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35 Bronchial Artery Embolization 359
Next, Identify Any Spinal Supply That
• Arises from proximal bronchial or intercostal arteries (medial to pedicle).
• Passes sharply cranially and then has a tight hairpin (180
the straight midline anterior spinal artery (Fig. 35.2)
◦
) bend before supplying
Embolization
• When embolizing –
◦ Inject embolic agent slowly to avoid reflux and non-target embolization.
◦ Continuous high-quality screening during embolization is mandatory, and
repeat angiograms should be performed frequently. Spinal and other important
collaterals may open up as the target vessel is being occluded. Intermittentcheck angiographic runs are recommended.
◦ Do not inject intercostals at the vessel origin as this increases the chance of
radiculomedullary branch embolization. Advance the catheter a few centimeters into the vessel (at least beyond the pedicle) to avoid particle reflux.
Clinical Scenarios
• BAE starts with airway management. Make sure that you have adequate clinical
support for this. I ntubation and ventilation may be much safer for the patient and
will also improve angiographic quality.
• If possible, lateralize the source of hemorrhage before starting. This will simplify
and shorten the procedure.
• Patients may feel a unilateral gurgling sensation or discomfort when bleeding
occurs. This is a reliable lateralizing symptom.
• Where clinical or imaging lateralization is not possible, bilateral BAE is required
(the underlying disease commonly causes bilateral pathological changes and the
culprit lesion cannot be identified).
Treatment Plan and Technique
• Start with the side most likely to be bleeding, When lateralization of the cause
has not been possible, treat any abnormal circulation on both sides.
• In massive hemoptysis, ALL POTENTIAL NON-BRONCHIAL SYSTEMIC
COLLATERALS SHOULD BE ASSESSED, after t reatment of all identifiable
bronchial arteries. Embolizing bronchial arteries alone is a common cause of
embolization failure.
• In less severe hemoptysis, it may be appropriate to assess the response to
BAE alone (the risk of persistent hemoptysis being weighed against the risk of
complication(s) from more extensive embolization).
360 S. McPherson
Aftercare
• Observe for signs/evidence of neurological deficit.
• If spinal cord damage occurs, it is likely due to focal infarction ( transverse
myelitis) caused by hypoperfusion from more proximal occlusion of spinal
branches.
• Supplemental oxygen, IV fluids, and blood pressure maintenance (mean arterial
pressure above 80 mmHg) are recommended.
• A spinal drain should be inserted, if spinal cord infarction cannot be immediately
confirmed.
Arterial Puncture Site
• A closure device may be useful. It allows patients with respiratory compromise
to immediately achieve a more comfortable sitting position.
Post-embolization
• Chest-wall pain and pain/difficulty swallowing are common and transient.
• If significant hemoptysis persists or recurs, repeat angiography is performed.
◦ Check that the embolized vessels remain occluded.
◦ Look for accessory bronchial arteries and collateral bronchial supply, particu-
larly from the intercostal, internal mammary, inferior phrenic and subclavian
arteries (including thyrocervical, costo-cervical, and lateral thoracic branches
of the subclavian).
◦ Consider pulmonary angiography, if no bronchial arterial abnormality is
detected.
Follow-Up
Most patients have chronic pathology. Many will require repeated embolization
every 2–3 years, as new collateral vessels open up. Patients, and their physicians,
should be made aware that recurrence of hemoptysis is to be anticipated and that
BAE is repeatable. However, these embolizations become increasingly challenging
as more collaterals develop.
Keypoints
• Knowledge of normal, aberrant, and collateral bronchial arterial circulation is a prerequisite. Multiple supplying vessels are the norm.
35 Bronchial Artery Embolization 361
• BAE involves the identification and then catheterization of multiple small
vessels. Diligent angiographic technique is required. Even microcatheters
may be difficult to advance.
• Preserve the main arterial trunk to allow future access/prevent particulate
reflux.
• Coils and other proximal occlusion techniques are rarely indicated, as
they block the access vessel without occluding the abnormal parenchymal
circulation.
Safety
• Have a low threshold for asking for anesthetic support.
• Identify any spinal arterial supply.
◦ Requires high-quality magnified screening and check angiographic acquisi-
tions.
◦ Modify the embolization technique if identified – this is often an indication for
coil embolization distal and proximal to the spinal branch.
Suggested Reading
[1] Uflacker R, Kaemmerer A, Picon P et al. Bronchial artery embolization in the management
of haemoptysis: technical aspects and long-term results. Radiology 1985; 157: 637–644
[2] Yoon W, Kim JK, Kim YH et al. Bronchial and nonbronchial systemic artery embolization for
life threatening haemoptysis: a comprehensive review. Radiographics 2002; 22:1395–1409
[3] Mauro, Murphy, Thomson, Venbrux and Zollikofer. Bronchial artery embolization. In: Image
guided interventions (Vol II). Eds Irani Z and Keller FS (2008) pp. 931–938 Elsevier ISBN
978-1-4-4160-29649
Chapter 36
Pulmonary Hemorrhage (Non-bronchial)
Hamed Aryafar and Thomas Kinney
Clinical features are as listed in Chapter 35.
