• Embolization can be performed of endoleak area using a
catheter to access the site of the leak. The leak can delin-
206
S. Kumar and A. Mukherjee
eated on angiography while ruling out a Type II endoleak
at the same time. The perigraft space can then be embolized using glue or onyx via a microcatheter.
• Type IB can be treated with the use of covered stents,
iliac extender limbs, or bare metal stents to cover the gap
and promote sealing of the graft to the artery. However,
in cases where internal iliac artery must be excluded,
such as treatment of an iliac artery aneurysm or pelvic
malignancy, the artery needs embolization prior. This is
important because exclusion of the artery can result in
blood ow changes that can contribute to the development of Type II endoleaks. By embolizing the artery rst,
the risk of subsequent Type II endoleaks can be
minimized.
Type II:
• Type II endoleaks are one of the most common complications following endovascular repair of abdominal
aortic aneurysms (EVARs). They occur when blood
ows into the aneurysm sac through collateral vessels,
such as lumbar or mesenteric arteries, around the endograft. Although many Type II endoleaks may be selflimited and resolve spontaneously, some may persist
and lead to enlargement of the aneurysm sac, ultimately
leading to rupture.
• The management of a Type II endoleak depends on
several factors, including the duration of the endoleak,
the size of the aneurysm sac, and the presence of associated symptoms. In general, intervention should be
reserved for patients who have a persistent Type II
endoleak after 6months, have an enlarging aneurysm
sac, or have a sac pressure that exceeds 20% of systolic blood pressure.
• The preferred mode of treatment for a Type II endoleak is
similar to treating an AVM, where we need to embolize
the endoleak nidus as well as the feeding arteries. The sac
can be accessed transarterially or via a translumbar
approach. If the nidus is not embolized and only the feeding arteries are blocked proximally, the endoleak will
recur as it would recruit additional branch vessels.
• A transarterial embolization can be done via the collaterals from the inferior mesenteric artery or lumbar artery.
Lumbar arterial endoleaks can be accessed through internal iliac artery, most commonly via the ascending iliolumbar branches.
• A transvenous/caval approach, rst described by Mansueto
etal., uses a curved puncture to gain the sac access from
the inferior vena cava. Embolization can be done when the
sac is successfully entered. This method has a reported
83% technical success with one-year freedom from intervention being 95% at a mean of 16.5months [26].
• In conclusion, managing type II endoleak should be individualized, taking into account the duration of the
endoleak, the aneurysm sac size, and associated symptoms. Endoleak nidus and feeding vessel embolization are
the preferred modes of treatment. A transvenous/caval
approach may be considered in some cases.
Type III:
• Immediate intervention is necessary for Type III endoleaks as they are related to device failure and can lead to
aneurysm rupture.
• The initial step is to identify the source of the leak, which
can be done using CTA or MRA.
• Treatment options include endovascular revision or conversion to open surgical repair.
• Endovascular revision involves placement of a new stentgraft device across the site of the Type III endoleak to
exclude the defect.
• Conversions to open surgical repair are necessary in cases
where endovascular revision is not possible, or if there is
evidence of ongoing bleeding or infection.
Type IV:
• Usually requires no treatment and spontaneously resolves
on follow-up.
Type V:
• Type V endoleaks, also known as endotension, occur
when there is persistent pressurization of the aneurysm
sac after endovascular aneurysm repair (EVAR), despite
the absence of any demonstrable endoleak on imaging.
This can be due to a number of factors such as incomplete
seal of the stent-graft, fabric porosity, or inadequate
anchoring of the stent-graft.
• The management of type V endoleaks can be challenging
and often requires a multidisciplinary approach involving
vascular surgeons, interventional radiologists, and imaging specialists. Treatment options for type V endoleaks
include close observation, aortic puncture, and explantation of the graft.
• In the initial phase, close observation with serial imaging
studies is usually recommended for stable Type V endoleaks. However, if the aneurysm sac continues to enlarge or
there is evidence of rupture or impending rupture, intervention may be necessary.
• Aortic puncture may be performed to analyze and empty
the accumulated uid, relieve pressure on the aneurysm
sac, and potentially improve the effectiveness of the stentgraft seal. This procedure involves the insertion of a needle or catheter through the aortic wall into the aneurysm
18 Interventions oftheAorta
207
sac under image guidance to aspirate the uid. This procedure can also be used to inject contrast material to evaluate the stent-graft and any potential defects that may be
causing the endotension.
