Radiological Management of Hemoptysis

REVIEW/STATE OF THE ART

Radiological Management of Hemoptysis: A ComprehensiveReview of Diagnostic Imaging and Bronchial ArterialEmbolization

Joo-Young Chun • Robert Morgan •

Anna-Maria Belli

Received: 14 October 2009 / Accepted: 8 December 2009 / Published online: 8 January 2010

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010

Abstract Hemoptysis can be a life-threatening respiratory

emergency and indicates potentially serious underlying

intrathoracic disease. Large-volume hemoptysis carries

significant mortality and warrants urgent investigation and

intervention. Initial assessment by chest radiography, bron-

choscopy, and computed tomography (CT) is useful in

localizing the bleeding site and identifying the underlying

cause. Multidetector CT angiography is a relatively new

imaging technique that allows delineation of abnormal

bronchial and nonbronchial arteries using reformatted

images in multiple projections, which can be used to guide

therapeutic arterial embolization procedures. Bronchial

artery embolization (BAE) is now considered to be the most

effective procedure for the management of massive and

recurrent hemoptysis, either as a first-line therapy or as an

adjunct to elective surgery. It is a safe technique in the

hands of an experienced operator with knowledge of

bronchial artery anatomy and the potential pitfalls of the

procedure. Recurrent bleeding is not uncommon, especially

if there is progression of the underlying disease process.

Prompt repeat embolization is advised in patients with

recurrent hemoptysis in order to identify nonbronchial

systemic and pulmonary arterial sources of bleeding. This

article reviews the pathophysiology and causes of hem-

optysis, diagnostic imaging and therapeutic options, and

technique and outcomes of BAE.

Keywords Hemoptysis �Multidetector computed tomography angiography �Bronchial artery � Embolization

Introduction

Hemoptysis can be a life-threatening respiratory emer-

gency that requires prompt investigation and management.

It is a relatively common presenting symptom in clinical

practice [1] and can signify potentially serious underlying

thoracic disease. Despite advances in modern-day medi-

cine, large-volume hemoptysis still poses a diagnostic and

therapeutic challenge.

Conservative management of massive hemoptysis has a

50–100% mortality rate [2, 3]. Until two decades ago,

surgery was regarded as the treatment of choice for hem-

optysis. However, a large proportion of patients are not

suitable candidates for surgery due to pre-existing comor-

bidities and poor respiratory reserve, and mortality rates of

up to 40% have been reported following emergency sur-

gery [4]. Bronchial artery embolization (BAE) is a mini-

mally invasive alternative, which is now considered to be

the most effective nonsurgical treatment in the manage-

ment of massive and recurrent hemoptysis. It plays an

important role in primary therapy and in stabilizing patients

prior to elective surgery.

This article reviews the pathophysiology and causes of

hemoptysis, initial investigations including diagnostic

imaging, options for management, systemic and pulmonary

artery anatomy, bronchial artery angiography and emboli-

zation technique, and complications associated with BAE.

Pathophysiology and Causes of Hemoptysis

The lungs have a dual arterial supply composed of the

pulmonary and bronchial arterial systems. The pulmonary

arteries account for 99% of the arterial supply and are

responsible for gaseous exchange. The bronchial arteries

J.-Y. Chun (&) � R. Morgan � A.-M. Belli

Department of Radiology, St. George’s Hospital,

Blackshaw Road, London SW17 0QT, UK

e-mail: [email protected]

123

Cardiovasc Intervent Radiol (2010) 33:240–250

DOI 10.1007/s00270-009-9788-z

make up the remaining 1% and supply nutrient branches to

the bronchi, vasa vasorum to the pulmonary arteries and

veins, and smaller bronchopulmonary branches to the lung

parenchyma [5, 6]. The two systems are connected by

numerous anastomoses between bronchial and pulmonary

arteries at the level of the bronchi and the pulmonary

lobules [5]. This communication produces a physiological

right-to-left shunt that accounts for approximately 5% of

the total cardiac output [6].

