Imaging in haemoptysis

Definition

• Hemoptysis (Gr. haima=blood; ptysis=spitting )

The spitting of blood derived from the lungs or bronchial tubes as a result of pulmonary or bronchial hemorrhage.

• Hemoptysis, defined as bleeding that originates from the lower respiratory tract, is symptomatic of potentially serious or even life-threatening thoracic disease and warrants urgent investigation

(Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000.)2

Pathophysiologic Featuresand Causes of Hemoptysis

• The lungs are supplied by a dual arterial vascular system composed of – (a) the pulmonary arteries, which account for 99% of the arterial

blood supply to the lungs and take part in gas exchange; and – (b) the bronchial arteries, which are responsible for providing

nourishment to the supporting structures of the airways and of the pulmonary arteries themselves (vasa vasorum) but do not normally take part in gas exchange.

• The bronchial vasculature feeding the intrapulmonary airways is situated close to the pulmonary arteries at the level of the vasa vasorum, and histologically the two systems are connected by anastomoses between the systemic and pulmonary capillaries .

• This communication between the bronchial and pulmonary arteries contributes to a normal right-to-left shunt that accounts for 5% of cardiac output.

• Conditions causing reduced pulmonary arterial perfusion such as chronic thromboembolic disease and vasculiticdisorders, in which there is a reduction in pulmonary arterial supply distal to the emboli, can lead to a gradual increase in the bronchial arterial contribution, thereby increasing the importance of bronchial-to- pulmonary artery anastomoses in regions of the lung that are deprived of their pulmonary arterial blood flow.

• Experimental studies have suggested that the increased bronchial arterial blood flow is due to neovascularization.

• Neoplastic disease can also be responsible for such humor-mediated neovascularization

• Such newly formed collateral vessels are usually fragile and “leaky” and prone to rupture.

Low pressure

Pulmonary Circulation

SBP = 15-20 mmHg

DBP = 5-10 mmHg

Patients with normal PAP ( no

PAH) rarely bleed: only 5% of

massive hemoptysis

High pressure

Bronchial Circulation

= systemic pressures

Bronchial arteries & collaterals

originate from the aorta

The source of bleeding in most cases

• Blood Circulation in the lungs :

2 Components

Bleeding mechanisms

• Inflammation Erosion of the vessel wall

• Increased pressure in the vessel Increase vessel size Rupture

Aneurysm formation

Etiology: Classification by site

Tracheobronchial source

Bronchitis

Bronchiactasis

Neoplasm

Broncholithiasis

Airway trauma

Foreign body

Pulmonary Parenchymal

Source

Lung abscess

Pneumonia

TB

Mycetoma (Fungus Ball)

GPS

Idiopathic pulmonary hemosederosis

WG

Lupus pneumonitis

Lung contusion

Pulmonary Vascular source

Pulmonary embolism

Arteriovenous malformations

Pulmonary arterial hypertension

Pulmonary venous hypertension

(Mitral stenosis)

Pulmonary artery rupture

Miscellaneous/rare causes

Pulmonary endometriosis

Systemic coagulopathy

Use of anticoagulants or thrombolytics

Etiology

It is the most common cause of hemoptysis worldwidewith 2 billion people infected worldwide with 5-10% developing disease (Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)

INFECTION

9

GRADE AMOUNT /24 HRS

Mild < 50 ml

Moderate 50 - 200 ml

Severe**/Major* > 200 ml * 150 ml per 12 hrs or**>400 ml per 24 hrs

Massive > 600 ml

Exsanguinating# #1,000 ml total or 150 ml/h

Life-threatening 200 ml/h or 50 ml/h in a patient with chronic respiratory failure.

*Corey R, Hla KM.Am J Med Sci 1987; 294:301–309.

**de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795#Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829–833.

Approach

Approach

• Localization and treatment of hemoptysisdemands a multifaceted evaluation involving medical, radiologic, and surgical disciplines.

Predictors of Mortality

71% in patients who lost =>600 ml of blood in 4 h

22% in patients with =>600 ml within 4–16 h

5% in those with 600 ml of within 16–48 h

Life-threatening massive : 5 to 15%.

• *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med 1968;121: 495–498.

Initial Evaluation

• Assess Severity & Urgency– Duration of bleeding– Extent of bleeding– Reliability

• Assess the Cardio-Respiratory reserve

• Prior Episodes of bleeding

• Clues to the cause

• In particular, the recognition of “sentinel bleeding” heralding

imminent major hemorrhage is of critical importance but is

often difficult on the basis of clinical findings alone.

Approach to a patient with haemoptysis

• History & Physical Examination

• Diagnostics

– Laboratory studies

– Radiologic studies

– Endoscopic studies

• Management

Clues from the Hx

Risk Factors for

Bronchogenic CA

Smoking, Asbestosis

Risk Factors for

Lung Abscess

Alcohol, Coma

Poor dental hygiene

Risk Factors for

HIV Infection

Drug Abuse, Sexual Practices

Hx of blood transfusion

Renal disease GPS,WG

Clues from the HxHistory of previous or co-existing disease

SLE Lupus Pneumonitis

Malignancy Primary

Metastatic

AIDS Endobronchial KS

Previous bleeding Bleeding diathesis

Anticoagulant use

Thrombocytopenia

Blood streaking of

mucopurulent or purulent

sputum

Bronchitis

Clues from the Hx

Chronic sputum production +

Recent change in quantity or appearance

Acute Exacerbation

of COPD

Fever & chills + Blood streaking of

purulent sputum

Pneumonia

Putrid smell of purulent sputum Lung abscess

Sudden chest pain &/ SOB PE

Make sure it is Hemoptysis

DDx:

• Hematemesis

• Epistaxis

• Other nasopharyngeal bleeding

Etiology

20

Hemoptysis Hematemesis

1 Cough + -

2 Sputum Frothy Bright red -pinkLiquid or clotted

Rarely frothyBrown to blackCoffee ground

3 Respiratorysymptoms

+ -

4 Gastric or Hepatic disease

- +

5 Vomiting & Nausea

- +

6 Melena - +

7 Asphiyxia usual unusual

8 Laboratory Parameters

Alkaline pH;Mixed with macrophages and neutrophils

Acidic pH;Mixed with food particles

Diagnostics

Basics

Labs

Radiologic studies

Endoscopic studies

After comprehensive Hx & P/EGoals:• Identify the cause• Localize the site of bleeding• Assess the general

condition of the patient

LABS

CBC

PT, PTT & INR

Sputum Studies

Cultures

Urine Analysis

ABG’s

Radiologic Studies

• Radiographs

• CT

• Angiography

• Further investigations

– Nuclear Medicine

– MRI

ACR Appropriateness Criteria Hemoptysis

Conventional radiography

• Conventional radiography is a basic study and is readily available even under emergency conditions.

• Due to its convenience and portability in the acutely ill patient, chest radiography remains a basic and useful diagnostic tool in the evaluation of hemoptysis.

• It may be helpful in diagnosing and localizing pneumonia, acute or chronic pulmonary tuberculosis, bronchogenic cancer, or lung abscess.

• Radiography can help lateralize the bleeding with a high degree of certainty and can often help detect underlying parenchymal and pleural abnormalities.

• The ability of chest radiography to accurately localize the disease process is highly variable, and can be normal in up to 30% of patients.

• Localization can be particularly difficult due to either opacification of both lungs during episodes of massive hemoptysis or in the setting of bilateral disease.

• Although radiography is a useful initial examination, it needs to be complemented with more detailed evaluation.

• In a retrospective evaluation of 208 patients with hemoptysis, Hirshberg et al found that radiography was considered to be diagnostic in only 50% of cases.

• In a study by Herth et al, almost one-quarter of patients presenting with acute hemoptysis secondary to malignancy had normal chest radiographic findings.