• Surgical removal of the existing stent-graft, followed by
insertion of a new stent-graft or surgical repair of the aortic defect, is another option.
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Vascular Thoracic Interventions
JunaidKazimi, AshuSeithBhalla, PriyankaNaranje,
andIqbalBashir
19
Key Messages
1. Major vascular thoracic interventions include bronchial
artery embolization, pulmonary arteriovenous malformation (PAVM)/pseudoaneurysm embolization, catheterdirected therapies for pulmonary embolism, thoracic
venous stenting, and thoracic duct interventions.
2. Split bolus CT angiography should be performed in cases
of haemoptysis for aetiological evaluation as well as vascular mapping.
3. Abnormal bronchial/non-bronchial arteries appear hypertrophied (>2 mm) and tortuous and can generally be
traced up to the pathology.
4. Non-bronchial systemic arteries should be searched for
particularly in case of associated pleural thickening, apical disease and pathologies reaching up to the lateral
chest wall. Ectopic bronchial arteries that appear arising
from subclavian artery or its branches coursing downwards in mediastinum and then through hila to reach the
pathology should be specially looked for in case one is
not able to nd any hypertrophied orthotopic bronchial
artery from descending thoracic aorta.
5. Polyvinyl alcohol (PVA) particles are the most commonly
used embolizing agent in BAE.Glue and gelfoam are the
alternative embolizing agents that may be used.
6. For pulmonary artery pseudoaneurysms, endovascular
coil embolization is generally the most commonly used
treatment option.
7. Any PAVM with a feeding artery with diameter of 2mm
or larger, measurable increase in size of PAVM or symptomatic hypoxemia/paradoxical emboli should be treated.
Endovascular plug/coils are the embolizing agents of
choice.
8. Endovenous intervention has emerged as a rst-line treatment for the management of severe or life-threatening
SVC syndrome irrespective of aetiology. Self-expanding
bare metal stents are the most common type of stents used
for SVC recanalization.
9. Percutaneous interventional techniques such as Thoracic
duct embolisation (TDE)/thoracic duct disruption (TDD)
or therapeutic lymphangiography with Lipiodol have
gained popularity as the initial management options for
chylothorax in conjunction with dietary measures.
19.1 Introduction
Thoracic interventional radiology has emerged as a minimally invasive lifesaving branch of radiology and covers a
wide spectrum of diagnostic and therapeutic procedures
ranging from pleural uid tapping to pulmonary arteriovenous malformation/pseudoaneurysm coiling (Table19.1).
The vascular thoracic interventions will be discussed in
this chapter. The non-vascular thoracic interventions will be
covered in Chap. 37.
J. Kazimi
Fellow Thoracic and GI Radiology, Department of Radiodiagnosis
and Interventional Radiology, All India Institute of Medical
Sciences, Delhi, India
A. S. Bhalla (
Department of Radiodiagnosis and Interventional Radiology,
All India Institute of Medical Sciences, Delhi, India
I. Bashir
Fellow Thoracic Radiology, Department of Radiodiagnosis and
Interventional Radiology, All India Institute of Medical Sciences,
Delhi, India
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2024
S. H. Chandrashekhara (ed.), Textbook of Interventional Radiology, https://doi.org/10.1007/978-981-97-9601-4_19
*) · P. Naranje
Table 19.1 List of thoracic interventions
Non-vascular interventions Endovascular interventions
Diagnostic
Transthoracic FNAC/
biopsy
Therapeutic/palliative
Drainage procedures
Tumour ablation
Airway interventions
Bronchial artery embolization
PAVM/pseudoaneurysm embolization
Pulmonary embolism—Lysis/
thrombectomy
Venous—SVC stenting
Chylothorax management
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210
19.2 Bronchial Artery Embolization (BAE)
Pre-procedure evaluation—In a patient presenting with haemoptysis, the pre-procedure workup includes clinical, laboratory, and radiological evaluation [1]. Clinically,
haemoptysis should be conrmed, its severity should be
assessed, and the cause should be determined. The common
causes of haemoptysis and indications and contraindications
for BAE are enumerated below [1, 2].
19.2.1 Common Causes ofHaemoptysis
• Tuberculosis—active and post-infective sequelae.
• Chronic pulmonary aspergillosis.
• Bronchiectasis.
• Other bacterial/fungal infection.