In conditions where the pulmonary circulation is com-

promised, such as hypoxic vasoconstriction, intravascular

thrombosis, and vasculitis, the bronchial arteries proliferate

and enlarge to gradually replace the pulmonary circulation

[6, 7]. Chronic inflammation of the lungs is also associated

with enlargement of the bronchial arteries as a result of

abnormal enhanced communication with the pulmonary

arterioles [8, 9]. Inflammatory processes release angiogenic

growth factors, which promote neovascularization and

recruitment of collateral supply from adjacent systemic

vessels [10]. These new vessels, which are usually thin-

walled and fragile, are exposed to increased systemic

arterial pressures and are prone to rupture into the airways,

resulting in hemoptysis.

The definition of massive hemoptysis varies in the lit-

erature from 100 to 1,000 ml over a period of 24 h, but the

most widely used figure is expectoration of 300–600 ml of

blood in 24 h [4, 8, 9, 11]. It is estimated that 400 ml of

blood in the alveolar space is sufficient to inhibit gaseous

exchange significantly [12] and the cause of death is usu-

ally asphyxiation rather than exsanguination [2].

There are multiple causes of hemoptysis (Table 1).

Bronchogenic carcinoma, chronic inflammatory lung dis-

eases due to bronchiectasis, and aspergilloma within a

chronic sarcoid or tuberculous cavity account for most

cases in the Western world, while active tuberculosis (TB)

continues to be the leading cause of hemoptysis worldwide

[9, 12, 13]. In some cases a cause cannot be found and is

termed idiopathic or cryptogenic hemoptysis. It is a diag-

nosis of exclusion and is reported to be responsible for

3–42% of hemoptysis episodes, particularly in smokers

[13–15].

Diagnosis of Hemoptysis

Initial evaluation of patients with hemoptysis should aim to

locate the source of bleeding and to identify the underlying

cause. Standard diagnostic studies include sputum exami-

nation, bronchoscopy, chest radiography, and chest com-

puted tomography (CT). Sputum should be tested for the

presence of bacteria, especially mycobacterium and fun-

gus, and for malignant cells, especially in smokers over

40 years of age [12].

Bronchoscopy is the primary method for diagnosis and

localization of hemoptysis for chest physicians [12, 16].

Rigid bronchoscopy is recommended in cases of massive

hemoptysis because of its ability to maintain airway

patency, although flexible bronchoscopy is used more

widely, as it can be performed at the patient’s bedside

without the use of general anaesthetic and a vasoactive

drug can be instilled directly into the bleeding source [1,

12]. However, the overall diagnostic accuracy of bron-

choscopy in localizing the site of bleeding is \50% [11,

17] and it is less useful in identifying the underlying cause.

Bronchoscopy has further disadvantages during active

hemoptysis because the airways are filled with blood,

making evaluation of the distal airways difficult, and

endobronchial therapies are ineffective in most cases [11,

12]. The ideal time for bronchoscopy is controversial but

the consensus is to perform urgent bronchoscopy in

patients with massive hemoptysis. A report from the

American College of Chest Physicians stated that 64% of

clinicians favoured early diagnostic bronchoscopy within

the first 24 h and 79% used flexible bronchoscopy [1].

Diagnostic Imaging

Chest radiography is readily available and may help lat-

eralize the bleeding and diagnose underlying parenchymal

Table 1 Causes of hemoptysis

Pulmonary diseases

Tuberculosis

Aspergilloma

Pneumonia

Bronchiectasis

Lung malignancy

Chronic obstructive airways disease

Lung abscess

Cystic fibrosis

Sarcoidosis

Vasculitis: Behcet’s disease, Wegener’s granulomatosis

Cardiovascular diseases

Pulmonary artery arteriovenous malformation/aneurysm

Pulmonary embolism

Pulmonary hypertension

Bronchial artery aneurysm

Thoracic aortic aneurysm rupture/dissection

Aortobronchial fistula

Others

Coagulopathy

Iatrogenic: anticoagulation, Swan-Ganz catheters

Trauma

J.-Y. Chun et al.: Radiological Management of Hemoptysis 241

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abnormalities. However, the positive diagnostic yield of

chest radiography has been reported to be only 50% in a

retrospective analysis [13], and almost a quarter of patients

presenting with hemoptysis secondary to malignancy

showed normal chest radiographic appearances in another

study [18].