• Therefore it is recommended that additional follow-up testing is done in patients presenting with hemoptysis in whom the underlying cause was not detected at initial radiography.

Role of CT in Haemoptysis

Role of CT

• Contrast material–enhanced multi– detector row CT has the unparalleled advantage of allowing acquisition of high-quality images of the entire thorax in a rapid, safe, and noninvasive manner.

• Published studies on the efficacy of single– detector row spiral CT have already demonstrated the capacity of this imaging technique to help predict the site of bleeding as accurately as bronchoscopy and to help detect underlying disease with high sensitivity.

• Multi–detector row CT provides extended volume coverage with higher image resolution and even greater scanning speed

• The aims of multi– detector row CT in the evaluation of hemoptysis are threefold: – (a) to depict underlying disease with high sensitivity by means

of detailed images of the lung parenchyma and mediastinum, and in particular to help detect early carcinoma;

– (b) to help assess the consequences of hemorrhage into the alveoli and airways, which may cause immediate clinical concerns as well as mask subtle underlying abnormalities; and

– (c) to provide a detailed “road map” of the thoracic vasculature by means of two-dimensional (2D) maximum-intensity-projection (MIP) reformatted images and three-dimensional (3D) reconstructed images. Such road maps are of great use to both the interventional radiologist anticipating arterial embolization and the thoracic surgeon contemplating surgery.

Multi–Detector Row CT Technique

• An extended spiral CT study of the thorax can easily be performed with a 16–detector row scanner during a single breath hold (normally lasting less than 15 seconds) in most patients.

• However, only a limited study with a four– detector row or single– detector row scanner may be possible, depending on the patient’s respiratory capacity.

• Image acquisition should be performed in a craniocaudaldirection from the base of the neck to the level of the renal arteries to include the supraaortic great vessels and the infradiaphragmatic arteries, which may be responsible for an abnormal collateral contribution to the lungs.

• With current multi– detector row systems, optimal enhancement of both the pulmonary and systemic arteries is achieved with the injection of approximately 120 mL of a relatively high-density contrast material (350 mg/dL) at a rate of 4 mL/ sec via an 18-gauge cannula into an antecubitalvein or central venous catheter.

• The scan should be started during the phase of peak systemic arterial enhancement (Table 2).

• Images should be acquired with thin collimation and with the table movement adjusted to allow extended volume coverage during a single breath hold.

• By adjusting the exposure parameters and kilovoltage according to the patient’s weight, the radiation dose to be minimized without compromising image quality.

• In certain cases, it may be useful or even necessary to perform follow-up CT several months after the episode of hemoptysis to study the evolution of underlying parenchymal lung abnormalities or to exclude the possibility that a small malignancy may have been missed at initial CT.

• Repeat evaluation of the bronchial arteries is not usually necessary unless there is continued hemoptysis; consequently, follow-up imaging can be performed without intravenously administered contrast material and at low milliamperage to minimize the radiation dose to the patient, which is of particular importance in young patients.

Data Manipulationand Image Interpretation

• Because of the very large number of images acquired with a thin-collimation scan of the extended thorax, studies are best interpreted at the scanner console or remote workstation by scrolling through the images.

• The lung parenchyma and gross soft-tissue structures can be adequately evaluated with a section thickness of 5 mm.

• Detailed analysis of the airways and lung interstitium requires thinner sections.

• Thoracic CT angiography with a combination of multiplanar reformatted images can help identify the variable origins and courses of arteries that may be responsible for bleeding in cases of hemoptysis and can aid in planning the embolization of these arteries.

• The origins of orthotopic mediastinalbronchial arteries are best depicted on overlapping axial thin-section images (eg, 1-mm-thick sections at 0.75-mm increments).

Axial 1-mm-thick CT scan obtained just below the aortic arch shows enlarged bronchial arteries (arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions of the mediastinum. These findings represent the typical appearance of enlarged bronchial arteries on axial images.

• Two-dimensional MIP reformatted images in the coronal oblique and sagittal planes readily depict the tortuous trajectories of the bronchial arteries from their origins (descending thoracic aorta) to the lungs along the main bronchi;

• reformatted images in straight coronal planes are better suited for analysis of the intercostal and internal mammary arteries; and axial reconstructed images are ideal for demonstrating the inferior phrenic arteries and branches from the celiac axis.

Coronal thin-section MIP image clearly demonstrates an enlarged intercostobronchial artery (arrows) coursing into the pulmonary parenchyma parallel to the bronchial airways.

Coronal thin-section MIP image obtained in a different patient provides a detailed analysis of the entire intrapulmonary course of an intercostobronchialartery (arrows). intracavitary mycetoma.

• The degree of obliquity of the reconstruction planes and the section thickness of the reformatted images normally have to be adjusted on a case-by-case basis to provide optimal depiction of the vessels in question.

• Three-dimensional volumetric and shaded surface- display (SSD) reformatted images are useful not only to interventional radiologists contemplating embolization therapy, for whom they provide a better perspective on the origin and course of the abnormal artery and aid in the choice of catheter shape, but also to surgeons anticipating arterial ligation, particularly when “minithoracotomy” techniques are used.

• In addition to depicting the abnormal vessel itself and its relationship to adjacent anatomic structures, volumetric reformatted images can furnish the surgeon with a “preview” of the osseocartilaginous and musculotendinousstructures that will be involved in any planned surgical intervention.

• In summary, a comprehensive range of reconstructed images that includes – thick- and thin-section axial images obtained with

both mediastinal soft-tissue and parenchymal lung window settings, as well as

– 2D MIP reformatted images in the coronal, sagittal, and

– axial planes and selected 3D volumetric and SSD reformatted images,

• are recommended for a thorough CT assessment of hemoptysis (Table 3).

• There are studies suggesting that multidetector CT may be more accurate than arteriography at delineating the origin and course of both the bronchial and nonbronchialsystemic arteries, especially when combined with 3D reconstructions.

Hartmann IJ, Remy-Jardin M, Menchini L, Teisseire A, Khalil C, Remy J. Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol2007;17(8):1943–1953

Remy-Jardin M, Bouaziz N, Dumont P, Brillet PY, Bruzzi J, Remy J. Bronchial and nonbronchialsystemic arteries at multidetector row CT angiography: comparison with conventional angiography. Radiology 2004;233(3):741–749

• It has been stated that CT and FOB are not competitive but complementary tools for assessing patients with hemoptysis, and indeed, the combined use of FOB and CT does yield the best results in evaluating hemoptysis.

• However, many researchers are currently suggesting that CT should be performed prior to bronchoscopy in all patients with hemoptysis.

Assessment of CT

• Urgent evaluation with thoracic CT angiography can help accurately identify the:

– source and

– predisposing causes of hemoptysis and

– effects of hemorrhage on the lungs.

Assessment of CT

• Assessment of the Lung Parenchyma

• Assessment of Pulmonary and Systemic Vasculature

– Pulmonary arteries

– Bronchial arteries

– Non Bronchial Systemic arteries

– Bronchial-to-Systemic artery communication

Assessment of the Lung Parenchyma

• Possible underlying causes of hemoptysis that are identifiable on axial CT scans obtained with lung parenchymal window settings include:

– bronchiectasis,

– lung carcinoma,

– acute and chronic lung infections (in particular, tuberculosis and aspergillosis), and

– cardiogenic pulmonary edema.

• In patients with extensive bilateral disease or equivalent findings, the site of hemorrhage can usually be localized on the basis of: – the presence of liquified material in

segmental and lobar bronchi and – hazy consolidation or – ground-glass infiltrates in the lung

parenchyma, findings that represent intraalveolar hemorrhage.

– show extravasation of contrast medium into a bronchus

– Intrapulmonary shunting

• The accurate localization of the site of bleeding is important both for possible future lung resection and prior to endovascular therapy, for which identification of the specific vessels that require embolization is necessary.