• Pulmonary artery malformation (PAVM).
• Pulmonary artery/bronchial artery pseudoaneurysm.
• Lung carcinoma—primary and secondary.
• Pneumoconiosis.
• Cryptogenic haemoptysis.
• Anticoagulant administration.
19.2.1.1 Indications forBAE
• Haemoptysis of volume more than 100 ml for three or
more episodes within 1week.
• Progressively increasing haemoptysis episodes.
• Signicant respiratory distress/airway compromise
caused by haemoptysis.
19.2.1.2 Contraindications forBAE
• Absolute contraindications
– Bronchial arteries supplying branches to vital organs:
• Heart—Carefully search for these vessels before
embolizing inferior phrenic artery and ectopic
bronchial arteries using oblique views if there is a
suspicion.
• Spinal cord—Carefully search for radiculomedullary branches with characteristic hairpin turn
before embolizing the right intercostobronchial
trunk and the posterior intercostal arteries. Any
branch coursing towards midline should be viewed
with suspicion and conrmed on oblique/lateral
views.
J. Kazimi et al.
• Brain—Especially while working near the vertebral
artery.
• Relative contraindication
– Congenital pulmonary artery stenosis—Partial embo-
lization may be done in case of massive ongoing
haemoptysis.
19.2.1.3 Pre-Procedure Evaluation
Laboratory investigations include hemogram, coagulation
parameters, and sputum examination. According to the
CIRSE standards of practice on peri-operative anticoagulation management [3], BAE is an interventional procedure
with low risk of bleeding, and acceptable blood parameters
are haemoglobin more than 7g/dl, platelet count more than
20,000/ml, and INR less than 2.0 if on vitamin K
antagonists.
Radiological Investigations—The most common and earliest investigation that is done in patients presenting to emergency with massive haemoptysis is a chest radiograph.
Although relatively insensitive, it gives a general sense of the
condition of the lungs and most of the time helps inlocalizing the side of bleed. Chest radiograph is generally followed
by CT angiography (Fig.19.1). At our institute we follow the
split bolus technique [4] which helps in the visualization of
both bronchial and pulmonary arteries in a single phase and
thus helps in identifying the culprit circulation/vessel. One
should have a look at the lung window rst to get an idea of
the primary disease and then look at the abnormal arteries
supplying the pathology in mediastinal/soft tissue window.
Abnormal bronchial/non-bronchial arteries appear hypertrophied (>2mm) and tortuous and can generally be traced up
to the pathology. Non-bronchial systemic arteries should be
searched for particularly in case of associated pleural thickening, apical disease, and pathologies reaching up to the lateral chest wall. Ectopic bronchial arteries appear as tortuous
hypertrophied vessels arising from subclavian artery or its
branches coursing downwards in mediastinum and then
through hila to reach the pathology and should be specially
looked for in case one is not able to nd any hypertrophied
orthotopic bronchial artery from descending thoracic aorta.
Inferior phrenic artery should also be evaluated in case of
middle lobe and lower lobe pathology. Bronchopulmonary
shunting on CT appears as non-tapering branch of pulmonary artery supplying the pathology and is one of the signs to
identify the site of bleed in case of multifocal pathologies. A
list of arteries to be embolized should be prepared in order of
priority before BAE using landmarks easily visible on angiography as references (Table19.2).
19 Vascular Thoracic Interventions
211
a
d
b c
e f
D
Fig. 19.1 (a) CT bronchial angiography demonstrating a hypertro-
phied right intercostobronchial trunk (white arrow). (b) Coronal CTA
image of the same artery in A showing the tortuous course (white
arrowhead). (c) Coronal MIP image showing a hypertrophied lateral
thoracic branch of left subclavian artery, with transpleural collaterals
supplying the abnormal lung parenchyma. (d) CTA images showing
Table 19.2 An example of the list of arteries planned to be embolized
for BAE
1. Right intercostobronchial trunk—9 o’clock, left main bronchus
upper border
2. Left bronchial artery—12 o’clock, left main bronchus lower
border
3. Left internal mammary artery branches—Arising from left
subclavian posterior just distal to vertebral artery, 1cm distal to
medial end of the clavicle
4. Left lateral thoracic artery branches—Arising from left
subclavian inferior at the level of lateral border of second rib
19.2.2 Bronchoscopy
It is useful to decipher the site of bleed, clot extraction, tamponade, and ablation of haemorrhagic arteries and for collection of samples for cytology and microbiology. CT is similar
in accuracy in detecting site and cause of bleed and better in
terms of planning BAE [1, 2] and is the preferred investigation in most of the cases.
features of bronchopulmonary shunting as Non-tapered segmental
branch of RUL pulmonary artery (white arrow) with (e) differential
opacication of another segmental branch (Black arrow) along with (f)
a cluster of vessels adjacentto the segmental branch of left lower lobe
pulmonary artery (dashed white arrow), representing an indirect sign of
shunting
19.2.2.1 Technique
Access route—Femoral route is most commonly used.