CT has proven to be of considerable diagnostic value in

diagnosing underlying disease, which alone can localize

the site of bleeding in 63–100% of patients [17, 19] and the

combined use of bronchoscopy and CT increases the

positive yield even further [13]. Contrast-enhanced single-

detector spiral CT can demonstrate bronchial and non-

bronchial systemic arteries and detect vascular lesions such

as thoracic aneurysm and arteriovenous malformation

(AVM) [20, 21]. A recent study demonstrated an accuracy

of 84% in predicting involvement of nonbronchial systemic

arteries in patients with massive hemoptysis [22].

Multidetector CT (MDCT) is a relatively new imaging

technique which has the capability to image a wider ana-

tomical range in a single breath hold, reducing scanning

time and respiratory motion artifacts. Contrast-enhanced

MDCT produces high-resolution angiographic studies with

a combination of multiplanar reformatted images [15, 23].

These include thick and thin section axial images, two-

dimensional (2D) maximum intensity projection (MIP)

images, three-dimensional (3D) volumetric images, and

shaded-surface-display (SSD) images. Therefore, MDCT

angiography (MDCTA) is able to depict a road map of the

thoracic vessels, as well as identifying the source of

bleeding and underlying pathology with high sensitivity.

This information is of particular importance to the inter-

ventional radiologist in planning arterial embolization.

A recent study [23] concluded that MDCTA provides a

more accurate demonstration of bronchial and nonbron-

chial systemic arteries than conventional angiography. The

same study and other recent studies reported that 3D

images were superior to 2D axial images in identifying

ectopic origins of bronchial arteries and demonstrating

mediastinal and hilar courses of bronchial arteries, espe-

cially if they were enlarged and tortuous [23–25]. A further

study [26] showed that 100% of bronchial and 62% of

nonbronchial arteries causing hemoptysis were detected on

MDCTA. In addition, MDCTA is able to identify bleeding

from a pulmonary artery origin, such as Rasmussen aneu-

rysm [27].

Management of Hemoptysis

The management of hemoptysis should include initial

resuscitation and supportive measures, such as monitoring

of cardiorespiratory parameters, correction of hypoxia,

stabilization of blood pressure, and transfusion with blood

products as necessary. In the case of massive hemoptysis,

most clinicians favor management in an intensive care

setting with early endotracheal intubation [1]. Endobron-

chial therapy such as infusion of cold saline solution, use of

balloon catheters, or instillation of epinephrine has been

reported to be unreliable and of limited use [1, 16].

Until the 1970s, surgery was regarded as the treatment

of choice for hemoptysis once the bleeding site was

localized by bronchoscopy. Documented mortality rates

following surgical intervention vary between 7.1 and 18.2

% but increase to 40% in the emergency setting [4, 28].

Surgery during an episode of acute hemorrhage carries a

high risk of operative bleeding, asphyxia, bronchopleural

fistula, and respiratory failure [29]. In addition, a large

proportion of patients with hemoptysis are not suitable

candidates for surgery due to pre-existing comorbidities

and poor respiratory reserve. However, surgery remains the

procedure of choice in the treatment of massive hemoptysis

caused by iatrogenic pulmonary artery rupture, chest

trauma, and aspergilloma resistant to other therapeutic

options [12, 30].

BAE has become a well-established vascular interven-

tional technique in the management of massive and

recurrent hemoptysis [4, 31–39]. The mode of action is the

occlusion of systemic arterial inflow to the fragile vessels

within inflammatory tissue, reducing the perfusion pressure

and the likelihood of further bleeding [9]. Interest in sys-

temic pulmonary circulation in the 1960 s led to visuali-

zation of the bronchial arteries by nonselective thoracic

aortography [40, 41]. In 1964, the first selective bronchial

artery catheterization and angiography was performed by

Viamonte [42]. The technique was slow to take off in the

subsequent decade due to reports of spinal cord ischemia,

which was caused by inadvertent occlusion of the spinal

arteries that may arise from bronchial or intercostal arter-

ies, exacerbated by large-diameter catheters in use at the

time and ionic contrast media [43–45]. These reports

prompted further evaluation of the arterial supply to the

spinal cord and improvements in angiographic techniques.

