Diagnostic Radiology

Treatment of Hemoptysis by Embolization of Bronchial Arteries 1 Jacques Remy, M.D., Alain Arnaud, M.D., Henri Fardou, M.D., Rene Giraud, M.D., and Cyr Voisin, M.D.

One hundred and four patients presenting with either massive or repeated hemoptysis were treated byembolization of the bronchial arteries witha resorbable material (Spongel). The procedure was performed via selective catheterization of the abnormal arteries. Forty-nine patients were treated during and 55 after hemoptysis. Ofthe 49 patients treated during hemoptysis, immediate arrest of bleeding was affected in 41 but6 of these patients suffered relapse two to seven months afterthe procedure. There wasno recurrence of bleeding in the remaining 35 patients. INDEX TERMS: Arteries, bronchial. (Arteries, therapeutic embolization 9. 129) • (Bronchial arteries, therapeutic embolization 9[ 43]. 129) • Catheters and catheterization • Embolism, therapeutic. Lungs, hemorrhage

Radiology 122:33-37, January 1977

• Table I:

RANSCATHETER HEMOSTATIC TECHNIQUES are gradually gaining acceptance for the management of arterial bleeding. From May 1973 to October 1975, we used this technique in 104 patients (TABLE I: columns A and B) with either massive (5), life-threatening, or repeated hemoptysis. The majority were resistant to medical hemostatic treatment and presented with temporary or permanent contraindication to surgical intervention.

T

A Tuberculosis Bronchiectasis Aspergilloma Pneumoconiosis in coal miners Bronchial carcinomas Sequelae of pulmonary embolism Hydatid cysts Cystic fibrosis Hodgkin's disease Undiagnosed

TECHNIQUE

Access to the systemic arteries was gained through the femoral artery with the Seldinger technique under local anesthesia. We started by evaluating the hypervascular areas of the lung (14) by means of thoracic aortography, visualization of the axillary and subclavian arteries and of each arterial abnormality which was then investigated by selective injection of radiopaque materlal.f Arteries to be embolized were selected after consideration of the relevant clinical, radiological, fiberendoscopic (17) and arteriographic information (1). To avoid regurgitation of embolization material into the aorta, it was necessary to introduce the catheter precisely into the artery chosen. Three types of arteries could be embolized: (a) bronchial arteries (3); (b) nonbronchial systemic arteries penetrating the lung via the triangular ligament (12); and (c) nonbronchial arteries penetrating the lung via pleural adhesions (15). The material utilized was Spongel 3 (14) cut into fragments 0.5 cm and 1-2 mm thick. The fragments were softened in dextrose-saline and injected in quantities of 3 to 5 at a time. The localization of the catheter and the progress of the embolization of the abnormal vascular bed were evaluated at regular intervals by further injections of radiopaque material. Finally, when sufficient Sponge I had been injected to obliterate all but a few proximal centimeters of the artery, the procedure was terminated. This required between 20 and 100 fragments per artery, de-

Total



Principal Diagnosis in 104 Patients B

C

D

E

35 27 19 14

16 12 6 6

12/16 12/12 4/6 6/6

2/12 1/12 3/4 0/6

3 1

3 1

2/3 1/1

0/2 0/1

2 1 1 1

2 1 1 1

2/2 1/1 0/1 1/1

0/2 0/1

-104

-49

0/1

--

--

41/49

6/41

A: Etiology of hemoptysis managed by embolization. B: Total number of patients in each group treated. C: Number of patients treated during hemoptysis. D: Results of embolization, number of patients with remission up to 2 months. E: Failure of embolization, number of patients with recurrence of hemoptysis up to 2 months (2 to 7 months).

pending upon the size of the abnormal vasculature (Fig. 1). The presence of an anterior spinal artery (6) arising from the cervico-intercostal trunk, from an intercostal artery ( 11) or from an intercosto-bronchial trunk (3), constitutes an absolute contraindication to embolization. The following complications occurred in the course of 104 investigations: (a) necrosis of 15 cm of the small bowel treated by segmental resection in one case; (b) epigastric pain in one patient which resolved spontaneously after a few hours; (c) the most frequent complication consisted of a burning retrosternal sensation with dysphagia (10 cases) (16, 18) and mild intercostal pain and fever (38-38.5°C) for two or three days (most of the patients) (2). There were no medullary complications (8, 11). MATERIAL

Table I (columns A and B) describes the principal di-

From Service Central de Radiologie, Hopital A. Calmette, 59033 Lille Cedex, France. Accepted for publication in June 1976. 2 lodotalamate de methyl-glucamine, Lab. Guerbet, Paris. 3 Laboratoires I.S.H., Paris. 1

33

shan

34

J.