Axial CT scan (1-mm-thick section) obtained with parenchymal lung window settingsin a patient with hemorrhage following an episode of hemoptysis demonstrates bronchial impaction from blood clot (arrow) in a subsegmental branch of the anterior segmental bronchus of the right upper lobe, a finding that helps localize the site of bleeding.







45-year-old man with hemoptysis.Axial MDCT reconstructions with 1-mm-thick slice viewed at lung window settings show ground-glass opacities on anterior segment of left upper lobe







Iodine extravasation into bronchi of 57-yearoldwoman with hemoptysis.

A, Sagittal multiplanar reconstruction image on lungwindow setting shows contrast medium (arrow) inbronchi of left upper lobe with air bubbles(arrowheads).

B, Sagittal multiplanar reconstruction image onmediastinal window setting shows same density inbronchi (arrows) and left pulmonary artery (asterisk) as that shown in A.







45-year-old man with right upper lobe atelectasis due to tubercular sequelae complicated by aspergilloma was admitted for mild hemoptysis.

Coronal thin-slab maximum-intensity-projection (MIP) image shows enhancement of pulmonary arteries (arrows) with reflux into right main pulmonary artery (arrowhead).

• The consequences of hemorrhageinto the airways and lung parenchyma may also mask subtle underlying disease.

• The filling of airway lumina or intraparenchymal cavities with blood may obscure small endobronchial tumors and intracavitary lesions such as mycetomas.

• In addition, blood clots may simulate more sinister disease entities such as nodules and masses.

• For these reasons, it is often advisable to perform follow- up CT several weeks after the episode of hemoptysis for a more thorough analysis of the underlying lung parenchyma and for the detection of early lung carcinoma.

Axial CT scan (1-mm-thick section) obtained at the level of the right lower lobe in a patient with lymphangioleiomyomatosis who presented with recurrent hemoptysis depicts an air-fluid level in a pulmonary cyst (arrow), a finding that represents intracavitary blood.

Assessment ofPulmonary and Systemic Vasculature

• Pulmonary arteries

• Bronchial arteries

• Non Bronchial Systemic arteries

• Bronchial-to-Systemic artery communication

Pulmonary Arteries

• The pulmonary arteries should always be analyzed to exclude the possibility of pulmonary emboli, particularly in the presence of subpleural areas of enhancement that could represent areas of lung infarction and that may be responsible for hemoptysis.

• Acute thromboembolic disease is a frequent cause of nonmassive hemoptysis that requires urgent diagnosis and treatment with anticoagulation therapy.

• The pulmonary arteries may also be the source of hemorrhage in cases of direct invasion by neoplastic disease or by necrotizing inflammatory disorders such as tuberculosis.

• Rasmussen aneurysms, representing fragile pulmonary arterial pseudoaneurysms arising within areas of tuberculousinflammation, may be responsible for sentinel bleeding prior to catastrophic hemorrhage and can be identified on contrast-enhanced CT scans as avidly enhancing nodules located within the walls of tuberculous cavities.

• Dieulafoy disease is a poorly understood condition characterized by abnormally dilated submucosal vessels that are prone to hemorrhage and has been described in the colon, the small intestine, and, more recently, the bronchial airways.

• It usually coexists with chronic inflammatory disorders such as chronic bronchitis and is thought to involve the pulmonary arterial system rather than the bronchial arteries.

• At fiberoscopic endoscopy, the visualization of a tangle of dilated submucosal blood vessels in the presence of mucosal inflammation should raise suspicion for Dieulafoy disease and alert the bronchoscopist to forego mucosal biopsy.

• There have been no published CT descriptions of this vascular anomaly.

• Life-threatening hemoptysis may occur, albeit uncommonly, following rupture of thin-walled pulmonary arteriovenousmalformations.

Bronchial Arteries

• In 95% of cases of hemoptysis, the systemic arterial system is the origin of the bleeding .

• Although there is poor correlation between bronchial arterial dilatation and the risk of hemorrhage , a diameter of more than 2 mm is considered abnormal.

• The bronchial arteries have highly tortuous but predictable trajectories that can easily be analyzed with a thorough knowledge of bronchial arterial anatomy.

• Because they course predominantly perpendicular to the scanning plane, on axial images they appear as a cluster of avidly enhancing nodules in the posterior mediastinum, usually just below the level of the aortic arch

• Although the bronchial arteries are the most common source of bleeding in hemoptysis, the actual hemorrhage usually occurs from fragile thin-walled anastomoses between distant bronchial arterial branches and pulmonary arteries that are under high systemic arterial pressure, located in the airway submucosa and too small to be directly visualized at CT.

• Active bleeding can rarely be detected at CT due to the presence of contrast material in the airway lumen.

• At conventional angiography, active hemorrhage can also manifest as staining of the lung parenchyma by contrast material. Axial thoracic CT scans obtained on a 16–detector row

scanner with lung parenchymal window settings and mediastinal soft-tissue window settings depict dense material (arrow) within the apical segmental bronchus of the right upper lobe.

• Active bleeding can rarely be detected at CT due to the presence of contrast material in the airway lumen.

• At conventional angiography, active hemorrhage can also manifest as staining of the lung parenchyma by contrast material. Sequential arteriograms of the intercostobronchial

artery demonstrate immediate filling of the apicalsegmental bronchus with contrast material (arrow), a finding that indicates active bleeding from the intercostobronchial trunk into the bronchial tree.

• Bronchial artery aneurysms are rare entities that may arise either within the mediastinum or from the intrapulmonary portion of the artery .

• Whereas intrapulmonarybronchial artery aneurysms may remain clinically silent, mediastinal aneurysms can manifest with symptoms related to local compressive effects .

• Rupture of intrapulmonary aneurysms gives rise to massive and often catastrophic hemoptysis; rupture of more proximal mediastinal aneurysms may manifest with acute tearing chest pain simulating aortic dissection.

• Bronchial artery aneurysms can be detected with contrast-enhanced CT.

• The success of coil embolization therapy depends on aneurysm location; attempts at embolization of aneurysms arising close to the ostia of the bronchial artery can be limited by difficulty in coil placement

• Bronchial arteries of anomalous origin are easily overlooked during bronchial artery embolization, even when complemented with arch aortography, but are well depicted with extended thoracic CT angiography that includes the base of the neck and the upper abdomen.

Nonbronchial Systemic Arteries

• Nonbronchial systemic arteries acting as a source of hemoptysis can arise from:– branches of the supraaortic great vessels

(brachiocephalic artery, subclavian arteries, thyrocervical and costocervical trunks),

– the axillary arteries,

– the internal mammary arteries and

– infradiaphragmatic branches from the inferior phrenic arteries, the gastric arteries, and the celiac axis.

Classification of the nonbronchialsystemic arteries

Classification on CT according to the anatomic location:– superolateral (branches of the subclavian and axillary

arteries at angiography and nonbronchial systemic arteries at the apex of the chest above the level of the aortic arch at CT),

– anteromedial (internal mammary artery and its branches at angiography and nonbronchial systemic arteries along the anterior and mediastinal pleura below the level of the aortic arch), and

– posterior (intercostal arteries at angiography and nonbronchial systemic arteries along the posterior pleura), regardless of the exact name of the artery.

Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ

. Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT.Radiology 2005;234(1):292–298

• At contrast-enhanced CT, these vessels manifest as abnormally dilated arteries that course into the lungs along trajectories that are not parallel to the bronchi; they are usually very tortuous and are well depicted on reformatted images. Posterior 3D SSD image from thoracic CT angiographic data

obtained with a 16–detector row scanner depicts an enlarged right internal mammary artery supplying hypertrophic mediastinal branches (arrows) to an area of the right upper lobe.

• On axial images, their presence can often be predicted on the basis of pleural thickening greater than 3 mm with enhancing arteries within the extrapleuralfat .