The first successful BAE for hemoptysis was performed by

Remy et al. in 1974 [46]. Since then, many authors have

demonstrated the efficacy and safety of this procedure in

controlling hemoptysis [31, 35–39, 47–50], and a survey by

the American College of Chest Physicians showed that a

higher proportion of chest physicians favored interven-

tional radiology over either conservative or surgical man-

agement [1].

Bronchial Artery Anatomy

The bronchial arteries have a variable anatomy in terms of

origin and branching distribution. It is important that the

242 J.-Y. Chun et al.: Radiological Management of Hemoptysis

123

operator is familiar with these variants prior to undertaking

BAE. Most commonly, they arise from the thoracic aorta at

a level between the superior margin of T5 and the inferior

margin of T6 in approximately 70–83.3% [51, 52]. Caul-

dwell et al. [51] described the four most common bronchial

branching patterns based on a study of 150 adult cadavers,

as illustrated in Fig. 1. Type 1 has one right bronchial

artery arising from an intercostobronchial trunk (ICBT)

and two left bronchial arteries (40.6%). Type 2 has one

right from an ICBT and one left (21.3%), type 3 has two

from the right (one from an ICBT) and two from the left

(20.6%), and type 4 has two from the right (one from an

ICBT) and one from the left (9.7%). The most constant

vessel is the right ICBT, present in 88.7% (Fig. 2). This

vessel usually arises from the right posterolateral aspect of

the thoracic aorta, whereas the individual left and right

bronchial arteries arise from the anterolateral aspect. The

right and left bronchial arteries can also arise from a

common trunk.

Bronchial arteries that originate outside the T5–T6

vertebral levels of the thoracic aorta are considered to be

anomalous or ectopic and their prevalence ranges from

16.7 to 30% [51, 52]. They have been reported to originate

from the aortic arch, brachiocephalic artery, subclavian

artery, internal mammary artery, thyrocervical trunk,

costocervical trunk, inferior phrenic artery, or abdominal

aorta [52]. All these variants can be distinguished from

nonbronchial systemic arteries because they extend along

the course of the major bronchi. The nonbronchial systemic

arteries enter the lung parenchyma through the inferior

pulmonary ligament or the adherent pleura, and their

course is not parallel to that of the bronchi [53].

Bronchial arteries are the most common source of

bleeding in hemoptysis [11]. They appear as enhancing

nodular or linear structures within the mediastinum and

around the central airway in contrast-enhanced axial CT

images. Abnormal bronchial arteries are most commonly

found in the retrotracheal and retroesophageal areas, as

well as the posterior wall of the main bronchus and aor-

topulmonary window [20, 21]. Bronchial arteries with a

diameter [2 mm are considered to be abnormal and are

candidates for embolotherapy.

The vascular supply of the thoracic spinal cord is an

important consideration during angiography. The anterior

portion of the cord is supplied by the anterior spinal artery

which originates from branches of the vertebral arteries. It

receives blood from anterior medullary branches, which

usually arise from intercostal and lumbar arteries [54]. In

the thoracic region, the anterior spinal artery is usually

supplied by a single anterior medullary artery but the

largest anterior medullary branch, also known as the artery

of Adamkiewicz, can arise at any level between T5 and L4

[52]. Although it is uncommon, the anterior medullary

Fig. 1 Four main types of bronchial artery anatomy. Type I: one

right bronchial artery from right intercostobronchial trunk (ICBT),

two left bronchial arteries (40.6%). Type II: one on the right from

ICBT, one on the left (21.3%). Type III: two on the right (one from

ICBT and one bronchial artery), two on the left (20.6%). Type IV:

two on the right (one from ICBT and one bronchial artery), one on the

left (9.7%). Adapted from Ref. 51

Fig. 2 Right interostobronchial trunk (ICBT). Selective right ICBT

angiogram shows an intercostal branch (black arrow) and a right

bronchial artery (white arrow) arising from a common trunk (openarrow)


123

artery can originate from the intercostal branch of the right

ICBT and has a characteristic ‘hairpin’ configuration on

angiography (Fig. 3). Embolization of the anterior medul-

lary artery has been associated with transverse myelitis and

should be avoided [43, 45]. When the source of bleeding is

seen in a vessel with a visible spinal branch, safe emboli-

zation can be achieved by advancing a microcatheter

beyond the origin of the spinal artery and injecting the

embolic material with care to prevent reflux into the spinal

branch [9].

