Massive
Hemoptysis
controlled
by Transcatheter
Bronchial
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
JOHN
Hemoptysis chial
is a dramatic
or
precise
pulmonary
process
bronchoscopy,
is possible plus
the
use of radiography and
may
be
defy conventional We report such resulted
apparently raphy and
benign bronchial transcatheter
artery
employed
from
to localize
methods a case
an
lesion . embolization
Case
The
onset
of
were
control
intercostal
artery
extravasation identified
of the
(fig.
contrast
bleeding
material site
in
area
of
vigorous etiology
bleeding.
in some
patients
Lindskog
[3]
In spite
into
the
the
proximal
left
function.
artery
embolization
of
the
bronchial
Department
3
Present
of address
Am J Roentgenol
Radiology. Department
128:302-304.
University
of Washington
of Radiology.
February
Group
1977
School Health
the
underlying
may
Most
acute
airway
For
inability
to
the
left
modern
with
will
upper
no
make
an
that
diag-
These
investi-
severity
to the and
minimal
and
etiologic
the
relationship
with
obscure
Pursel
hemoptysis.
disease
occur
diagnostic
remain
example,
5] emphasize
hemoptysis
is small
When
massive
obstruction
threatening
and
and
section [3]. preoperative Fellows
serve
of the
gravity
that
or
or
massive
undiagnosable
et al. [6]
identified
a solitary
Bronchial
angiography
site
by
demonstration
in one patient. In two ties were subsequently correspond Pinet
mild
to the and
Froment
tomograms negative,
but
with
localization
of
to
bronchial
of hemorhemoptysis.
of
contrast
bleeding
in
a
focal
extravasation
arterial
plain
abnormalconfirmed
to
bleeding
site
recurrent
was positive
angiography findings
with radiographs
Bronchoscopy disclosed
abnormal
the
[3].
22 patients
studied
Bronchial
1 1 patients,
life re-
identified
negative
the chest. bronchography
patients.
be accurate
source and
source of
stop
site.
[7]
but
of
pulmonary
others, localized bronchoscopically
bleeding
hemoptysis
may
for
of the fibrosis
Bronchoscopy bleeding
shock
bronchoscopy
localization with cystic
will
however,
surgery requires of the bleeding site
five
patients.
and
unremitting,
indications
compared
in the patients
in volume
and
impending as
Successful localization
arteriography rhage in six
was
and uniformly findings
was
performed
in four,
but
was
made
in
in
precise only
one
patient. Botenga four
[8]
patients
utilized
with
of Medicine, Seattle,
302
and Veterans Seattle,
was
Administration
Washington
Washington
98104
bronchial
recurrent
hypervascularization
13, 1976. of Medicine
Hospital.
se bears
spontaneously.
elected. The preliminary angiograms were carefully scrutinized for radicular spinal artery branches of the intercostobronchial trunk; none were seen. A total of nine Gelfoam (Upjohn) pledgets approximately 1 x3 mm were embolized. Repeat angiography
2
per
with
4).
patients [4,
of
in 20
Received August 10. 1976, accepted after revision October Department of Radiology. University of Washington School Washington 98108. Address reprint requests to J. D. Harley.
of
a
disease.
lobe
was conpulmonary
carina
hemoptysis
3,
others
hemoptysis
lumen
upper
and
nature
and
bronchial
at the
evaluation of
reported
hemoptysis
He
bronchus. In spite of precise localization, pulmonary resection sidered to carry a high risk due to compromised Therefore.
biopsies
[1,
in 13 of 105
gators
in good thiazide
hyperemia
procedure.