Prediction of nonbronchial systemic arterial supply. Contrast-enhanced CT scan demonstrates diffuse pleural thickening at the upper thorax (solid arrows) and tortuous, enhancing vascular structures within a hypertrophic extrapleural layer of fat (open arrows). Hypertrophic bronchial arteries are also seen in the aortopulmonary window.

• Nonbronchial systemic arteries have been reported to be important contributing sources in 41%–88% of cases of massive hemoptysis.

• Like dilated bronchial arteries, they are often observed with other radiologic signs of chronic pulmonary inflammatory disease, usually with evidence of pleural adhesions.

• Failure to recognize such systemic arteries can lead to recurrent hemoptysis following bronchial artery embolization.

• The CT evaluation of hemoptysisshould always be extended, if possible, to include the supraaorticgreat vessels and the upper abdomen.

• Pseudosequestration, or purely vascular pulmonary sequestration, is a rare entity that may be responsible for hemoptysis from nonbronchialsystemic arteries and that has traditionally been treated with surgical resection but may also be suitable for embolotherapy.

• Unlike bronchopulmonary sequestration, pseudosequestration is characterized by a purely vascular anomaly without involvement of the bronchial tree or lung parenchyma.

• There is usually a single systemic artery arising from the descending thoracic aorta that supplies a normal part of the lung, usually in the lung bases, with venous drainage via the pulmonary veins.

• Although purely vascular sequestrations are mostly asymptomatic and are usually discovered incidentally at chest radiography or thoracic CT, they may be complicated by massive hemoptysis, which can be effectively controlled with catheter embolization of the aberrant systemic artery.

• Other possible complications include thrombosis of the systemic artery, causing acute pulmonary infarction and pain, and left-sided heart failure due to left-to-left shunting.

Bronchial-to-Systemic Artery Communications

• Important communications can also exist between the bronchial and coronary arteries.

• In disease entities that cause diminished pulmonary arterial blood flow such as cyanotic congenital heart disease, chronic thromboembolic disease, and vasculitidessuch as Takayasu arteritis, shunting can occur from coronary arteries to pulmonary arteries via the bronchial arteries.

• Coronary-to-bronchial artery anastomoses are most often identified in the region of the retrocardiac “bare areas” of the heart, where the relatively wide pericardial reflections permit the development of communications between the coronary and extracoronary arteries.

• In situations of decreased pulmonary blood flow, anastomoses between the bronchial arteries and the pulmonary arteries at the level of the vasa vasorum are reinforced by collateral blood flow from the high pressure coronary arterial system by way of coronary-to-bronchial arterial shunting.

• Coronary-to-bronchial arterial anastomoses normally arise from the atrial branches of both coronary arteries.

• Such shunting may be involved in the “pulmonary steal” syndrome that manifests in some patients as classic angina-like symptoms in the presence of angiographically normal coronary arteries.

• Conversely, in certain situations atherosclerotic coronary artery disease can promote the development of bronchial-to-coronary arterial shunting.

• Coronary-bronchial arterial anastomoses can be identified at thoracic CT angiography and constitute an important finding prior to anticipated bronchial artery embolization therapy.

Coronary-bronchial arterial anastomoses in a 49-year-old man with recurrent hemoptysis. (a) Posteroanterior chest radiograph demonstrates severe

cystic bronchiectasis in the lingula. (b) Axial 5-mm-thick CT scan obtained at the level of the

lingula with parenchymal lung window settings (window center, 600 HU; window width, 1600 HU) demonstrates severe cystic bronchiectasis.

(c) Axial 5-mm-thick CT scan obtained at the same level with mediastinal softtissue window settings (window center, 50 HU; window width, 350 HU) depicts dilated systemic arteries (arrow) in the region of the pericardial reflection of the retrocardiac area.

(d) Axial 5-mm-thick MIP image obtained at a slightly lower level demonstrates a dilated systemic artery (thin arrow) coursing toward the left main coronary artery (thick arrow). The systemic artery was identified as a dilated bronchial artery.

(e) Axial 1-mm-thick image obtained at the level of the thoracic inlet depicts dilated nonbronchial systemic arteries (arrow) arising from the left subclavian artery.

(f) Axial 1-mm-thick image obtained at the level of the aortopulmonary window shows dilated bronchial arteries (arrow) in the mediastinum.

(g) Three-dimensional volume-rendered reformatted image more clearly depicts the tortuous knot of dilated systemic arteries (arrows) extending from the left subclavian artery to the retrocardiac region.

Cryptogenic Hemoptysis

• Hemoptysis for which no cause has yet been identified• Diagnosis of exclusion • Reported prevalence of approximately 3%–42%. • most often in patients who smoke.• Its importance lies in the reported statistic that 6% of such patients

will present with unresectable lung carcinoma within the next 3 years.

• This risk rises to 10% among patients who are over 40 years old and have a history of smoking.

• This emphasizes the importance of a detailed evaluation of the lung parenchyma and bronchi to exclude early lung carcinoma in patients who present with a first episode of hemoptysis.

• In patients who present with hemoptysis with no identifiable cause, it is prudent to perform repeat CT several months later to ensure that a small, occult neoplasm has not progressed in the interval.

Radiologic Studies

• Radiographs

• CT

• Angiography

• Further investigations– Nuclear Medicine

• Pulmonary embolism

• malignancies

– MRI

Radiologic Studies

• Radiographs

• CT

• Angiography

• Further investigations– Nuclear Medicine

• Pulmonary embolism

• malignancies

– MRI

Endoscopic studies

Flexible Bronchoscopy

• Better visualization

•Ability to navigate

smaller segments

• @ bedside in ICU

• Poor ability to suction

blood

• Less interventions

Rigid Bronchoscopy

• Better blood Suctioning

• More therapeutic

interventions

• Needs OR / GA

• Needs More Skills

Bronchoscopy

Flexible Bronchoscope Rigid Bronchoscope

• In a recent article, Hsiao et al documented that FOB prior to BAE is unnecessary in patients with hemoptysis of known cause if the site of bleeding can be determined on conventional radiographs.

Management of haemoptysis

Varies with

• the severity of bleeding

• The cause of bleeding

• General condition /Cardio-resp. Reserve

Management

Sirajuddin & Mohammed,Cleveland Clinic Journal of Medicine, Vol 75( 8),August 2008

ALGORITHM FOR HEMOPTYSIS MANAGEMENT

Management of Non-Massive Hemoptysis

• Blood-streaking of sputum or production of small amounts of pure blood

• Gas exchange is usually preserved

Priority

Establishing a diagnosis

Specific therapy

Antibiotics

Immunosupression

Chemotherapy

Radiotherapy

FB removal

……etc

Management of Massive Hemoptysis

MEDICAL

EMERGENCY

ICU ALWAYS Urgent need for treatment is

dictated by:

•Rapidity of bleeding

•Respiratory function

Priorities

Airway protection

ETT / MVS

Patient Stabilization

Find the site /cause of

bleeding

Attempt to stop bleeding

Prevent recurrence of

bleeding

Specific therapy

Air way

Breathing

circulation

Provide suction.

Provide O2

crystalloid solutions

Management of Massive Hemoptysis

Needs ICU management

Keep NPO

Positioning of the patient

Strong cough suppressant

Large IV access + Fluid resuscitation

Correction of any coagulopathy

Conservative management

• Suppressing cough (codeine based)

• Antibiotics

• Antifibrinolytics like tranexemic acid.

• Sedation (Avoid over sedation)

• Coagulation disorders should be rapidly reversed.



• Bronchospic interventions

• Radiologic interventions (BAE etc.)

• Surgery ( Lobectomy / Pneumonectomy)

Interventions

Airway and Bronchoscopic

management

98

Protection of nonbleeding lung

If bleeding side is known

Keep patient at:

-Rest

-Lateral decubitus

-Bleeding side down

-Head tilted down.