Assessment of Nonbronchial Systemic Arteries

In addition to bronchial arteries, chronic inflammatory

processes recruit collateral blood supply from nonbronchial

arteries via transpleural vessels. Overlooking these sys-

temic arteries at initial angiography may result in persistent

hemoptysis after what is thought to be a technically suc-

cessful BAE. These collateral vessels can arise from

branches of the subclavian, axillary, and internal mammary

arteries as well as infradiaphragmatic branches from the

inferior phrenic, left gastric, and celiac axis (Figs. 4 and 5).

Many studies have reported the importance of actively

searching for nonbronchial collateral supply on initial

angiography [9, 11, 21, 34, 55] and CT has an important

role to play in predicting the presence of these vessels prior

to BAE. On contrast-enhanced CT, they appear as arteries

running a course that is not parallel to the bronchi, usually

along a pleural surface (Fig. 6). Features suggestive of a

Fig. 3 Anterior medullary artery. Selective right intercostal angio-

gram shows an anterior medullary artery with the typical hairpin

configuration (arrows). The right bronchial branch is not visible, as it

has already been embolized superselectively

Fig. 4 Nonbronchial systemic artery. Selective catheterization of the

left gastric artery shows an abnormal tortuous vessel (arrows)

supplying a hypervascular area in the right lung

Fig. 5 Right subclavian angiogram demonstrates abnormal tortuous

nonbronchial supply (arrows) arising from a branch of the thyrocer-

vical trunk


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nonbronchial systemic arterial supply as a source of hem-

optysis include pleural thickening of more than 3 mm

adjacent to an area of pulmonary abnormality and tortuous

enhancing vascular structures within hypertrophic extra-

pleural fat [22, 26].

Assessment of Pulmonary Arteries

Although the systemic arterial system is the primary source

of bleeding in hemoptysis [31], bleeding may result from a

pulmonary arterial source in approximately 5% of cases [33,

56]. Pulmonary angiography has been advocated in patients

with early recurrent hemoptysis following systemic arterial

embolization, especially in cases of chronic TB [9, 57]. One

study of 306 patients [33] showed that the pulmonary artery

was the source of bleeding in 93% of patients in whom

immediate control of hemoptysis was not achieved. The

underlying diagnosis in these patients included lung abscess,

TB, and lung malignancy. Muthuswamy et al. [58] descri-

bed a patient with active TB who had a normal bronchial

angiogram but went on to have emergency pneumonectomy

for persistent hemoptysis. The resected specimen revealed a

fistula from a pulmonary artery to an adjacent bronchus,

which may have been identified on pulmonary angiography

had it been performed.

The most common cause of bleeding from the pul-

monary circulation is Rasmussen’s aneurysm, which is a

pseudoaneurysm due to erosion of a peripheral pulmonary

artery by chronic inflammation, such as chronic cavitary

TB. These can be identified on contrast-enhanced CT

images as avidly enhancing nodules within walls of

tuberculous cavities [59]. Their incidence varies between 4

and 11% in the literature [56, 57, 60]. In a series of 1114

autopsies of patients with chronic pulmonary TB, 45 cases

(4%) of such aneurysms were found [60]. In 38 of these

cases, aneurysm rupture was the immediate cause of death.

A prospective study of 72 patients presenting with hem-

optysis was carried out to determine the incidence of pul-

monary arterial source of hemorrhage [56]. These patients

underwent both bronchial and pulmonary angiography,

which revealed pulmonary artery pseudoaneurysms in five

cases (6.9%). Three of these patients had cavitary TB, one

of which was complicated by an aspergilloma. This patient

was treated with embolization of branches of the right

pulmonary artery without further rebleeding.