Discussion
the
cough.
the
normal.
methods,
was with
of
and
were
arteriogbronchial
the
a gentle
1 ). A small
washings
bronchus
nosis
followed
from
and
was admitted to another hospital 2 hr later after an estimated 300 ml of hemorrhage. Physical examination was unrevealing except for the hemoptysis. A chest film was normal. The hematocrit was 43%. By the next morning there had been 1 .500 ml of measured hemoptysis and the hematocrit had fallen to 30%. Fiberoptic bronchoscopy identified no endobronchial lesion and failed to localize a bleeding segment. Chest radiographs now showed a left lower lung alveolar infiltrate. Bleeding continued. Approximately 36 hr after the onset of hemoptysis the patient had received 1 0 units of blood with total hemoptysis approaching 5,000 ml. The patient experienced increasing respiratory difficulty, and the arterial PO2 fell to 52 (room air). The patient was transferred to the University of Washington Hospital. An admission chest radiograph showed extensive bilateral alveolar infiltrates. Tomography disclosed no endobronchial lesions. Repeat bronchoscopy was contemplated. but in view of the massive hemoptysis and previously unrewarding examination. arteriography was undertaken in an effort to localize the bleeding site for surgical resection. Selective bronchial arteriography demonstrated a major left bronchial artery arising from a right
no complications
Bronchial
lobe
Report
hemoptysis
G. PECK2
of diagin which
Bronchial of a
and
ANTHONY
Repeat bronchoscopy at 6 weeks was normal except for shallow epithelialized pit in the proximal left upper lobe bronchus.
and
undiagnosed
A. H.. a 44-year-old truck driver and smoker, health except for modest hypertension controlled diuretics.
and
mycologic
massive
AND
showed occlusion of peripheral branches of the bronchial artery and no further evidence of extravasation of contrast (fig. 2). Clinical results were dramatic; hemoptysis ceased and the exhausted patient fell asleep Bleeding did not recur and there
tracheobron-
cases reasonably underlying patho-
bacteriologic,
hemoptysis
hemorrhage
were
of
most of the
KILLIEN,2-3
most acute episodes of hemoptyhr and gradually subside [2, 3].
however,
life threatening and nosis and treatment. massive
with
cytologic,
studies [1 1. Fortunately, sis last less than 24 Occasionally,
In
of the
Arteries
F. CHRISTIAN
manifestation
disease. identification
antemortem
logical
D. HARLEY,’
Embolization
98195
Hospital.
angiography
hemoptysis. demonstrated
4435
Beacon
to
A local as
Avenue
study
bronchial
the
probable
South.
Seattle,
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
CASE
303
REPORTS
a
b
\,
ti,. .,:,
.
/ Fig
1 -Arterial
Right
third
phase
intercostal
radiograph
artery
(a)
of selective
and
left
bronchial artery
bronchial
Ib)
arteriogram arise from
short common trunk Focal site of contrast extravasation is identified (arrow) from upper lobe branch of bronchial artery Additional contrast material is present in bronchial lumen (arrowheads)
source of hemorrhage was not obtained. To
our
knowledge,
bronchial two
arteries
groups.
tions
has
of
as
of
with
had
have the
and
one
significant
of
the
by
only
embolized
to injury
be
a
hazard,
since
radicular
bronchial 17, 18].
arteries We agree
were
por-
and,
spinal spinal
safe cord
12].
Interruption
of both
precautions,
procedure
[13-16].
arteries
or from intercostobronchial with Remy et al. [9]
primary may that
cord
at its first
vasculature
showing
bifurcation
Therefore,
while
bronchoscopy graphy in the of disease
careful subtraction
that
this
prove
embolization
and
and
than angioand location may
occa-
studies are contraembolization of
for control of hemoptysis has number of patients. At present, be limited and
to patients
temporary
Hopefully, and
justify
anbrief
bronchography
angiography
procedure
efficacy
contraindication
when these Transcatheter
to surgery. the
oc-
extravasation
preembolization films, and
and specific the etiology
hemoptysis.
hemorrhage
contraindication
that
sensitive of
circulation in a small
complete No
between embolizations this complication.
appears
be a valuable tool or inconclusive.
suggest
will
it
are more identification
producing
nearly
(arrow)
is an absolute
suggest with
clinical neurological examination as minimum precautions against
life-threatening
examined
arteriogram
artery
to embolization and giography, preferably
we
certain
is the
Postembolization
the bronchial been successful
achieved
arteriography
been
with
Control
was particles.