Rt.Main bronchus

Left main brochus flooded with blood

Selective Intubation

SINGLE LUMEN ETT

Selectively intubate

the non bleeding lung.

100

Selective intubation of Lft Main bronchusin Rt sided massive hemoptysis

Selective Intubation

DOUBLE LUMEN ETT

Specially designed for selective intubation of the right or left main bronchi

Last option in an asphyxiating pt.

Bronchoscopic measures

• Iced Saline Lavage• Topical vasopressors• Selective intubation / ventilation• Endobronchial tamponade

– Fogarthy balloon– Silicone Spigot– Topical Hemostatic Tamponade(THT)– Biocompatible Glue

• Laser photocoagulation• Argon Plasma Coagulation• Endobronchial Electrocautery

102

103

Cold-Saline Lavage

o Reported in 1980.* by Conlan et al.

• Lavage: Normal saline at 4 ° C in 50-ml aliquots

• Stopped the bleeding with massive hemoptysis( 600 ml/24 h), obviating the need for emergency thoracotomy.*

Rigid scope is better over FOB

*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 120–

124.

Topical Vasoconstrictive Agents

• Local instillation

• Topical epinephrine

(1: 20,000)

Effective :

mild to moderate.

Not useful:

massive bleeding*

• Endobronchialepinephrine-side effects

-Tachyarrythmias

- HTN

• Newer agents: ADH derivative

- ornipressin

104* Cahill BC, Ingbar DH: Massive hemoptysis. Assessment and management. Clin Chest Med 1994; 15: 147–167.

Tranexamic Acid(TA)

• Antifibrinolytic drug

• Route : PO ,IV & Topical (recently)

• Endobronchial :*DOSE: 500–1,000 mg

• Response time: stops bleeding within seconds

* Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M: Pulmonary hemorrhage: a novel mode of therapy. Respir Med 2009; 103:

1196–1200.

Fibrinogen/Thrombin

• Local application

• Immediate arrest of bleeding.

• Initial strategy before BAE.*

• Alternative treatment when endovascular procedures cannot be performed.

* Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG: Treatment of recurrent hemoptysis in a child with cystic fibrosis by repeated

bronchial artery embolizations and long-term tranexamic acid. Pediatr Pulmonol 1996; 22: 275–279

Balloon Tamponade

• Described: 1974*

• Life threatening hemoptysis.

4 Fr 100 cm Fogarthyballoon catheter by FOB.

• Inflated for 24-48 hrs

107* Hiebert C: Balloon catheter control of lifethreatening hemoptysis. Chest 1974; 66: 308– 309.

Fogarthy balloon catheter of various sizes

108

Inflated fogarthy catheter bronchoscopically

Advantages:

• Air way protection

• Allows gas exchange

• Supports patient before embolization or surgery

Disadvantages:

• Ischemic mucosal injury

• Post obstructive pneumonia.

109

Endobronchial Airway Blockade

(Silicone Spigot)• Dutau et al.* reported first case.

Temporary management.

• Silicone spigot is placed endobronchially .

Stabilizes patient before endovascular embolization .

• *Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone spigot as a temporary treatment for massive hemoptysis. Respiration 2006; 73: 830–832.

A rigid bronchoscope initially allowed aspiration of blood and removal of clots followed by cold saline and topical vaso active agents ,clearing the vision to place spigot

posterior segment of the right upper lobe

Silicon spigots of various sizes

Following this procedure, the patient underwent BAE, and the spigotwas removed 2 h later.

6-mm silicone spigot in place

posterior segment of the right upper lobe

Bronchoscopy-Guided Topical

Hemostatic Tamponade(THT)

• Oxidized regenerated cellulose mesh, a sterile kitted fabric is used. *

Saturates with blood- swells-brownish or black gelatinous mass -clot.

• Successful in life threatening hemoptysis.

• Immediate arrest of bleed: 98%(56 of 57)

*Valipour A, Kreuzer A, Koller H, Koessler W, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade therapy for the Management of life-threatening hemoptysis. Chest 2005; 127: 2113–2118.

114

Endobronchial view of a bleeding subsegmental bronchus before THT

During bronchoscopy guided THT

Disavantages:

• Not suitable for proximal sites, trachea.

Patients who cannot tolerate occlusion.

Recurrence of hemoptysis

Endobronchial Sealing with Biocompatible

Glue

• Parthasarathi Bhattacharyya et al,* 2002

• Material: n-butyl cyanoacrylate (adhesive)

• Injected into the bleeding airway through a catheter via a flexible FOB.

• Used in mild hemoptysis.

• * *From the EKO Bronchoscopy Centre, Calcutta, India(CHEST 2002; 121:2066–2069)

Laser Photocoagulation

• First introduced by Dumon et al. *

• Nd-YAG laser: employed since 1982.

• Effective in: Bronchoscopically visible source.

MECHANISM:• Photocoagulation of the bleeding mucosa with

resulting hemostasis.

Achieves photoresection and vaporization

118*Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection. Chest 1982; 81: 278–284.

Flooding of the bron.intermed.

Suctioning airway clearance

visualization

Coagulation and devascularizationof tissues

Carbonization of the bleeding site

Argon Plasma Coagulation (APC)

• TYPE : Thermal tissue destruction

• Non contact electrocoagulation tool*.

• Used:

In bronchoscopicallyvisible areas of sources of bleed

*Keller CA, Hinerman R, Singh A, Alvarez F: The use of endoscopic argon plasma coagulation In airway complications after solid organ transplantation. Chest 2001; 119: 1968–1975.

APC machine

• Once desired dessication is done ,deeper penetration of current is stopped and damage to further tissue is stopped.*

• Used for superficial and spreading lesions.

Advantages of APC over YAG laser.:

• It provides easy access to lesions.

• Allows homogeneous tissue dessication.

Endobronchial Electrocautery• TYPE: Thermal tissue

destruction

• Coagulation mode: contact

• Readily available in most of the OT with gastroenterology colleagues

• .

Contact probes Electro cautery machine

Probe through working channel

• Indications :

- Bleeding endobronchialgrowth & benign tumors

• Less expensive alternative to laser.

• Control of hemoptysis using endobronchialelectrocautery was achieved in 75%* of the cases

* Homasson JP: Endobronchial electrocautery. Semin Respir Crit Care 1997; 18: 535–543



RADIOLOGIC INTERVENTIONS

Radiologic interventions

• Bronchial artery embolisation

• Pulmonary AVM embolisation

• MAPCOS embolisation

BRONCHIAL ARTERY EMBOLOTHERAPY FOR HEMOPTYSIS

Anatomic Considerations

• The bronchial and pulmonary arteries comprise a divided blood supply to the lungs.

• The bronchial arteries course in conjunction with these structures to the level of the respiratory bronchus, where their terminal branches achieve significant overlap with the pulmonary arterial circulation.

• Although less significant clinically with regards to hemoptysis, the pulmonary artery provides the vast majority of pulmonary perfusion at 99%, but there is significant overlap between the bronchial arteries and the pulmonary arteries at multiple levels throughout the lung’s anatomic structure.

• In addition, nonbronchial systemic arteries are common offenders in the patient with hemoptysis.

• This obviously necessitates a thorough understanding of the various anatomic permutations and their associated potential clinical significance when considering bronchial artery embolization.

BRONCHIAL ARTERIES

• The bronchial arterial distribution supplies the:

– bronchi and interstitium of the lung

– contributes to the

• visceral pleura,

• the aortic and pulmonary artery vasa vasorum,

• mediastinum, and

• middle one-third of the esophagus.

