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PATIENT CHARACTERISTICS ASSOCIATED WITH BRONCHIAL ARTERY
EMBOLIZATION OUTCOMES
An Evidence Review from Penn Medicine’s Center for Evidence-based Practice
June 2015
Project director: ..................... Kendal Williams, MD, MPH (CEP) Lead analyst: ....................... Matthew D. Mitchell, PhD (CEP) Internal review:...................... Nikhil Mull, MD (CEP)
Keywords: hemoptysis, embolization, tuberculosis, aspergillosis, cystic fibrosis
EVIDENCE SUMMARY Published clinical studies of bronchial artery embolization (BAE) for treatment of massive or life-threatening hemoptysis
used differing thresholds for determining which patients needed this treatment. There were no additional patient selection
criteria in these studies that could be used in developing evidence-based guidelines for use of this procedure.
Most patient characteristics including age, sex, underlying disease, and comorbidity do not appear to have an effect on the
rate of recurrent hemoptysis after BAE. The evidence for this conclusion is weak; all of the evidence came from retro-
spective cohort studies conducted in Asia or South Africa. This evidence may be less applicable to patients and practice in
the United States.
There is very weak evidence that patients with aspergillosis are at greater risk of recurrent hemoptysis after BAE than
patients whose hemoptysis is caused by other diseases. There is no evidence on recurrence risk specific to patients with
cystic fibrosis or with interstitial lung diseases other than tuberculosis. There is also little or no evidence relating to possible
differences between groups in procedure success rates, rate of complications, or other relevant outcomes.
Patients whose hemoptysis is of highest volume (at least 400 ml per 24 hours or 200 ml per event) are at greater risk of
recurrent hemoptysis after BAE; though evidence for this conclusion is inconsistent and very weak. Patients with a history
of previous hemoptysis are also at greater risk of recurrent hemoptysis; the evidence for this conclusion is weak. A history
of previous BAE was not associated with increased risk of recurrent hemoptysis. There is a possible increase in recurrence
risk for patients with a bronchio-pulmonary shunt or other abnormal vascular anatomy.
© Copyright 2015 by the Trustees of the University of Pennsylvania. All rights reserved. No part of this publication
may be reproduced without permission in writing from the Trustees of the University of Pennsylvania. R300
CEP Evidence Review: Bronchial artery embolization 2
Table of Contents
Introduction ................................................................................................................................................................................................. 3
Previous CEP reports .............................................................................................................................................................................. 3 Methods....................................................................................................................................................................................................... 4
Protocol for Systematic Review .............................................................................................................................................................. 4
Literature Search ..................................................................................................................................................................................... 5 Table 1. Medline search ..................................................................................................................................................................... 5
Table 2. EMBASE search .................................................................................................................................................................. 6 Table 3. Cochrane Library search ...................................................................................................................................................... 6
Results ......................................................................................................................................................................................................... 7
Guidelines ............................................................................................................................................................................................... 7 Reviews ................................................................................................................................................................................................... 7
Primary literature .................................................................................................................................................................................... 7 Risk of recurrent hemoptysis .............................................................................................................................................................. 7 Table 4. Primary studies: recurrence of hemoptysis ........................................................................................................................ 8
Other outcomes ................................................................................................................................................................................. 10 Conclusion ................................................................................................................................................................................................ 11
Table 5. Evidence summary and GRADE analysis ......................................................................................................................... 11
References ................................................................................................................................................................................................. 13
Appendix. GRADE criteria for rating a body of evidence on an intervention ........................................................................................ 14
CEP Evidence Review: Bronchial artery embolization 3
Introduction
There is disagreement among clinicians over how much hemoptysis is necessary for it to warrant immediate action. Concerns with
overuse of bronchial artery embolization (BAE) and its risks to patients cause some to argue for higher thresholds and selective use of
BAE while concerns with the consequences of continued bleeding cause others to argue for lower thresholds and broader use of the
procedure. Published clinical guidelines vary in the threshold defining “massive” or “life-threatening” hemoptysis, and they do not
cite specific evidence to support their thresholds. The purpose of this review is to search for and analyze clinical studies which might
be used to develop evidence-based guidelines for use of bronchial artery embolization and other interventions to treat massive or life-
threatening hemoptysis.