REMY AND OTHERS

January 1977

Fig. 1. Massive hemoptysis (400 ml in 24 hours). Masses are due to massive progressive pulmonary fibrosis in a coal miner with pneumoconiosis. Bilateral hypertrophy of the bronchial vasculature (A) is seen arising from a common trunk which divides into the right and left bronchial arteries. Embolization of the common trunk (B) with 70 fragments of Spongel resulted in interruption of the blood supply and immediate arrest of hemoptysis.

agnosis in 104 patients treated by embolization. Tuberculosis, bronchiectasis, aspergilloma complicating posttuberculous cavities and pneumoconiosis in coal miners were the most frequent causes of hemoptysis. To evaluate the efficacy of embolization, we listed the patients treated during the period of bleeding separately (TABLE I, column C). There were 49, aged 16 to 72, presenting either with massive hemoptysis (in excess of 500 ml in 24 hours) (Fig. 1) or more moderate loss (100 ml in 24 hours) or continual hemoptysis for weeks or months. During the same period, we encountered 28 patients who could not be treated by this procedure for the following reasons: death due to massive hemoptysis before embolization (1 case); failure to achieve stable localization of the catheter (14 cases); presence of a spinal artery (12 cases); and major vasoconstriction caused by previous intra-arterial injection of vasopressin (1 case) (14). RESULTS

The aim of treatment was to achieve immediate arrest of hemoptysis during embolization and the absence of relapse during the following months. Of the 49 patients listed in TABLE I, column C, hemoptysis was immediately arrested in 41 (TABLE I, column D); of the 41 patients, 6 suffered relapse 2 to 7 months after the procedure (TABLE I, column E) and in 5 of those patients the hemorrhage was less severe than before treatment. Of the 35 remaining patients, the remission had lasted between 2 and 30

months by 1 November 1975. Duration of remission is listed according to diagnosis in TABLE II. DISCUSSION

The arrest of hemoptysis by interruption of the bronchial arterial supply confirms the systemic origin of the majority of hemoptysis (1, 14). Occlusion of bronchial arteries experimentally (4, 7) and in man has not caused any clinical or radiologically detectable pulmonary ischemia. Fiberendoscopy in one patient revealed a zone of necrosis in the right main bronchus which slowly resolved after several weeks. An elevation of lactic dehydrogenase was observed in 10 patients which resolved in 3 to 5 days (2). Postmortem examination of lobectomy or pneumonectomy specimens from 7 patients who had previously benefitted from embolization failed to reveal any evidence of pulmonary ischemia with the exception of one in whom pneumonectomy for bronchietasis had been performed five days after embolization. This treatment is only a palliative measure because (a) the primary cause of increased vascularity has remained; revascularization occurs via small previously insignificant arteries (9, 13) (Fig. 2). (b) The material used to effect embolization is reabsorbed. One frequently encounters recanalization of the embolized artery, which returns to its initial or a smaller diameter (Fig. 3). Interruption of the abnormal arteries results in reduction or disappearance of associated pulmonary-bronchial arterial shunts (Fig. 4).

35

Fig. 2. A-D. Heavy bleeding caused by progressive massive fibrosis in a coal miner with pneumoconiosis. Embolization interrupts the blood supply but spares the collateral vessels. (tt) C. Repeat examination after eight months shows revascularization of the mass by collateral vessels (it) as well as by arteries which had not been noticed on the first examination (A). Embolization (D) was repeated. B.

Diagnostic Radiology

36

J. REMY

AND OTHERS

January 1977

Fig. 3. A-C. Massive hemoptysis due to intracavitary aspergilloma. Abnormal vasculature arises from two intercostal arteries and from the right bronchial artery, the latter leaving three principal branches (A). Embolization of the bronchial and intercostal arteries (B) four weeks after reappearance of hemoptysis (C) demonstrates recanalization of the intercostal artery and two of the three branches of the right artery which are now thinner. The third branch remained obstructed. Note the bronchopulmonary arterial shunt opacified behind the right upper lobe branch artery.

The size of the Spongel fragments prevents their entry into the pulmonary artery. TABLE I, columns D and E and TABLE II show that results are particulary interesting in patients with tuberculosis, bronchiectasis and in coal miners with pneumoconiosis. The method was less successful in preventing hemoptysis in patients with intracavitary aspergilloma; none of these patients experienced a remission of more than 18 months. Aspergilloma developes especially in post-tuberculous cavities or in cavitated progressive massive fibrosis in relation to pneumoconiosis. These cavities occur particulary in the upper lobes at which level the cavity wall can receive a systemic blood supply from the axillary and the subclavian arteries via pleural adhesions (internal mammary artery, thyrocervical trunk, costocervical trunk, external mammary artery); embolization of all of these abnormal systemic arteries is difficult or impossible. On the other hand, the other bronchopulmonary diseases mentioned received their blood supply mostly or exclusively from the bronchial arteries