The most useful definition of massive hemoptysis is a volume sufficient to
cause life-threatening condition. In the literature, this ranges from 100 to 1000 cc
per day.
• Emergency surgery performed for hemorrhage has a 17–40% mortality.
Etiology
• 90% of massive hemoptysis derives from bronchial or systemic arteries, 5%
from the pulmonary arteries, and 5% from other systemic arteries or from
miscellaneous causes such as aorto-bronchial fistula.
• Pulmonary artery abnormalities co-exist with systemic abnormalities in up to
10% of patients.
Causes of Pulmonary Arterial Hemorrhage
• Pulmonary artery aneurysm/pseudoaneurysm (Rassmusen’s aneurysm: see
Fig. 36.1)
• Pulmonary AVM (Chapter 15)
• Pulmonary artery iatrogenic injury from Swan-Ganz catheter placement
• Pulmonary embolus
• Pulmonary hypertension
• Mitral stenosis
• Trauma
Transcatheter Embolization and Therapy,
Techniques in Interventional Radiology, DOI 10.1007/978-1-84800-897-7_36,
C
Springer-Verlag London Limited 2010
363
364 H. Aryafar and T. Kinney
Fig. 36.1 A male patient with
TB who had massive
hemoptysis unresponsive to
conservative treatment. He
had a negative bronchial
angiogram, and a pulmonary
arteriogram was performed.
This showed extensive
cavitary change to the left
upper l obe with a
Rasmussen’s aneurysm along
the inferior margin of the
cavity; this was successfully
embolized with coils
Diagnostic Evaluation
• Clinical assessment and airway management are crucial.
• Must exclude other source of bleeding such as nose, mouth, pharynx, and
hematemesis.
Laboratory
• Arterial blood gas and oxygen saturation.
• Any clotting abnormalities must be corrected.
Imaging
• Plain radiographs are often normal and seldom establish the source.
• Bronchoscopy (not always performed, but may give more information regarding
etiology and side of bleeding for planned embolotherapy).
• Contrast-enhanced computed tomography scan (CECT) (Chapter 9).
◦ Useful for evaluation of anatomy and possible direct diagnosis of source of
hemorrhage. Some advocate CT scan prior to bronchoscopy. The primary goal
36 Pulmonary Hemorrhage (Non-bronchial) 365
is to identify which lung the hemoptysis arises from and possibly pinpoint the
specific pulmonary segment.
◦ A secondary goal is to determine if the bleeding arises from the pulmonary
artery or intercostals or systemic collaterals.
◦ Lastly, if the supply arises from the pulmonary arterial supply, it is important
to determine if the anatomy is simple (one feeding artery) or complex (multiple
feeding arteries).
Pulmonary angiography: The logistical requirements for treating acute or chronic
recurrent hemoptysis include the following:
◦ Availability of high-quality digital angiographic equipment
◦ On-call interventional radiologist and radiologic technologist and nurse
◦ Embolization material and a variety of different catheters (including stent
grafts)
◦ Availability of an intensive care unit and advanced airway management.
Patients may require intubation (including selective endobronchial balloon
occlusion) prior to the procedure
Indications
Pulmonary arteriography is indicated
• In patients with hemoptysis suspected to be arising from the pulmonary
circulation.
• When conservative medical therapy fails.
• In operative candidates when surgery cannot be performed.
• Recurrent hemoptysis in patients with bilateral widespread disease.
• To control bleeding as a temporary measure before definitive surgery is planned.
Contraindications
• All contraindications are relative!
• Severe pulmonary arterial hypertension is a contraindication to pump
angiography.
• Inability to find exact source of bleeding via diagnostic pathway or clinical
instability would preclude treatment.
• Due to the contrast load, renal insufficiency is a relative contraindication.
• A recent electrocardiogram is necessary to exclude a left bundle branch block.
Right heart block induced by attempted catheterization of the pulmonary arteries may result in complete heart block. If the patient has right heart block,
then a temporary pacemaker (transvenous or transcutaneous) is required before
angiography.
366 H. Aryafar and T. Kinney
Equipment
Catheters
• Pulmonary artery catheterization for diagnosis (Fig. 36.2)
◦ 5 Fr Omniflush catheter
◦ 7 Fr Grollman Catheter
◦ 6–7 Fr Pigtail catheter with tip-deflecting wire technique
◦ Balloon flotation catheter
• Selective catheterization for transcatheter therapy
◦ 5 Fr Kumpe, headhunter, or cobra for conventional-sized coils
◦ 7–8 Fr White Lumax Catheters
◦ 3 Fr microcatheters for situations requiring subselective embolization with
microcoils
◦ 4–7 Fr sheath or 5–9 Fr guide catheter (for Amplatzer Vascular Plug II)
Fig. 36.2 Catheters to use for pulmonary artery catheterization. From left to right, these include
the Grollman, Pigtail catheter (used with tip-deflecting wire technique), and the Ominflush
catheter
Embolic Agents
• Amplatzer vascular plug
• Embolization coils (stainless steel, platinum (Nestor), detachable (GDC or
other))
36 Pulmonary Hemorrhage (Non-bronchial) 367
Exclusion
• Covered stent graft.