Previous CEP reports
The Center for Evidence-based Practice has published an Annotated Bibliography on algorithms for management of patients with
massive hemoptysis (1) and an Evidence Advisory on guidelines for management of patients with massive hemoptysis (2). Neither
report found evidence-based guidance for deciding which patients should or should not be treated with bronchial artery embolization.
CEP Evidence Review: Bronchial artery embolization 4
Methods
CENTER FOR EVIDENCE-BASED PRACTICE
PROTOCOL FOR SYSTEMATIC REVIEW SPECIFIC AIM:
Identify patient groups for whom bronchial artery embolization is especially effective, especially ineffective, or for whom potential risk outweighs potential benefit.
METHODS:
Inclusion and exclusion criteria:
Participants: Patients with hemoptysis, particularly massive or life-threatening hemoptysis. Report subgroup of patients with cystic fibrosis if data permits.
Interventions: Bronchial artery embolization (BAE).
Comparisons: Subgroups of patients with hemoptysis such as those with particular demographics or comorbidities, those with differing causes of hemoptysis, and those with differing degrees of hemoptysis.
Outcomes: Mortality, paralysis, other procedure-related adverse events, rebleeding, need for second procedure, length of stay, length of ICU stay.
Data collection
Databases: Cochrane databases, Medline, EMBASE.
Study design: All clinical studies, though RCTs will be given priority.
Study quality assessment: Randomized trials (if any) assessed using modified Jadad scale.
Data synthesis (calculation of relative risks and confidence intervals, meta-analyses, exploration of heterogeneity): Random-effects meta-analysis following Cochrane methods if quantity and homogeneity of data permit, otherwise qualitative analysis.
Assessment of quality of evidence base: GRADE (Appendix).
CEP Evidence Review: Bronchial artery embolization 5
Literature Search
Searches were completed in May and June 2015 and were not restricted by date. Medline searches made use of diagnosis
subcategories of the VTE indexing terms. Guideline sources were searched in our previous report on guidelines for management of
massive hemoptysis, where we found that none of the thresholds in published guidelines were based on specific evidence. Reference
lists of published review articles were also checked: this resulted in four additional articles retrieved, but those articles did not report
any risk factor information.
Table 1. Medline search
Search Syntax Hits Retrieved Included
1 Embolization, Therapeutic/ 24,817 — —
2 (bronchial or hemoptysis or haemoptysis).mp. 100,979 — —
3 1 and 2 830 — —
4 (bronchial adj3 (emboliz* or embolis*)).mp. 513 — —
5 3 or 4 1,000 — —
6 (guideline or guidance).mp. or exp Guideline/ or exp Practice Guideline/ 139,917 — —
7 5 and 6 11 3 0
8 limit 5 to (meta analysis or systematic reviews) 5 — —
exclude 3 references included in guideline results 2 1 0
9 limit 5 to (clinical trial, all or clinical trial or controlled clinical trial or
pragmatic clinical trial or randomized controlled trial)
15 — —
10 exp Embolization, Therapeutic/ae, ct, mo, sn [Adverse Effects, Contraindications,
Mortality, Statistics & Numerical Data]
4,409 — —
11 2 and 10 112 — —
12 9 or 11 124 — —
exclude 1 duplicate reference within set 123 24 4
mp: keyword (title, abstract, subject heading)
CEP Evidence Review: Bronchial artery embolization 6
Table 2. EMBASE search
Search Syntax Hits Marked for
retrieval Included
1 'artificial embolism'/exp 60,172 — —
2 bronchial 93,019 — —
3 #1 AND #2 1,153 — —
4 bronchial NEAR/3 (embolization OR embolisation) 756 — —
5 #3 OR #4 1,249 — —
6 hemoptysis OR haemoptysis 18,474 — —