(14) and in these conditions, embolization was most successful. Long-term success of embolization depends not only on the quality of arterial occlusion but also on the efficacy of the medical treatment. The prognosis for severe hemoptysis (10) can be improved by this new therapeutic procedure. Prof. Jacques Remy Hopital A. Calmette 59033 Lille Cedex, France

REFERENCES 1. Arnaud A, Giraud P, Autran P, et al: Arteriographle bronchique selective et hemoptysies. J Radiol Electrol Med NucI55:105-109, Feb 1974 2. Arnaud A, Chauvin G, Giraud R, et al: L'embolisation des arteres systerniques pulmonaires. Technique, indications, incidents et accidents. Rev Fr Mal Resp (to be published)

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EMBOLIZATION OF BRONCHIAL ARTERIES

Vol. 122

Diagnostic Radiology

Fig. 4. Same patient as in Figure 3. Massive transpleural intercostal-pulmonary artery shunt (A) crosses a pulmonary adhesion. Note reduction (B) then disappearance of the shunt (C) following embolization.

Table II:

Follow-up of Patients Without Relapse No Recurrence of Hemoptysis

Tuberculosis Bronchiectasis Aspergilloma Pneumoconiosis in coal miners Bronchial carcinomas Sequelae of pulmonary embolism Hydatid cysts Cystic fibrosis Undiagnosed Total

More than

Number of Patients Treated

2 to 6

7 to 12

13 to 18

18

Months

Months

Months

Months

10

6

4

5

3

11 1 6 2 1 2 1 1

35

3. Botenga ASJ: Selective Bronchial and Intercostal Arteriography. Leiden, Holland, H. E. Stenfert Kroese, 1970 4. Boushy SF, Helgason AH, North LB: Occlusion of the bronchial arteries by glass microspheres. Am Rev Resp Dis 103:249-263, Feb 1971 5. Crocco JA, Rooney JJ, Fankushen OS, et al: Massive hemoptysis. Arch Intern Med (Chicago) 121:495-498, Jun 1968 6. Oi Chiro G: Unintentional spinal cord arteriography: a warning. Radiology 112:231-233, Jul 1974 7. Ellis FH Jr, Grindlay JH, Edwards JE: The bronchial arteries. Experimental occlusion. Surgery 30:810-826, Nov 1951 8. Feigelson HH, Ravin HA: Transverse myelitis following selective bronchial arteriography. Radiology 85:663-665, Oct 1965 9. Fisher AB, Kollmeier H, Brody JS, et al: The rate of regeneration of the bronchial arteries following bronchial transsection and reanastomoses (abst). Am Rev Resp Dis 99:994-995, Jun 1969 10. Fellows KE, Stigol L, Shuster S, et al: Selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis. Radiology 114:551-556, Mar 1975 11. Kardjiev V, Symeonov A, Chankov I: Etiology, pathogenesis and prevention of spinal cord lesions in selective angiography of the

3 3 2 1

1

2

1

1 1 1

-13

9

6

7

bronchial and intercostal arteries. Radiology 112:81-83, Jul 1974 12. Parke WW, Michels NA: The nonbronchial systemic arteries of the lung. J Thorac Cardiovasc Surg 49:694-707, Apr 1965 13. Rabinovich JJ: Re-establishment of bronchial arteries after experimental lung lobe autotransplantation. J Thorac Cardiovasc Surg 64:119-126,JuI1972 14. Remy J, Voisin C. Dupuis C, et al: Traitement des bernoptysies par embolisation de la circulation systemlque, Ann Radiol (Paris) 17: 5-16, Jan-Feb 1974 15. Remy J, Beguery P, Froment T, et al: La vascularlsation systemlque du poumon: technique d'exploration et anatomie raolologique appllquees au diagnostic topographique des hernoptysles. Ann Radiol (Paris) 18:47-54, Jan 1975 16. Shapiro AL, Robillard GL: The esophageal arteries. Their configurational anatomy and variations in relation to surgery. Ann Surg 131:171-185, Feb 1950 17. Smiddy JF, Elliott RC: The evaluation of hemoptysis with fiberoptlc bronchoscopy. Chest 64: 158-162, Aug 1973 18. Swigart LL, Siekert RG, Hambley WC, et al: The esophageal arteries. An anatomic study of 150 specimens. Surg Gynecol Obstet 90:234-243, Feb 1950

Treatment of hemoptysis by embolization of bronchial arteries.

• Diagnostic Radiology Treatment of Hemoptysis by Embolization of Bronchial Arteries 1 Jacques Remy, M.D., Alain Arnaud, M.D., Henri Fardou, M.D., R...
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