.
sionally indicated
hemoptysis.
bronchial 1 1,
five
categorized
pathology.
circulation Gelfoam
now
complica-
reported
persistent
[8, has
relatively
to the
cases
of
documented
no
[10]
chest
safety
clinically
were
et al.
recurrent
circulation and
lschemic
as
and
experimentally
appears
Four
of the bronchial utilizing 1 mm
well
bronchial
There
underlying
techniques been
lung. Wholey
hemoptysis.
by embolization in three patients The
attempted
successfully
2
of spinal
confirmation
embolization
previously [9]
the
procedures.
massive
All
al.
but
bronchial arterial circulation in seven patients hernoptysis. All had acquired systemic hy-
the
patients
been
et
pervascularization tions
patients,
therapeutic
Remy
of the massive
with
in three
Fig
clusion of bronchial of contrast is seen
or further
safety
of
an
alternative
it as
with
permanent experience
bronchial
artery
to
surgery.
potential arise
REFERENCES
from
trunks visualization
18.
1
American on
Therapy
Thoracic
Am
Society
Rev
Respir
Statement
Dis
93471-474.
by
the
Committee
1966
304
CASE
2. Lindberg
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
EJ: Emergency operation in patients with massive hemoptysis. Am Surg 30: 1 58-1 59. 1964 3. Pursel SE. Lindskog GE: Hemoptysis: a clinical evaluation of 1 05 patients examined consecutively on a thoracic surgical service. Am Rev Respir Dis 84:329-336, 1961 4. Moersch HJ: Clinical significance of hemoptysis. JAMA 148:1461-1465,
1952
5. Ehrenhaft JL, Taber RB: Management of massive hemoptysis not due to pulmonary tuberculosis or neoplasm. J Thorac Surg 30:275-287, 1955 6. Fellows KE, Stigol L, Shuster 5, Khaw KT, Shwachman H: Selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis. Radiology 1 14:551-556. 1975 7. Pinet F, Froment JC: Le bilan bronchographique de l’hemoptysie maladie: de faible importance confrontation avec l’arteriographic bronchique. Ann Radiol 18:89-92, 1975 8. Botenga ASJ : Selective Bronchial and Intercostal Arteriography. Baltimore, Williams & Wilkins, 1970 9. Remy J, Voisin C, du Puis C, Beguery P. Ponnel AB, Penies JC. Dovay B: Traitment des hemoptysies par embolisation de Ia circulation systemique. Ann Radiol 1 7:5-1 8, 1974 10. Wholey MA, Chamorro HA, Gopal R, Ford WB: Bronchial artery embolization for massive hemoptysis. JAMA. In press.
REPORTS
1977 1 1 . Aeuter graphy.
SA. Olin T. Abrams HL: Selective bronchial Am J Roentgenol 84:87-95, 1965
1 2. Viamonte
M,
Parks
AE,
Smoak
WM:
Guided
arterio-
catheterization
of the bronchial arteries. Radiology 85:205-226, 1965 13. Liebow AA, Hales MA, Lindskog GE: Enlargement of the bronchial arteries and their anastomoses with the pulmonary arteries in bronchiectasis. Am J Pathol 25:21 1 -231 , 1949 14. Fisher AB, Kollmeier H. Brody JC. Hyde AW, Hansill J. Friedman JN, Waldhausen JA: Restoration of systemic flow to the lung after division of bronchial arteries. J AppI Physiol 29:839-846, 1970 1 5. Boushy SF, Helgason AH, North LB: Occlusion of the bronchial arteries by glass microspheres. Am Rev Respir Dis 103:249-263, 1971 16. Ellis FH, Grindlay MD, Edwards JE: The bronchial arteries. I . Experimental occlusion. Surgery 30:81 0-826, 1951 17.
Dichiro
G:
Unintentional
spinal
cord
arteriography:
a warn-
Radiology 112:231-233, 1974 18. Kardjiev V. Symeonov A. Chankov I: Etiology, pathogenesis, and prevention of spinal cord lesions in selective angiography of the bronchial and intercostal arteries. Radiology 1 1 2:81 83. 1974 ing.