The bronchial arteries vary considerably in their site of origin and subsequent branching pattern

The four most prevalent patterns of bronchial artery anatomy. Type I: single right bronchial artery via intercostobronchial trunk (ICBT), paired left bronchial arteries.Type II: single right bronchial artery via ICBT, singleleft bronchial artery. Type III: paired right bronchial arteries with one from ICBT, paired left bronchial arteries. Type IV: paired right bronchial arteries with one from ICBT, solitary left bronchial artery.

Origin

• 70 % - from the descending thoracic aorta between the upper T5 to the lower T6 vertebral bodies

• 10% - a first order branch of the thoracic aorta or arch, but outside of the T5–T6 confines

• 20 % - from other thoracic or abdominal branches

• Thoracic– brachiocephalic,

– Subclavian

– internal mammary

– pericardiophrenic, or

– Thyrocervical

• Abdominal – aorta,

– inferior phrenic,

– celiac

• Thoracic– brachiocephalic,

– Subclavian

– internal mammary

– pericardiophrenic, or

– Thyrocervical

• Abdominal – aorta,

– inferior phrenic,

– celiacSubselective angiogram of the right phrenic artery (black arrow) shows arterial flow (white arrows) to the poorly aerated rightlung base

Venous return • Most often via the pulmonary veins, • smaller contributions from the superior vena cava, azygos, and hemiazygos

systems. • This venous system is well visualized during bronchial angiography and the

interventionist must determine if direct arteriovenous shunting is present.

NONBRONCHIAL SYSTEMIC ARTERIES

• This arterial supply may originate from thoracic or abdominal vascular distributions.

• Must be differentiated from true aberrant bronchial arteries.• The most reliable method to distinguish bronchial from systemic

collaterals is through careful observation of the congruence of the vascular course with that of the associated bronchi.

• It is important to note that both ectopic and orthotopic bronchial arteries assume a more vertical or horizontal course prior to joining the bronchial tree.

• Systemic nonbronchial collateral arteries do not adhere to this pattern, instead following a transpleural course or potentially ascend via the inferior pulmonary ligament, never joining the bronchial tree.

**imp**

• The anterior spinal artery courses along the ventral surface of the spinal cord receiving collaterals from up to eight anterior segmental medullary arteries throughout its course.

• Angiographically, these assume the classic ‘‘hairpin’’ configuration.

• The most prominent of these, the artery of Adamkiewicz, arises in the majority of cases from an intercostal artery at T8–L1 .

• Contribution to one or more of these medullary arteries in the thorax is documented in 5– 10% of cases involving the intercostal branch of an intercostobronchial trunk.

• Nontarget embolization of the medullary artery has been associated with transverse myelitis; therefore, meticulous technique with coaxial microcatheter approach distal to the origin of the artery should be undertaken.

(A) A 24-year-old man undergoing spinal angiography for hemorrhage, same patient as Fig. 2A. Injection of the leftT12 intercostal artery demonstrates a prominent normal anterior spinal artery (artery of Adamkiewicz) (arrows). (B) A 24-year-old woman with cystic fibrosis and hemoptysis. Injection of the right supreme intercostal artery (black arrowhead) demonstrates a large, abnormal bronchial artery (white arrow) designating this as an intercostobronchial trunk. Note supply to the anterior spinal artery from the supreme intercostal arterial supply (black arrows). Embolization was performed in this patient beyond the originof the supreme intercostal artery with the microcatheter placed at the level of the white arrow (see Fig. 8). Care was taken notto reflux particles into the supreme intercostal artery distribution (white arrowheads).

Embolotherapy Technique for Hemoptysis

• Since its introduction in 1974, bronchial artery embolization is now considered by many to be first-line therapy.

• A recent survey of clinicians revealed 50% prefer an interventional radiology approach over observation or surgery when treating massive hemoptysis.

Purposes of BAE

• Three purposes for the BAE treatment were defined:

– to achieve immediate control of bleeding in all patients;

– to obtain lasting control of bleeding in patients without surgical conditions;

– to improve clinical conditions for a prospective surgery.

ANGIOGRAPHY IN THE DIAGNOSIS OF HEMOPTYSIS

• Digital subtraction arteriography prior to undergoing bronchial artery embolization is optimally undertaken utilizing radiographic units capable of high frame-rate acquisition.

• This allows for excellent delineation of both bronchial and non-bronchial systemic arteries.

• Angiography and intervention are performed under either moderate sedation or general anesthesia, as dictated by the clinical presentation and status of the patient.

Value of preliminary thoracic aortography.

• Descending thoracic aortogram demonstrates:

– two hypertrophic bronchial arteries (solid arrows) and

– one intervening intercostal artery (open arrow)

• that supply a hypervascular lesion in the right upper lobe.

Technique

• Standard common femoral arterial access predominates although brachial artery access may be necessary to address extraordinarily difficult nonbronchial systemic arterial contributions.

• All arteriography should be performed with either low-osmolar or iso-osmolar nonionic contrast material, as high-osmolar contrast has been implicated in transverse myelitis.

• Many advocate initial thoracic aortography to delineate the number, size, and position of the bronchial arteries. This is particularly helpful in cases of aberrant or ectopic bronchial arteries.

• Both normal and enlarged diameter bronchial arteries discovered via thoracic aortography should be investigated for signs of abnormality in the terminal vascular bed.

• Active extravasation, while extremely helpful and specific, occurs in up to only 10.7% of examinations.

The identification of extravasateddye --INFREQUENT

• Absent identifying a bleeding site, findings sensitive for localization of hemoptysis are:– vascular hypertrophy and

tortuosity, – neovascularity, – hypervascularity, – aneurysm formation, and – shunting (bronchial artery

to pulmonary vein or bronchial artery to pulmonary artery)

Vascular hypertrophy





tortuosity, – neovascularity,– hypervascularity, – aneurysm formation, and – shunting (bronchial artery


Parenchymal hypervascularity




aneurysm



to pulmonary vein or bronchial artery to pulmonary artery).

• Generally accepted guidelines for abnormal bronchial artery diameter is >3 mm, with normal vascular diameter typically 1.5 mm.

• Combining chest CT findings with angiographic findings may further increase the sensitivity and specificity of localization of hemoptysis at angiography.

• Of particular importance is the presence of pleural thickening measuring 3 mm or greater adjacent to a parenchymal abnormality.

• Extrapleural fat hypertrophy may also be present with enlarged vessels visualized in this expanded space.

• The use of microcatheters in a coaxial technique is now widespread, and its utility is well documented both for superselectiveangiography as well as for the administration of embolic agents.

• This can be of benefit when the 5F catheter is unable to maintain secure access for diagnostic angiography, and of course for the delivery of embolic materials.

• When negotiating an intercostobronchialtrunk with the microcatheter, special attention is paid to manipulation of the catheter beyondthe intercostal moiety that may give rise to the aforementioned anterior spinal artery.

(A) A 24-year-old woman with cystic fibrosis and hemoptysis, same patient as Fig. 5B. Chest radiograph showsbilateral opacities in this patient with cystic fibrosis.

(B) Injection of the right supreme intercostal artery shows the enlargedbronchial artery (arrow).

(C) A microcatheter (arrowhead) was placed beyond the intercostal branch, which contributes arterialsupply to the anterior spinal artery (see Fig. 5B), and embolization was successfully performed using large (1000–1180 mm) polyvinyl alcohol particles. Larger particles were used to prevent migration into spinal artery supply should accidental refluxtranspire, although care was taken not to reflux into the intercostal artery.

(D) Postembolization angiogram of the right supreme intercostobronchialtrunk. Note the very slow flow in the bronchial artery (arrow) and its distal branches (black arrowheads).Microcatheter tip is in the intercostobronchial trunk (white arrowhead). Note the excellent filling of the distal supreme intercostal artery, which supplied the anterior spinal artery in the lower cervical/upper thoracic region (Fig. 5B). Patient was neurologically intact following the procedure.

• The injection method and rate should be selected based also on intraprocedural assessment of individual bronchial artery diameter and rate of blood flow.