7 embolization OR embolization 53,920 — —
8 #6 AND #7 1,302 — —
9 #4 OR #4 OR #8 1,732 — —
10 #9 AND 'guidelines'/exp 18 — —
delete 2 references duplicating Medline results 16 6 0
11 #9 AND ([cochrane review]/lim OR [systematic review]/lim OR [meta analysis]/lim) 6 — —
delete 1 reference duplicating Medline results 5 2 0
12 #9 AND ('clinical trial'/de OR 'cohort analysis'/de OR 'comparative study'/de OR
'controlled clinical trial'/de OR 'controlled study'/de OR 'prospective study'/de) 150 — —
delete 18 references duplicating Medline results 132 33 3
Table 3. Cochrane Library search
Search Syntax Total
Hits
Cochrane
reviews DARE
Cochrane
Central
Register
HTA Marked for
retrieval Included
1 MeSH descriptor: [Embolization, Therapeutic] explode all trees 773 8 133 532 54 — —
2 bronchial 7,002 402 63 6,482 26 — —
3 #1 AND #2 1 1 0 0 0 — —
4 embolization or embolization 1,248 125 101 904 58 — —
5 #2 AND #4 7 3 0 3 0 — —
6 hemoptysis or haemoptysis 292 93 12 178 2 — —
7 #4 AND #6 5 3 0 1 0 — —
8 #3 OR #5 OR #7 8 4 0 3 0 — —
delete 2 references duplicating EMBASE results 6 4 0 1 0 0 0
CEP Evidence Review: Bronchial artery embolization 7
Results
Guidelines
As discussed in our previous report (2), none of the published guidelines on this topic cited specific evidence as the basis for
thresholds defining massive or life-threatening hemoptysis. The searches described above found no additional relevant guidelines.
Note that many of the articles identified as guidelines in the Medline and EMBASE searches actually were narrative review articles.
Reviews
None of the reviews found in our searches provided any numeric data on the relationship between amount of hemoptysis and patient
outcomes after bronchial artery embolization. Two articles (3, 4) did provide evidence tables, which we used as a supplement to our
literature searches to locate potentially relevant primary articles. None of the articles retrieved from those references provided any
additional evidence for our tables.
Primary literature
Risk of recurrent hemoptysis
The seven studies that reported the effect of any patient characteristic on risk of rebleeding after bronchial artery embolization for
patients with massive or life-threatening hemoptysis are listed in Table 4. All of these studies were retrospective; three of the seven
were focused on tuberculosis patients while the other four studies included patients with various underlying conditions causing
hemoptysis. There was too much heterogeneity in design and execution of the studies to permit meta-analysis or other quantitative
data synthesis. None of the articles reported any criteria for selection or exclusion of this procedure other than the massive or life-
threatening hemoptysis.
None of the studies were done in the United States or other western countries. Patient characteristics and patterns of care are likely to
be different in the Asian and South African hospitals where these studies were carried out, compared to their U.S. counterparts.
Therefore the results should be used with caution when applying them to American practice.
Three studies compared hemoptysis recurrence rates between male and female patients, and between older and younger patients. No
statistically significant risk differences were found among these groups. A few studies compared patients with different underlying
diseases, including tuberculosis, lung cancer, aspergillosis, and bronchiectasis; the only significant finding was for increased
rebleeding risk for patients with aspergillosis in a single study. One other study found an increased risk of recurrence in patients with
inactive tuberculosis compared to patients with active tuberculosis.