Hemoptysis
controlled
by Transcatheter
Bronchial
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
JOHN
Hemoptysis chial
is a dramatic
or
precise
pulmonary
process
bronchoscopy,
is possible plus
the
use of radiography and
may
be
defy conventional We report such resulted
apparently raphy and
benign bronchial transcatheter
artery
employed
from
to localize
methods a case
an
lesion . embolization
Case
The
onset
of
were
control
intercostal
artery
extravasation identified
of the
(fig.
contrast
bleeding
material site
in
area
of
vigorous etiology
bleeding.
in some
patients
Lindskog
[3]
In spite
into
the
the
proximal
left
function.
artery
embolization
of
the
bronchial
Department
3
Present
of address
Am J Roentgenol
Radiology. Department
128:302-304.
University
of Washington
of Radiology.
February
Group
1977
School Health
the
underlying
may
Most
acute
airway
For
inability
to
the
left
modern
with
will
upper
no
make
an
that
diag-
These
investi-
severity
to the and
minimal
and
etiologic
the
relationship
with
obscure
Pursel
hemoptysis.
disease
occur
diagnostic
remain
example,
5] emphasize
hemoptysis
is small
When
massive
obstruction
threatening
and
and
section [3]. preoperative Fellows
serve
of the
gravity
that
or
or
massive
undiagnosable
et al. [6]
identified
a solitary
Bronchial
angiography
site
by
demonstration
in one patient. In two ties were subsequently correspond Pinet
mild
to the and
Froment
tomograms negative,
but
with
localization
of
to
bronchial
of hemorhemoptysis.
of
contrast
bleeding
in
a
focal
extravasation
arterial
plain
abnormalconfirmed
to
bleeding
site
recurrent
was positive
angiography findings
with radiographs
Bronchoscopy disclosed
abnormal
the
[3].
22 patients
studied
Bronchial
1 1 patients,
life re-
identified
negative
the chest. bronchography
patients.
be accurate
source and
source of
stop
site.
[7]
but
of
pulmonary
others, localized bronchoscopically
bleeding
hemoptysis
may
for
of the fibrosis
Bronchoscopy bleeding
shock
bronchoscopy
localization with cystic
will
however,
surgery requires of the bleeding site
five
patients.
and
unremitting,
indications
compared
in the patients
in volume
and
impending as
Successful localization
arteriography rhage in six
was
and uniformly findings
was
performed
in four,
but
was
made
in
in
precise only
one
patient. Botenga four
[8]
patients
utilized
with
of Medicine, Seattle,
302
and Veterans Seattle,
was
Administration
Washington
Washington
98104
bronchial
recurrent
hypervascularization
13, 1976. of Medicine
Hospital.
se bears
spontaneously.
elected. The preliminary angiograms were carefully scrutinized for radicular spinal artery branches of the intercostobronchial trunk; none were seen. A total of nine Gelfoam (Upjohn) pledgets approximately 1 x3 mm were embolized. Repeat angiography
2
per
with
4).
patients [4,
of
in 20
Received August 10. 1976, accepted after revision October Department of Radiology. University of Washington School Washington 98108. Address reprint requests to J. D. Harley.
of
a
disease.
lobe
was conpulmonary
carina
hemoptysis
3,
others
hemoptysis
lumen
upper
and
nature
and
bronchial
at the
evaluation of
reported
hemoptysis
He
bronchus. In spite of precise localization, pulmonary resection sidered to carry a high risk due to compromised Therefore.
biopsies
[1,
in 13 of 105
gators
in good thiazide
hyperemia
procedure.
Discussion
the
cough.
the
normal.