• Hand injection of contrast through microcatheters is best executed with small-volume syringes capable of generating adequate pressures to achieve the flow rates necessary for satisfactory vascular opacification.

• Alternatively, power injection may be performed with attention to the maximal pressure tolerable by the individual microcatheter.

Subselective angiogram of the right phrenic artery (black arrow) shows arterial flow (white arrows) to the poorly aerated rightlung base

• Interrogation of the subclavian artery and its distribution or the abdominal vasculature should be made with selective end-hole catheters.

• It is well known that bronchial arteries comprise the vast majority of instances of hemoptysis.

• However, it has been reported that up to 5% of patients presenting with hemoptysis have the pulmonary artery as the offending vascular bed.

• In patients with disease known to result in direct pulmonary arterial injury such as tuberculosis, lung abscess, iatrogenic trauma, or malignancy, bronchial artery embolization may not achieve adequate clinical resolution.

• It is not uncommon that patients with hemoptysis of pulmonary arterial origin may require multiple interventions in the angiographic suite prior to definitive diagnosis and treatment.

• Aneurysmal disease and pseudoaneurysm contribute to pulmonary arterial hemorrhage and hemoptysis.

• The classic situation is the finding of enhancing nodules along the periphery of cavitarylesions of a patient with known tuberculosis where hemoptysis should suggest the possibility of Rasmussen aneurysm.

• Aneurysmal rupture is possible and carries a high mortality rate, but is fortunately rare in developed countries due to the rarity of tuberculosis.

49 Y/M DM II,Htn. C/o Rt Fungal Pneumonia (Aspergillosis) with massive hemoptysis



• Rarely, in a patient with hereditary hemorrhagic telangiectasia rupture of a congenital pulmonary arteriovenousmalformation may result in hemoptysis.

MATERIALS AND TECHNIQUES OF THE EMBOLIZATION OF HEMOPTYSIS

• The interventional radiologist has at his or her disposal a variety of materials capable of achieving vascular occlusion.

• Considerations when choosing an embolic agent should include:– ease of delivery,

– durability of occlusion,

– propensity for recanalization, and

– size.

• Size depends clinically upon the site of desired vessel occlusion (proximal vs distal) as well as the catheter lumen used for delivery.

• Regarding the former, utilization of materials of diminutive size results in very distal embolization occluding at the end-arteriolar level, which conceivably may result in ischemic complications to the bronchi, esophagus, or vascular structures.

• Alternatively, shunting of small embolic agents into the pulmonary venous system in effect places the embolic agent into the left heart with subsequent systemic arterial embolization.

• Alternatively, however, embolization with agents that occlude proximally may produce a suboptimal result due to the propensity to form collaterals around the occlusion site.

• As with all embolotherapy, the choice of agent is critical to the success and safety of the procedure.

Gelatin sponge

• Advantages:– Readily available– Inexpensive– Easy to handle

• Disadvantages:– No radiopaque– Absorbable – recanalisation of

the vessel

• Not the embolic agent of first choice

• Efficient temporary embolic agent

Polyvinyl alcohol (PVA) particles

• Readily available and relatively inexpensive.

• Do not undergo absorption - more durable vascular occlusion.

• The most common particle size for bronchial artery embolization ranges from 250–500 mm.

• Size above a threshold of 325 mm theoretically ensures that no significant bronchopulmonaryshunting will occur.

Polyvinyl alcohol (PVA) particles

• Nonspherical PVA particles are, however, prone to clumping resulting in a more proximal occlusion than anticipated based solely on particle size.

• Currently agent of first choice.

Light microscopic findings of PVA particles with irregular shape,

Microspheres

• tris-acryl gelatin microspheres • cross-linked gelatin• utilized successfully in

embolization of uterine fibroids. • Due to their smoothly spherical

shape and hydrophilic nature, they are less prone to clumpingand are more uniform in size than their PVA counterpart.

• In a recent study, bronchial artery embolization with 500–700 mm microspheres achieved short-term clinical success comparable to PVA particles.

Liquid Embolic Agents

• The use of liquid embolic agents such as n-butyl- 2-cyanoacrylate (NBCA; e.g., TruFill1 n-BCA Liquid Embolic System, Johnson & Johnson/DePuy, Raynham, MA) and ethylene vinyl alcohol polymer (Onyx Liquid Embolic System, eV3 Neurovascular, Irvine, CA) for bronchial artery embolization have been infrequently reported.

• Utilization of NBCA requires expertise and knowledge in the art of varying the concentration to alter the rate of polymerization and the depth of vascular penetration.

• This, in conjunction with the risk of distal embolization with tissue necrosis and propensity for nontarget embolization, has relegated NBCA to a very peripheral role in bronchial artery embolization to date.

In a recent study examining 25 patients who underwent bronchial artery embolization with NBCA, technical and clinical success was similar to standard particulate embolic agents. No major complications were noted, but 16% had prolonged chest pain or dysphagia perhaps due to distal embolization.

Metallic coils

• To achieve a relatively proximal occlusion in the vascular bed. In this patient population with a high rate of rebleeding, this position within the vascular tree may jeopardize further embolic attempts.

• In addition, as with the gelatin sponge, proximal occlusion permits collateral flow resulting in poor control of hemoptysis.

• Both pushable and detachable coils have been utilized. In a study comparing mechanically detachable coils to conventional coils, a lower rate of recurrence was noted with the detachable group.

• Data on the efficacy of coil embolization is scarce and dated, probably signifying that most do not employ the use of these agents for bronchial artery embolization today.

(A) A 12-year-old woman with Lennox-Gastaut syndrome and history of recurrent hemoptysiswith multiple previous embolization procedures. As this patient had undergone multiple prior bronchial embolization procedures, pulmonary angiogram was performed to exclude this arterial circulation as a source. It is normal with no evidence for a bleeding site.

(B) Angiogram viaa microcatheter (white arrowhead) of an enlarged collateral branch of the left thyrocervical artery shows collateral filling (blackarrows) around and through the coils placed from a previous embolization. Proximal embolization such as with coils can often lead to this situation.

(C) Embolization successfully performed via the microcatheter(white arrowhead) using 355–500 mm polyvinyl alcohol particles resulting in slow flow in the main trunk (black arrow) and no flow distally (black arrowheads).

• Although not first-line therapy for hemoptysisper se, the presence of pseudoaneurysm in the bronchial arteries may represent an ideal situation to be managed by application of metallic coils.

Outcomes for Bronchial Artery Embolization for Hemoptysis

• Multiple studies have established transcatheter embolization as an effectivetreatment for massive hemoptysis arising from both the bronchial and nonbronchialsystemic circulation.

Technical success occurs in greater than 90% of interventions, with associated clinical success immediately post-embolization attainable in 73–99% of patients.

Unfortunately, recurrence remains frequent ranging from 10–55% for follow-up as long as 46 months.

• Technical success rates have been increasedwith:

– More meticulous technique

– Using superselective embolisation

– Performing control thoracic aortography

• Procedural failures are usually caused by:– Inability to achieve stable catheter position– Inability to achieve catheter position beyond spinal cord

branches– technically inadequate occlusion– incomplete characterization of all arteries responsible for

hemorrhage at initial arteriography

• Recurrence at long term follow up can be as high as 52%, however, success rates of 100% can be achieved using repeat embolisation and control of underlying disease either pharmacologically or surgically.

• However, attaining control of hemoptysis does NOTalleviate the underlying cause of hemorrhage.

• Dependent upon the etiology, recurrence rates can be highly variable, and in the setting of infectious (e.g., tuberculosis, aspergillus) or neoplastic (e.g., bronchogenic carcinoma) offenders, one can expect nearly all patients to eventually rehemorrhage.

• Although the embolization technique may be entirely adequate, clinical remission is not always achieved. Generally accepted rates of cessation of hemoptysisfollowing bronchial artery embolization approach 90%.