Medications
• Consider moderate sedation for patient.
• Atropine 0.5 mg IV for prophylaxis against bradycardia.
• Antibiotic prophylaxis (e.g., 1 gm cefazolin).
• Some patients may require endotracheal intubation to protect aspiration into the
unaffected lung.
Procedure
Access: femoral (more common), brachial, or jugular vein.
Pulmonary Artery Catheterization
Always monitor for ectopic ventricular beats, particularly for ventricular tachycardia.
• Omniflush technique: the 5 Fr catheter is advanced to the right atrium. At that
level, a stiff hydrophilic guidewire is inserted, which opens the curve of the
catheter directing the guidewire superiorly toward the right ventricular outflow
tract and pulmonary artery.
• Grollman catheter technique: the pre-shaped catheter is positioned with the
Pigtail in the right atrium. Twisting the catheter directs the catheter tip through
the tricuspid valve and further catheter twisting and advancement selects the right
ventricular outflow and main pulmonary artery.
• Pigtail and deflecting wire technique: the Pigtail is advanced to the right atrium.
The tip deflecting wire is inserted into the catheter near the catheter tip and the
wire deflected towards the right ventricle. The catheter is fed forward off the wire
into the right ventricle. The deflection of the wire is released, straightening the
catheter which is advanced through the right ventricular outflow tract and into the
main pulmonary artery.
• Balloon flotation catheter: analogous to Swan-Ganz catheter insertion. The bal-
loon catheter is inserted to the right atrium; t he balloon is inflated with air and
carefully advanced under fluoroscopy into the pulmonary circulation.
• In the setting where a right-to-left shunt is suspected, careful attention must
be paid to decreasing the risk of small clot or air bubble injection. Even a
small thrombus or air embolus in the setting of such a shunt could prove to be
devastating to the patient, particularly if the embolus travels to the heart or brain.
368 H. Aryafar and T. Kinney
Pulmonary Arterial Pressures
◦ Pulmonary arterial pressures are typically determined. Elevated pressures may
alter the diagnostic and therapeutic techniques (e.g., decreasing rate and volume
during angiography).
Pulmonary Angiography
◦ Pulmonary artery injection (15–20 cc/s for total of 30–40 cc) with rapid digital
subtraction imaging (>15 frames/second) on side causing suspected hemoptysis.
◦ If possible, respirations are suspended.
◦ Multiple views, including obliques and cranially–caudally angulated views, may
be helpful for subselective catheterization and defining the pathologic lesion
(aneurysm neck, number of supplying arteries, sizes and lengths of arteries for
coil selection or stent-graft implantation).
Assess Bleeding
• Prior imaging (CT) will be helpful in determination of source.
• The most common finding is an aneurysm, pseudoaneurysm, or arteriovenous
fistula.
• Demonstration of contrast extravasation is highly unusual, and the lack of definite
contrast extravasation should not preclude embolization if a bleeding source is
noted.
Embolization
• In cases where embolization is considered, the coils should exclude the aneurysm
completely (Fig. 36.3). The coils should be appropriately sized for diameter
and length to achieve adequate coverage without excluding normal pulmonary
segments. Situations with communication to the pulmonary veins warrant extra
consideration, as air or coil embolism may result in significant complications.
Proper sizing of coils, detachable coils, and the Amplatzer plugs are useful in
these situations. If a particular case involves stent grafting, appropriate sheaths,
stent graft diameters, and lengths are crucial.
Follow-up angiography: if hemoptysis persists despite transcatheter pulmonary
artery therapies, consider a systemic source (Chapter 35).
Alternative approach: conventional surgery or rarely direct percutaneous
embolization of diseased vessel(s).
36 Pulmonary Hemorrhage (Non-bronchial) 369
a
b
d
c
Fig. 36.3 A 37-year-old female with history of IVDA and AIDS was admitted with bacterial endo-
carditis (staph aureus). After antibiotic therapy she improved but had a persistent right-lung opacity
(a). She developed massive hemoptysis and was evaluated by cardiothoracic surgery but was denied
surgery. She underwent pulmonary arteriography, which showed a pseudoaneurysm arising from a
right lower lobe subsegmental pulmonary artery branch (b). This was embolized with coils distal
to the aneurysm, within the aneurysmal sac, and proximal to the aneurysm (c). The patient was
evaluated at 1 year follow-up, which showed no evidence for recurrent aneurysm by CT and chest
radiograph (d)
Complications/Follow-Up
◦ Rebleeding (early/late) can occur. This is usually due to a failure to rec-
ognize the involvement of other pulmonary/bronchial arteries or of nonbronchial systemic vessels that were not identified and occluded during the first
procedure.
◦ Late rebleeding is generally due to disease progression, but may result from
recanalization of embolization coils.
◦ Lung parenchyma ischemia with pleuritis (usually from large segment emboliza-
tion therapy).