A recent study observed that 8 (10.5%) in a series of 76

patients undergoing bronchial angiography for hemoptysis

had visible pulmonary artery pseudoaneurysms [57]. Five

of these patients had a history of TB, three with cavitary

disease and two with active TB. Although the majority of

pseudoaneurysms were easily detected on bronchial and

nonbronchial arterial angiograms due to bronchial-pul-

monary arterial shunt and complete reversal of flow in

pulmonary artery branches, they were only seen on sub-

sequent pulmonary angiography in two of the eight

patients. Both patients initially underwent BAE and con-

tinued to rebleed until pulmonary angiography was per-

formed and the underlying pseudoaneurysm successfully

embolized. The conclusion from all these studies is that

pulmonary angiography should be performed in any patient

who continues to bleed or has early recurrent bleeding,

after what is believed to have been adequate BAE or in the

presence of normal bronchial arteries.

More uncommonly, hemoptysis may occur following

rupture of a pulmonary AVM, which is an abnormal

communication between pulmonary arterial and pulmonary

venous circulations resulting in a right-to-left shunt. The

majority are congenital and occur in patients with heredi-

tary hemorrhagic telangectasia [61]. Embolization of the

feeding pulmonary artery with stainless-steel coils and

detachable balloons has demonstrated high success rates,

with permanent involution in the majority of treated cases

[62–64].

Bronchial Artery Embolization: Angiographic

Technique

BAE should be carried out in a dedicated vascular inter-

ventional suite equipped with digital subtraction technol-

ogy, by experienced interventional radiologists familiar

with embolization techniques. Rapid acquisition and

review of images with good contrast resolution are

Fig. 6 Nonbronchial systemic collateral vessels. MDCT angiogram

demonstrates abnormal branches of the right internal mammary artery

(arrows) coursing along thickened pleura in the anterior middle lobe

in a patient with cavitary tuberculosis


123

necessary during embolization procedures. Prior to embo-

lization, a preliminary descending thoracic aortogram is

carried out in order to demonstrate bronchial artery anat-

omy and to identify other systemic collateral vessels

(Fig. 7). The majority of abnormal, hypertrophied bron-

chial arteries are visualised on this initial flush aortogram

[9, 11, 65].

Selective catheterization of bronchial arteries should be

attempted even in cases with an apparent normal aorto-

gram, as bleeding may occur from normal diameter vessels

[9]. Although Cobra catheters are most commonly used, a

variety of shaped catheters should be readily available for

optimal selective arterial catheterization. These may

include Simmons, Shepherd’s hook, Headhunter, Side-

winder, and Sos-Omni catheters. Coaxial microcatheters

allow superselective catheterization in cases where a secure

catheter position cannot be achieved with a conventional

catheter. This is of particular importance when catheteriz-

ing the bronchial branch of the right ICBT, in order to

avoid occlusion of the intercostal branch that can occa-

sionally give off the anterior medullary artery [9, 11].

Opacification of bronchial arteries during selective

angiography is achieved by hand injection of nonionic

contrast medium. The rate and volume of injection are

dependent on the size of the bronchial artery and concur-

rent acquisition images. Angiographic findings in hem-

optysis include hypertrophic and tortuous bronchial

arteries, areas of hypervascularity and neovascularity,

shunting of blood into pulmonary artery or vein, and

bronchial artery aneurysm (Figs. 8, 9, 10). Although

extravasation of contrast medium is a specific sign of

active bronchial bleeding, it is an uncommon finding, with

a reported prevalence ranging between 3.6 and 10.7%

[17, 36]. It is important to note that although bronchial

circulation is the source of hemoptysis in the majority of

cases, bleeding may occur from nonbronchial systemic

arteries as well as the pulmonary arteries [11]. Therefore, if

Fig. 7 Preliminary thoracic aortography. A Descending thoracic

aortogram demonstrates a hypertrophied right bronchial artery (whitearrow). Normal intercostal arteries are denoted by black arrows.