CEP Evidence Review: Bronchial artery embolization 8
There appears to be an increased risk of hemoptysis recurrence after BAE in patients with higher volume of hemoptysis, though one of
the three studies measuring this variable did not find a significant effect. History of previous hemoptysis was associated with
increased risk of recurrence in two studies, but two studies examining the effect of previous embolization procedures found no
significant recurrence risk increase. The number of vessels involved or embolized does not appear to have a significant effect on
recurrence risk. The presence of a bronchio-pulmonary shunt may be associated with increased recurrence, as is the presence of
pleural thickening. Comorbidity in general was not a risk factor for recurrence.
Chung et al. (5) found significant associations between several patient variables and risk of hemoptysis recurrence, but there are
apparent discrepancies in the odds ratios and confidence intervals presented in their results table. We sought clarification from the
authors but did not receive a response. Therefore we will consider the results of this study to be of high risk for bias in our GRADE
analysis of the evidence (while we do not have reason to believe that the findings are biased, this GRADE category applies to studies
where there is reason to believe there is a risk that published findings do not represent the actual results of a study).
Criteria in these studies for defining hemoptysis as massive or life-threatening varied. Mal’s definition of life-threatening hemoptysis
(6) was unusual: loss of 200 ml or more blood per hour, loss of 50 ml or more per hour in patients with chronic respiratory failure, or
more than two episodes of moderate hemoptysis (30 ml or more) within 24 hours despite the use of IV vasopressin. This paper did not
report the association of any patient variables with recurrent hemoptysis so it is not included in the main evidence table.
Garcia-Olivé et al (7, 8) reported on patient characteristics and time to recurrence in patients requiring a second embolization, but did
not report the effect of these characteristics on risk of recurrence.
Table 4. Primary studies: recurrence of hemoptysis
Author Study design Patients Hemoptsys criteria Patient variable Results (95% CI) Comment
Pei 2014 China (9)
Retrospective cohort
Tuberculosis
N = 112
400 ml/24 h Inactive tuberculosis vs. active tuberculosis
Hazard ratio 2.1 (1.01-4.4) Follow-up 2-52 months, median 20
Recurrence defined as 40 ml/24 h
Age > 50
Female
Hazard ratio 2.0 (0.81-4.9)
Hazard ratio 1.7 (0.63-4.5)
Govind 2013 South Africa (10)
Retrospective cohort
Tuberculosis
N = 107
300-600 ml/24 h or requires transfusion
HIV infection status No effect on short-term procedure success rate
Follow-up period not reported
Recurrence requiring further treatment
CEP Evidence Review: Bronchial artery embolization 9
Author Study design Patients Hemoptsys criteria Patient variable Results (95% CI) Comment
Anuradha 2012 India (11)
Retrospective cohort
Tuberculosis
N = 58
600 ml or more (time period not specified)
Inactive tuberculosis vs. active tuberculosis
Multiple arteries embolized
Non-bronchial systemic artery collaterals
No significant increase in rebleeding rate
Follow-up 11 days-5 years, median 14 months
No factors found to be statistically significant
Age, sex, degree of hemoptysis not tested
Trend towards increased risk in pts with systemic to pulmonary venous shunts (p = 0.054)
Recurrence defined as 30 ml
Chan 2009 Hong Kong (12)
Retrospective cohort
Various
N = 167
200 ml/24 h or bleeding that was life-threatening
History of hemoptysis
Incomplete embolization in initial procedure
Bronchio-pulmonary shunt
Hazard ratio 2.1 (1.1-4.0)
Hazard ratio 2.5 (1.4-4.5)
Hazard ratio 2.1 (1.2-3.4)
Median follow-up 6.5 years
Regression analysis
Recurrence defined as further life-threatening bleeding
Past history of embolization
Number of abnormal vessels on arteriogram
Hazard ratio NS
Hazard ratio NS
Not significantly different from 1.0
Chung 2006 Korea (5)
Retrospective cohort
Various
N = 66
100 ml or more (time period not specified)
Hemoptysis > 200 ml
Bilateral lesion
Pleural thickening
Odds ratio 10.2 (10.0-50)