• Recurrence of haemoptysis may occur due to:– Recanalisation of embolised vessels– Incomplete embolisation– Revascularisation by new collateral formation– Presence of anomalous bronchial arteries

• Tuberculosis and aspergillus have been identified as independent risk factors for the recurrence of hemoptysis.

• Patients with lung cancer carry a 10–30% risk of developing hemoptysis, and are also at risk for recurrence following embolization.

• Re-embolization is an accepted approach to recurrent hemoptysis; however, surgery remains as the definitive treatment of hemoptysis recalcitrant to multiple embolizations and maximum medical therapy.

Complications of Bronchial Artery Embolization for Hemoptysis

• Aside from the typical complications associated with angiography, adverse events most frequently arise from unintentional, non-target embolization.

• As previously discussed, the vascular distribution of the bronchial arteries includes:– mediastinal structures,

– pleura,

– bronchi,

– esophagus, and

– walls of the thoracic and pulmonary vasculature.

• Hence, the complications arise due to unintentional embolisation of these strucures.

Common complications

• Transient chest pain– Most common– 24 – 91%– Probably due to ischemia of embolised branches.– Can be severe when intercostal branches are

inadvertently embolised.– self-limiting in the vast majority of cases

• Pleural pain– Can be avoided with

• Superselective embolisation techniques• Use of larger particles

• Transient dysphagia

– Esophageal nontarget embolization

– up to 18% of interventions

– usually self-limiting.

• Low grade fever

• Nausea / Vomiting

Common complications

• Transverse myelitis due to spinal cord ischemia

– most serious complication

– 1.4–6.5%

– Superselective microcatheter techniques with special attention to position distal to the anterior medullary arteries

– Performing regular check angiograms before and after administration of embolic agents

• Although some believe spinal ischemia may in fact be due to toxicity related to the contrast media, low and iso-osmolar contrast agents have for the most part eliminated this line of thinking.

• Cortical blindness has been reported and represents an extraordinarily rare neurologic complication.– The predominant proposed pathway is from

unintentional embolization of the occipital cortex in the setting of fistula formation arising from the bronchial artery to either the pulmonary veins or the vertebral arterial distribution.

• Pain in the orbit or temporal region ipsilateral to the side of embolization may occur, but is thought to be referred pain rather than nontargetembolization in these territories.

Incidental complications

• Subintimal dissection or perforation of the bronchial artery

– Caution with the use of glide-wire type guidewires

• Dissection of aorta

• Other rare complications include:– bronchial stenosis,

– bronchial necrosis, and

– bronchoesophageal fistula • left main bronchus

• presumably due to bronchial wall ischemia as well as ischemic necrosis of the aorta with or without associated dissection.

– Pulmonary infarction• Especially in patients who have suffered pulmonary artery

embolism

– Non target embolisation• Colon, coronary and cerebral circulation

Pulmonary AVMs

• Abberent connection between pulmonary artery and venous circulation that bypasses capillary system

• 50-70% located in the lower lobes

Complications from PAVM

• Haemorrhage:– Haemoptysis or haemothorax

• Massive R to L shunting:– Hypoxia, dyspnoea, clubbing, cyanosiss,

polycythemia

• Paradoxical Emboli:– Cerebral abscess, embolic stroke, TIAs

– Serious neurological complications occur in upto35% of patients with PAVM

Treatment

• Preferrred for :

– Symptomatic PAVMs

– Asymptomatic lesions more than 3mm

• Trans Catheter Embolotherapy (TCE) is the treatment of choice.

– Avoids major surgery and general anaesthesia

– Loss of lung parenchyma

Trans Catheter Embolotherapy (TCE) for PAVMs

• Coil Embolisation

• Amplatzer Vascular Plug

Coil embolisation

Coil embolisation

The Amplatzer® vascular plug

• self-expandable cylindrical device that allow the device to compress inside a catheter, and then when released from the catheter, return to its intended shape to occlude the target vessel.

• The device has platinum markers on both ends.

• The AVP is available in diameters ranging from 4 mm to 16 mm, in 2-mm increments.

The Amplatzer® vascular plug

• It is preloaded in a loader and delivered through currently available guiding catheters in sizes ranging from 5F to 8F.

• Once positioned by holding the delivery shaft steady and pulling the outer guiding catheter back, it is released by rotating the delivery cable counter clockwise.

• It is recommended to select a device approximately 30%–50% larger than the vessel diameter.

• Since the AVP is a flexible nitinolwire mesh, it adjusts to the shape of the vessel and thus, oversizing prevents device migration after deployment.

Major aortopulmonary collateral arteries (MAPCAs)

• Major aortopulmonarycollateral arteries (MAPCAs) are blood vessels that bring systemic blood flow to the pulmonary arteries.

• They develop in response to decreased pulmonary blood flow and cyanosis.

• Tetralogy of Fallot (TOF) with pulmonary stenosis is associated with the development of MAPCAs in less than 5% of cases, although it is seen in about two thirds of patients having pulmonary atresia.

• MAPCAs are usually clinically silent, presenting only in late cases with haemoptysis.

• Their presence complicates the operative management of TOF as excessive return of blood floods the operative field.

• Postoperatively also, the presence of MAPCAs may make it difficult to wean a patient off the ventilator because of pulmonary congestion, and may provoke congestive cardiac failure by raising pulmonary arterial pressures.

• Therefore, appropriate management of MAPCAs is necessary for both short and long term outcome.

• Occlusion of the MAPCAs before open heart surgery is important.

• Coil embolization of large MAPCAs under fluoroscopic control is a useful technique.

• Coiling of the MAPCAs may also be done aftersurgery to allow better growth of native pulmonary arteries.

3Y/F C/O CCHD,TOF,MAPCOS

• Bronchospic interventions

• Radiologic interventions (BAE etc.)

• Surgery ( Lobectomy / Pneumonectomy)

Interventions

SURGICAL MANAGEMENT

• BAE unavailable

• Uncontrolled bleed with BAE.

• Localised lesions

• Mortality : 1% to 50%

• Mortality :7.1-18.2% (massive hemoptysis)

• Mortality :upto 40% (emergency procedure)

Indications of surgery

Procedure of choice in:

• Bronchial adenoma

• Aspergilloma

• Hydatid cyst

• Iatrogenic pulmonary rupture

• Chest trauma

Contra indications for surgery

• Unresectable carcinoma

• Inability to lateralize the bleeding site

• Diffuse disease

• Multiple AVM

• Cystic fibrosis

• Arterial hypoxia

• Co2 retention

• Marginal pulm. Reserve

• Dyspnea at rest

• Non-localizing bronchiectasis

Life Threatening hemoptysis

Pulmonary isolation & identification of bleeding source

(Radiological/Bronchoscopic means:CT Thorax,Balloon bronchial blockers)

Rigid Bronchoscopy

Surgery BAE

(Delayed TREATMENT)

Follow up at OPD

SUCCESS

FAILURE

Conclusion

• Massive hemoptysis is a medical emergency that requires prompt assessment.

• CT is a quick and noninvasive tool that is helpful in the diagnosis and management of hemoptysis, and its use should be considered in any patient who presents with this condition.

• The management of life-threatening hemoptysis demands a well-integrated, multidisciplinary approach.

• Bronchial artery embolization serves as both first-line therapy for massive hemoptysis, and as a bridge to more definitive therapies targeted to the underlying etiology.

• Bronchial artery embolization possesses high rates of immediate clinical success coupled with low complication rates.

• It can be performed repeatedly for hemorrhage recurrence and associated angiography can elucidate alternative sources of hemoptysis including nonbronchial systemic and pulmonary arteries.

Date post:	02-Jul-2015
Category:	Health & Medicine
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Imaging in haemoptysis

Health & Medicine