However, radial route can be used in cases of difcult-tohook subclavian artery branches.
Sheaths and catheters—Usually a 6F 11cm arterial sheath
is used in adults for maintaining vascular access. Longer
sheaths can be used in case of tortuous arteries.
Embolic agent—Polyvinyl alcohol (PVA) particles are
the most commonly used embolizing agent in BAE.Particle
size of 355–500 μm is commonly used; however, larger
particle size can be used in case of bronchopulmonary
shunts. It is mixed with non-ionic iodinated contrast agent
to prepare a suspension. The dilution depends on the size
of the artery, the presence of shunts, and the ow velocity
in the vessel. The aim is to embolize the abnormal parenchymal bed and shunts rather than embolize the main
artery itself. N-butyl 2-cyanoacrylate glue is an alternative and has been successfully and safely used in many
studies [5, 6]; however, it should be done by a trained
212
bc
J. Kazimi et al.
a
de
Fig. 19.2 Anatomy of bronchial arteries. (a) Common bronchial
angiogram demonstrating the right (black arrow) and left (white arrow)
bronchial arteries. (b) Right bronchial (black arrow) arteriogram. (c)
Table 19.3 Angiographic signs of culprit arteries
Lung parenchyma blush
Neovascularity
Tortuous hypertrophic arteries
Pseudoaneurysm of bronchial or pulmonary arteries
Bronchial to pulmonary artery/vein shunts
interventional radiologist who has experience working
with glue.
After the femoral artery puncture and securing access
with vascular sheath, the culprit artery is hooked using an
end-hole catheter. After hooking, we push approximately
1–2ml of 50–60% diluted contrast agent under uoroscopy
to conrm a secure position and then a DSA run is taken to
ascertain the anatomy and course of the artery (Fig.19.2).
Various angiographic signs of abnormal arteries that are seen
in case of haemoptysis are summarized in Table 19.3
(Figs. 19.3, 19.4, and 19.5). Then we use microwire and
microcatheter (2.7F Progreat microcatheter) to advance into
the artery. When we reach a secure position with microcatheter and have crossed any branch we do not wish to embolize, another DSA run is taken to conrm the same and judge
the blood ow velocity within the vessel. PVA particles
(355–500μm) suspended in iodinated contrast agent are then
injected under intermittent uoroscopy guidance using 1ml
insulin syringe paralleling the blood ow velocity in the vessel so that there is only forward ow and no back ow. After
Right intercosto-bronchial trunk (black arrow) arteriogram. (d)
Left bronchial (black arrow) angiogram. (e) Left internal mammary
arteriogram (white arrow)
a few PVA injections one should ush the microcatheter with
NS, and the Sheath should be ushed with heparinized saline
every 15–20minutes. Once stasis is achieved, another DSA
run is taken to conrm the absence of parenchymal blush.
The whole coaxial system should then be removed and
ushed, and the next artery should be hooked. Technical success is said to be achieved when all the abnormal arteries
have been embolized, and clinical success is indicated by
cessation or signicant reduction in the amount of haemoptysis for at least 24h or within 30days of BAE.
19.2.2.2 Post-Procedure Care
After completion of the procedure, all limb movements and
distal pulses should be checked. Patients should be monitored for 24hours in the hospital and can be discharged after
that. The primary disease should be further evaluated and
treated to prevent recurrent haemoptysis.
19.2.2.3 Complications
The most dreaded complication is spinal cord infarction
which is now very uncommon (<1%) [1, 2] due to super
selective catheterization. Other complications include postembolization syndrome and chest pain, but these are usually
transient and self-limiting. Transient cortical blindness,
stroke, bronchial infarction, esophago-bronchial stula,
myocardial infarction, and ischaemic colitis have been
described but are rarely seen.