Odds ratio 13.3 (1.4-138)
Odds ratio 20.8 (3.4-128)
Follow-up 1-56 months, median 20
Recurrence defined as 100 ml
Female
Age 50 and above
Previous embolization
Lung cancer
Multiple feeding vessels
Odds ratio 0.59 (0.53-4.4)
Odds ratio 0.42 (0.34-2.4)
Odds ratio 2.0 (0.36-3.6)
Odds ratio 1.8 (0.77-11.8)
Odds ratio 2.2 (0.36-13.4)
Unexplained discrepancies in results table: see text
CEP Evidence Review: Bronchial artery embolization 10
Author Study design Patients Hemoptsys criteria Patient variable Results (95% CI) Comment
Kim 2006 Korea (13)
Retrospective cohort
Various
N = 118
200 ml/24 h or hematocrit < 30
Aspergillosis Significant increase in rebleeding rate
Minimum 1 year follow-up
80% of pts. had massive hemoptysis
Sex
Age
Degree of hemoptysis
Tuberculosis
Bronchiectasis
Lung cancer
APACHE II score
No significant increase in rebleeding rate
Recurrence requiring readmission
Kim 1997 Korea (14)
Retrospective cohort
Various
N = 51
400 ml/24 h or multiple episodes > 100 ml or 100 ml or more for 5 days
Hemoptysis > 400 ml/24 hrs
History of 3 or more hemoptysis events
Multiple arteries involved
Significant increase in rebleeding rate
Follow-up 7-60 months
Insufficient patients with aspergillosis for any conclusions to be drawn
Recurrence defined as 100 ml
Tuberculosis
Bronchiectasis
No significant increase in rebleeding rate
Highlighted variables denote statistically significant association with subsequent rebleeding
Other outcomes
In most of the studies found by our searches, the only clinical outcome reported by group was recurrence of hemoptysis; studies
focused on recurrence as the main outcome of interest. Pei et al. were the only investigators to report any other outcome: they found
no significant differences in short-term control of bleeding (procedure success) as a function of age, sex, or disease status (active or
inactive) in tuberculosis patients (9). While many articles reported on the number of BAE patients with complications and/or
mortality, including some articles that did not meet the inclusion criteria for the recurrence analysis above, none analyzed these
outcomes as a function of any specific patient characteristics.
There were no studies reporting results by patient group for any of the other outcomes of interest, including (but not limited to)
procedure-related bleeding, paralysis, length of stay, or cost of care.
CEP Evidence Review: Bronchial artery embolization 11
Conclusion
There are no guidelines or systematic reviews identifying patient groups for whom bronchial artery embolization carries an increased
risk of long-term success or failure. The only evidence on comparative rates of hemoptysis recurrence came from small to medium-
sized retrospective studies, all done in Asian countries or South Africa. We summarize the results of those studies in the GRADE
table below (Table 5). Because the only evidence is from retrospective cohort studies, the strength of evidence is low at best, and very
low for comparisons where one or more downgrades had to be applied because of inconsistent results or there being only a single
study involving a particular variable.
The only variable for which there was a significant association and no downgrade of evidence was a history of previous hemoptysis,
which is associated with an increased risk of recurrence after embolization. Patient demographic variables such as sex and age do not
appear to be associated with recurrence risk, and most specific etiologies of hemoptysis (such as tuberculosis and lung cancer) do not
appear to have an association either. A single study found that patients with aspergillosis had an increased recurrence risk, but the
strength of that evidence is very low. There is inconsistent evidence (strength: very low) suggesting that patients with inactive
tuberculosis are at greater risk of recurrent hemoptysis than patients with active tuberculosis. Two of three studies that made the
comparison found that patients with high-volume hemoptysis were at greater risk of recurrence than patients with lower-volume, but
still massive or life-threatening hemoptysis, but the inconsistency of results causes us to rate the strength of that evidence as very low.