B Descending thoracic aortogram in the same patient at a later phase

demonstrating abnormal shunting to the pulmonary artery (arrow)

Fig. 8 Selective right bronchial angiogram demonstrates a hypertro-

phied tortuous bronchial artery


123

no abnormal bronchial arteries are identified, nonbronchial

systemic arteries should be scrutinized including the

intercostal, subclavian, and inferior phrenic arteries,

depending on the known site of pulmonary disease.

Bronchial Artery Embolization: Embolic Material

The aim of embolization is to reduce the perfusion pressure

to fragile vessels in pathological areas of lung by occluding

the systemic arterial inflow. It is important to embolize as

close to the site of the abnormal bronchopulmonary anas-

tomoses as possible, in order to prevent their recurrence

from nonbronchial systemic collateral vessels. A number of

embolic materials are available for BAE. It is important to

avoid embolic material that can pass through abnormal

bronchopulmonary anastomoses, as there is a risk of pul-

monary infarction via bronchial artery-pulmonary artery

shunts or systemic artery embolization via bronchial artery-

pulmonary vein shunts. Bronchopulmonary anastomoses of

up to 325 lm have been demonstrated in an anatomical

study [5] and embolic materials less than this diameter

should not be used in BAE.

Absorbable gelatin sponge is readily available and easy

to use. However, it can be resorbed by the body, resulting

in recanalization and recurrent bleeding [35, 66]. Polyvinyl

alcohol (PVA) is a nonabsorbable particulate agent avail-

able in a variety of particulate sizes, with 350- to 500-lm-

diameter particles the most frequently used worldwide

[67]. More recently, gelatin cross-linked particles called

tris-acryl microspheres have been used in BAE [68]. These

are of a more uniform diameter than PVA particles, have a

hydrophilic coating, which prevents clumping inside the

catheter lumen, and are especially useful with microcath-

eters. Metal coils are generally avoided because they tend

to occlude more proximal vessels and preclude further

embolization if bleeding recurs. However, they are used to

occlude pulmonary artery aneurysms and pulmonary

AVMs. Other agents which have been used include glue (n-

butyl-2-cyanoacrylate) [69].

Outcomes of Bronchial Artery Embolization

Transcatheter embolization of bronchial and nonbronchial

systemic arteries is now a well-established procedure for

the control of massive and recurrent hemoptysis in various

pulmonary diseases [4, 31–39, 70, 71]. Immediate control

of hemoptysis is achieved in 73–99% of treated patients.

However, recurrent hemoptysis is not uncommon, occur-

ring in 10–55.3% [4, 31–39, 70–72]. Table 2 compares

outcomes of BAE in previous reports. There has been some

improvement in the immediate success rates, probably

secondary to refinement of angiographic and embolization

techniques, but there has been no significant change in the

overall recurrence rates since the 1970s. This is unsur-

prising, as BAE is essentially a palliative procedure for

symptomatic control of hemoptysis, which does not

address the underlying disease process.

Fig. 9 Selective right bronchial angiogram demonstrates abnormal

bronchial arteries (black arrows) supplying a hypervascular area in

the lung. The left bronchial artery (white arrow) is also seen filling

from a common origin

Fig. 10 Selective right bronchial angiogram shows a hypertrophied

artery with bronchial artery-pulmonary vein shunting


123

Early recurrent bleeding, within the first weeks and

months of embolization, is caused by incomplete emboli-

zation of the abnormal vessels, which may be due to the

extensive nature of the underlying disease or incomplete

search for all abnormal vessels. Several studies have

reported rebleeding within the first month of embolization

in 10%–29% of patients [33, 36–38, 70]. Late rebleeding

following embolization occurs due to recanalization of

previously embolized vessels or revascularization of col-

lateral circulation secondary to progression of the under-

lying pulmonary disease [33, 35, 37, 50, 70]. It is therefore

important to identify and embolize all vessels that may be

contributing to the abnormal blood supply, including any

nonbronchial systemic or pulmonary arteries. The under-

lying pathology should be treated if possible, in order to

achieve long-term hemoptysis control.

Long-term hemoptysis control can be improved with

repeat BAE, which has been shown to improve the outcome

of those with recurrent bleeding by embolizing previously

overlooked feeder vessels. However, if the underlying dis-

ease process continues, revascularization results in further

rebleeding after a period of 2–5 years [50, 70].