methods,
was with
of
and
were
arteriogbronchial
the
a gentle
1 ). A small
washings
bronchus
nosis
followed
from
and
was admitted to another hospital 2 hr later after an estimated 300 ml of hemorrhage. Physical examination was unrevealing except for the hemoptysis. A chest film was normal. The hematocrit was 43%. By the next morning there had been 1 .500 ml of measured hemoptysis and the hematocrit had fallen to 30%. Fiberoptic bronchoscopy identified no endobronchial lesion and failed to localize a bleeding segment. Chest radiographs now showed a left lower lung alveolar infiltrate. Bleeding continued. Approximately 36 hr after the onset of hemoptysis the patient had received 1 0 units of blood with total hemoptysis approaching 5,000 ml. The patient experienced increasing respiratory difficulty, and the arterial PO2 fell to 52 (room air). The patient was transferred to the University of Washington Hospital. An admission chest radiograph showed extensive bilateral alveolar infiltrates. Tomography disclosed no endobronchial lesions. Repeat bronchoscopy was contemplated. but in view of the massive hemoptysis and previously unrewarding examination. arteriography was undertaken in an effort to localize the bleeding site for surgical resection. Selective bronchial arteriography demonstrated a major left bronchial artery arising from a right
no complications
Bronchial
lobe
Report
hemoptysis
G. PECK2
of diagin which
Bronchial of a
and
ANTHONY
Repeat bronchoscopy at 6 weeks was normal except for shallow epithelialized pit in the proximal left upper lobe bronchus.
and
undiagnosed
A. H.. a 44-year-old truck driver and smoker, health except for modest hypertension controlled diuretics.
and
mycologic
massive
AND
showed occlusion of peripheral branches of the bronchial artery and no further evidence of extravasation of contrast (fig. 2). Clinical results were dramatic; hemoptysis ceased and the exhausted patient fell asleep Bleeding did not recur and there
tracheobron-
cases reasonably underlying patho-
bacteriologic,
hemoptysis
hemorrhage
were
of
most of the
KILLIEN,2-3
most acute episodes of hemoptyhr and gradually subside [2, 3].
however,
life threatening and nosis and treatment. massive
with
cytologic,
studies [1 1. Fortunately, sis last less than 24 Occasionally,
In
of the
Arteries
F. CHRISTIAN
manifestation
disease. identification
antemortem
logical
D. HARLEY,’
Embolization
98195
Hospital.
angiography
hemoptysis. demonstrated
4435
Beacon
to
A local as
Avenue
study
bronchial
the
probable
South.
Seattle,
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
CASE
303
REPORTS
a
b
\,
ti,. .,:,
.
/ Fig
1 -Arterial
Right
third
phase
intercostal
radiograph
artery
(a)
of selective
and
left
bronchial artery
bronchial
Ib)
arteriogram arise from
short common trunk Focal site of contrast extravasation is identified (arrow) from upper lobe branch of bronchial artery Additional contrast material is present in bronchial lumen (arrowheads)
source of hemorrhage was not obtained. To
our
knowledge,
bronchial two
arteries
groups.
tions
has
of
as
of
with
had
have the
and
one
significant
of
the
by
only
embolized
to injury
be
a
hazard,
since
radicular
bronchial 17, 18].
arteries We agree
were
por-
and,
spinal spinal
safe cord
12].
Interruption
of both
precautions,
procedure
[13-16].
arteries
or from intercostobronchial with Remy et al. [9]
primary may that
cord
at its first
vasculature
showing
bifurcation
Therefore,
while
bronchoscopy graphy in the of disease
careful subtraction
that
this
prove
embolization
and
and
than angioand location may
occa-
studies are contraembolization of
for control of hemoptysis has number of patients. At present, be limited and
to patients
temporary
Hopefully, and
justify
anbrief
bronchography
angiography
procedure
efficacy
contraindication
when these Transcatheter
to surgery. the
oc-
extravasation
preembolization films, and
and specific the etiology
hemoptysis.
hemorrhage
contraindication
that
sensitive of
circulation in a small
complete No
between embolizations this complication.
appears
be a valuable tool or inconclusive.
suggest
will
it
are more identification
producing
nearly
(arrow)
is an absolute
suggest with
clinical neurological examination as minimum precautions against
life-threatening
examined
arteriogram
artery
to embolization and giography, preferably
we
certain
is the
Postembolization
the bronchial been successful
achieved
arteriography
been
with
Control
was particles.