There was only one study reporting on the relationship between patient characteristics and procedure success (short term control of
bleeding) and there was no evidence for any other outcomes, including mortality, complications of BAE, or cost.
Table 5. Evidence summary and GRADE analysis
Variable Outcome Conclusion
Quantity and type of
evidence
Starting level of evidence
strength Ris
k o
f b
ias
Inco
nsi
sten
cy
Ind
irec
tnes
s
Imp
reci
sio
n
Pu
blic
atio
n b
ias
Str
on
g o
r ve
ry
stro
ng
ass
n.
Do
se-r
esp
on
se
Co
nfo
un
der
s
con
sid
ered
Final level of evidence
strength
Sex Risk of recurrence No significant effect 3 cohort Low 0 0 0 0 0 0 0 0 Low
Age Risk of recurrence No significant effect 3 cohort Low 0 0 0 0 0 0 0 0 Low
Tuberculosis vs. other causes Risk of recurrence No significant effect 2 cohort Low 0 0 0 0 0 0 0 0 Low
Inactive vs. active TB Risk of recurrence Possible increase in risk 2 cohort Low 0 –1 0 0 0 0 0 0 Very low
Lung cancer Risk of recurrence No significant effect 2 cohort Low 0 0 0 0 0 0 0 0 Low
CEP Evidence Review: Bronchial artery embolization 12
Variable Outcome Conclusion
Quantity and type of
evidence
Starting level of evidence
strength Ris
k o
f b
ias
Inco
nsi
sten
cy
Ind
irec
tnes
s
Imp
reci
sio
n
Pu
blic
atio
n b
ias
Str
on
g o
r ve
ry
stro
ng
ass
n.
Do
se-r
esp
on
se
Co
nfo
un
der
s
con
sid
ered
Final level of evidence
strength
Aspergillosis Risk of recurrence Increased risk 1 cohort Low 0 0 0 –1 0 0 0 0 Very low
Bronchiectasis Risk of recurrence No significant effect 2 cohort Low 0 0 0 0 0 0 0 0 Low
HIV Risk of recurrence No significant effect 1 cohort Low 0 0 0 –1 0 0 0 0 Very low
Other comorbidity (APACHE) Risk of recurrence No significant effect 1 cohort Low 0 0 0 –1 0 0 0 0 Very low
†–Very severe hemoptysis Risk of recurrence Increased risk 3 cohort Low 0 –1 0 0 0 0 0 0 Very low
Number of vessels involved Risk of recurrence No significant effect 4 cohort Low 0 –1 0 0 0 0 0 0 Very low
History of prev. hemoptysis Risk of recurrence Increased risk 2 cohort Low 0 0 0 0 0 0 0 0 Low
History of prev. embolization Risk of recurrence No significant effect 2 cohort Low 0 0 0 0 0 0 0 0 Low
Bronchio-pulmonary shunt or other collateral vessel
Risk of recurrence Possible increase in risk 2 cohort Low 0 –1 0 0 0 0 0 0 Very low
Pleural thickening Risk of recurrence Increased risk 1 cohort Low –1 0 0 –1 0 0 0 0 Very low
Patient age or sex Short term control of bleeding
No significant effect 1 cohort Low 0 0 0 –1 0 0 0 0 Very low
All variables Complications No evidence None None
All variables Mortality No evidence None None
All variables All other outcomes No evidence None None
†–At least 200 ml/event or 400 ml/24 hours.
CEP Evidence Review: Bronchial artery embolization 13
References 1. Lavenberg JG, Umscheid CA, Mull N. Algorithms for the management of massive hemoptysis in the acute care setting. Annotated
Bibliography. Philadelphia: University of Pennsylvania Health System; 2015 January. Report No. 288.
2. Mitchell MD, Mull N, Umscheid CA, Williams K. Guidelines for management of massive hemoptysis. Evidence Advisory.
Philadelphia: University of Pennsylvania Health System; 2015 July. Report No. 299.