Several studies have noted varying outcomes according

to the underlying cause. Favorable outcomes have been

reported in patients with active TB where concurrent

management with embolization and antituberculous ther-

apy has resulted in high immediate success rates and low

recurrence rates [50, 70]. Poor outcomes have been

observed in patients with aspergilloma [34, 47, 70, 73, 74],

where the underlying disease process is known to be

aggressive and extensive, often involving nonbronchial

arteries. A recent study showed a recurrence rate of 100%

in these patients, the majority of which occurred within the

first 2 weeks of BAE, and a mortality rate of 50% within

the first month [70]. Aspergilloma has been shown to be a

statistically significant risk factor for development of

recurrent hemoptysis [70, 73] and these patients should be

managed aggressively with a combination of repeat

embolization and elective surgery. Pulmonary malignancy

has also been reported to show poor immediate and

long-term outcomes and is associated with a high mortality

due to the progressive nature of the disease [35, 38].

Complications of Bronchial Artery Embolization

Bronchial arteries not only supply the bronchi and vasa

vasorum of the aorta and pulmonary vessels, but also

contribute to the esophagus, diaphragmatic and mediastinal

visceral pleura, and spinal cord. Reported complications

result from inadvertent occlusion of these branches. The

most common side effects are chest pain and dysphagia,

reported in 24–91% and 1–18%, respectively [36, 75, 76].

These symptoms are usually transient and are likely to

represent occlusion of intercostal and esophageal vessels.

The most serious complication of BAE is transverse

myelitis due to spinal cord ischemia. Although the majority

of cases of spinal cord damage are thought to be related to

the toxic effects of nonionic contrast medium during the

early years, the reported prevalence ranges between 1.4 and

6.5% [36, 37, 66, 77] in more recent studies. Superselective

embolization has been shown to reduce the risk of inad-

vertent embolization of the anterior medullary artery by

embolization of more terminal branches of the bronchial

artery beyond the origin of the spinal arteries [66]. Other

rare reported complications include aortic and bronchial

necrosis, non-target-organ embolization causing ischemic

colitis, pulmonary infarct, bronchoesophageal fistula, and

transient cortical blindness [78–82].

Conclusions

Hemoptysis can present as a life-threatening respiratory

emergency and warrants urgent investigation. Initial

assessment with chest radiography, bronchoscopy, and CT

is useful in localizing the bleeding site and diagnosing the

underlying cause. MDCTA allows rapid and detailed

assessment of the lung parenchyma and thoracic vascula-

ture. It is possible to delineate abnormal bronchial and

Table 2 Comparison of

hemoptysis control in past

reports

Study Year of study No. of patients Immediate control, n Recurrence, n

Remy et al. [31] 1977 49 41 (84%) 14 (28.6%)

Rabkin et al. [33] 1987 306 278 (90.8%) 103 (33.7%)

Hayakawa et al. [35] 1992 58 50 (86.2%) 14 (28%)

Ramakantan et al. [36] 1996 140 102 (73%) 38 (27.1%)

Mal et al. [37] 1999 56 43 (77%) 31 (55.3%)

Swanson et al. [38] 2002 54 51 (94%) 13 (24.1%)

Poyanli et al. [39] 2007 140 138 (98.5%) 14 (10%)

Lee et al. [71] 2008 70 69 (99%) 25 (26%)

Chun et al. [70] 2009 50 43 (86%) 14 (28%)


123

nonbronchial arteries using a variety of reformatted ima-

ges, which can be used to guide therapeutic arterial

embolization procedures. BAE is a proven effective tech-

nique in the management of massive and recurrent hem-

optysis, either as a first-line therapy or as an adjunct to

elective surgery. It is a safe procedure when performed by

experienced operators who are aware of the potential pit-

falls. Recurrent bleeding is not uncommon and prompt

repeat embolization is advised in patients with recurrent

hemoptysis where a search for nonbronchial systemic and

pulmonary arterial sources should be performed.

Ackowledgment We would like to thank Dr. Robin Swain for his

assistance in the preparation of this manuscript.

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Radiological Management of Hemoptysis

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