.
sionally indicated
hemoptysis.
bronchial 1 1,
five
categorized
pathology.
circulation Gelfoam
now
complica-
reported
persistent
[8, has
relatively
to the
cases
of
documented
no
[10]
chest
safety
clinically
were
et al.
recurrent
circulation and
lschemic
as
and
experimentally
appears
Four
of the bronchial utilizing 1 mm
well
bronchial
There
underlying
techniques been
lung. Wholey
hemoptysis.
by embolization in three patients The
attempted
successfully
2
of spinal
confirmation
embolization
previously [9]
the
procedures.
massive
All
al.
but
bronchial arterial circulation in seven patients hernoptysis. All had acquired systemic hy-
the
patients
been
et
pervascularization tions
patients,
therapeutic
Remy
of the massive
with
in three
Fig
clusion of bronchial of contrast is seen
or further
safety
of
an
alternative
it as
with
permanent experience
bronchial
artery
to
surgery.
potential arise
REFERENCES
from
trunks visualization
18.
1
American on
Therapy
Thoracic
Am
Society
Rev
Respir
Statement
Dis
93471-474.
by
the
Committee
1966
304
CASE
2. Lindberg
Downloaded from www.ajronline.org by 117.253.106.165 on 11/03/15 from IP address 117.253.106.165. Copyright ARRS. For personal use only; all rights reserved
EJ: Emergency operation in patients with massive hemoptysis. Am Surg 30: 1 58-1 59. 1964 3. Pursel SE. Lindskog GE: Hemoptysis: a clinical evaluation of 1 05 patients examined consecutively on a thoracic surgical service. Am Rev Respir Dis 84:329-336, 1961 4. Moersch HJ: Clinical significance of hemoptysis. JAMA 148:1461-1465,
1952
5. Ehrenhaft JL, Taber RB: Management of massive hemoptysis not due to pulmonary tuberculosis or neoplasm. J Thorac Surg 30:275-287, 1955 6. Fellows KE, Stigol L, Shuster 5, Khaw KT, Shwachman H: Selective bronchial arteriography in patients with cystic fibrosis and massive hemoptysis. Radiology 1 14:551-556. 1975 7. Pinet F, Froment JC: Le bilan bronchographique de l’hemoptysie maladie: de faible importance confrontation avec l’arteriographic bronchique. Ann Radiol 18:89-92, 1975 8. Botenga ASJ : Selective Bronchial and Intercostal Arteriography. Baltimore, Williams & Wilkins, 1970 9. Remy J, Voisin C, du Puis C, Beguery P. Ponnel AB, Penies JC. Dovay B: Traitment des hemoptysies par embolisation de Ia circulation systemique. Ann Radiol 1 7:5-1 8, 1974 10. Wholey MA, Chamorro HA, Gopal R, Ford WB: Bronchial artery embolization for massive hemoptysis. JAMA. In press.
REPORTS
1977 1 1 . Aeuter graphy.
SA. Olin T. Abrams HL: Selective bronchial Am J Roentgenol 84:87-95, 1965
1 2. Viamonte
M,
Parks
AE,
Smoak
WM:
Guided
arterio-
catheterization
of the bronchial arteries. Radiology 85:205-226, 1965 13. Liebow AA, Hales MA, Lindskog GE: Enlargement of the bronchial arteries and their anastomoses with the pulmonary arteries in bronchiectasis. Am J Pathol 25:21 1 -231 , 1949 14. Fisher AB, Kollmeier H. Brody JC. Hyde AW, Hansill J. Friedman JN, Waldhausen JA: Restoration of systemic flow to the lung after division of bronchial arteries. J AppI Physiol 29:839-846, 1970 1 5. Boushy SF, Helgason AH, North LB: Occlusion of the bronchial arteries by glass microspheres. Am Rev Respir Dis 103:249-263, 1971 16. Ellis FH, Grindlay MD, Edwards JE: The bronchial arteries. I . Experimental occlusion. Surgery 30:81 0-826, 1951 17.
Dichiro
G:
Unintentional
spinal
cord
arteriography:
a warn-
Radiology 112:231-233, 1974 18. Kardjiev V. Symeonov A. Chankov I: Etiology, pathogenesis, and prevention of spinal cord lesions in selective angiography of the bronchial and intercostal arteries. Radiology 1 1 2:81 83. 1974 ing.