3. Ashleigh RJ, Webb AK. Radiological intervention for haemoptysis in cystic fibrosis. J R Soc Med. 2007;100 Suppl 47:38-45.
4. Swanson KL, Johnson CM, Prakash UBS, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience
with 54 patients. Chest. 2002;121(3):789-95.
5. Chung WY, Byun MK, Park MS, Hahn CH, Kang SM, Lee DY, et al. Risk factors of recurrent hemoptysis after bronchial artery
embolization. Tuberc Respir Dis. 2006;60(1):65-71.
6. Mal H, Rullon I, Mellot F, Brugiere O, Sleiman C, Menu Y, et al. Immediate and long-term results of bronchial artery embolization
for life-threatening hemoptysis. Chest. 1999;115(4):996-1001.
7. Garcia-Olive I, Sanz-Santos J, Centeno C, Radua J, Andreo F, Sampere J, et al. Predictors of recanalization in patients with life-
threatening hemoptysis requiring artery embolization. Arch Bronconeumol. 2014;50(2):51-6.
8. Garcia-Olive I, Sanz-Santos J, Centeno C, Andreo F, Munoz-Ferrer A, Serra P, et al. Results of bronchial artery embolization for
the treatment of hemoptysis caused by neoplasm. J Vasc Interv Radiol. 2014;25(2):221-8.
9. Pei R, Zhou Y, Wang G, Wang H, Huang X, Yan X, et al. Outcomes of bronchial artery embolization for life-threatening
hemoptysis secondary to tuberculosis. PLoS ONE. 2014;9(12).
10. Govind M, Maharajh J. The impact of coinfection with human immunodeficiency virus and pulmonary tuberculosis on the success
of bronchial artery embolisation. Br J Radiol. 2013;86(1021):20120256.
11. Anuradha C., Shyamkumar N.K., Vinu M., Surendra BN, Christopher D.J. Outcomes of bronchial artery embolization for life-
threatening hemoptysis due to tuberculosis and post-tuberculosis sequelae. Diagn Intervention Radiol. 2012;18(1):96-101.
12. Chan VL, So LKY, Lam JYM, Lau K, Chan C, Lin AWN, et al. Major haemoptysis in Hong Kong: aetiologies, angiographic
findings and outcomes of bronchial artery embolisation. Int J Tuberc Lung Dis. 2009;13(9):1167-73.
13. Kim YG, Yoon H, Ko GY, Lim C, Kim WD, Koh Y. Long-term effect of bronchial artery embolization in Korean patients with
haemoptysis. Respirology. 2006;11(6):776-81.
14. Kim KJ, Yoo JH, Sung NC, Won HS, Yoou KH, Kang HM. The factors related to recurrence after transcatheter arterial
embolization for the treatment of hemoptysis. Korean J Intern Med. 1997;12(1):45-51.
CEP Evidence Review: Bronchial artery embolization 14
Appendix. GRADE criteria for rating a body of evidence on an intervention
Developed by the GRADE Working Group (www.gradeworkinggroup.org)
Grades and interpretations:
High: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low: Any estimate of effect is very uncertain.
Type of evidence and starting level
Randomized trial–high
Observational study–low
Any other evidence–very low
Criteria for increasing or decreasing level
Reductions
Study quality has serious (–1) or very serious (–2) problems
Important inconsistency in evidence (–1)
Directness is somewhat (–1) or seriously (–2) uncertain
Sparse or imprecise data (–1)
Reporting bias highly probable (–1)
Increases
Evidence of association† strong (+1) or very strong (+2)
Dose-response gradient evident (+1)
All plausible confounders would reduce the effect (+1)
†Strong association defined as significant relative risk (factor of 2) based on consistent evidence from two or more studies with no plausible confounders Very strong association defined as significant relative risk (factor of 5) based on direct evidence with no threats to validity.