JIMSA January-March 2013 Vol. 26 No.

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Bronchial Artery Embolization in Pulmonary Diseases: Current Scenario

Deep Narayan Srivastava, Manisha Jana, Ashu Bhalla, S Thulkar, S Sharma
Department of Radiodiagnosis, All India Institute of Medical sciences, New Delhi, India.

Abstract: Massive Haemoptysis is an acute emergency in patients and required urgent management. Though surgery definitely is a method of choice for
treatment in certain selected conditions like Aspergilloma, Hydatid Cyst, Thoracic Vascular injuries but Endovascular management of haemoptysis has great
potential and shown promising results. The Bronchial Artery Embolization in a case of Massive Haemoptysis not only saves lives in emergency conditions but
also bridges the time period before definitely elective surgical management can be undertaken. The detail vascular Anatomy, procedure and its possible
complications are being highlighted in the present Article.

INTRODUCTION
Endovascular management in bleeding states has established itself as a
promising and effective treatment modality. Massive hemoptysis is one of
the several hemorrhagic emergencies which has been successfully treated
using bronchial artery embolization (BAE). Massive hemoptysis, defined as
an expectoration of more than 300 ml of blood in a day,1 has a very high
mortality when left untreated 2. The management of massive hemoptysis and
recurrent non-massive hemoptysis ( expectoration of > 100 ml of blood in a
day for a few days or weeks) includes surgical and endovascular treatment.
Though most of the patients with massive hemoptysis are not surgical
candidates, but surgery remains the definitive treatment in some conditions (
aspergilloma, hydatid cyst, thoracic vascular injuries). BAE in acute massive
hemoptysis not only saves lives in emergency conditions but also bridges
the time period before definitive elective surgical treatment can be undertaken
in these conditions2.
BAE was first described by Remy in 19733 . Since then, the procedure has
proven its safety and effectiveness in controlling hemoptysis in diverse lung
conditions in different studies4-7 . In this article, we describe the anatomy of
the bronchial circulation and the non-bronchial systemic collaterals
responsible for hemoptysis, imaging, BAE technique, the results and potential
complications of this procedure.
PATHOPHYSIOLOGY OF ACUTE
HEMOPTYSIS
In most of the conditions causing massive hemoptysis (90%), the bleeding
occurs from the bronchial arteries8 rather than pulmonary circulation. Other
a b
less common causes of massive hemoptysis include bleeding source from
aorta ( aortobronchial fistula) or non-bronchial systemic collaterals9-11. In
chronic or acute lung conditions, there are obliterative changes in the
pulmonary arteriolar level, leading to enlarged bronchial arteries. These high
pressure systemic vessels often tend to rupture owing to increased regional
blood pressure in an inflamed lung, leading to hemoptysis. The major cause
of mortality in massive hemoptysis is asphyxiation due to hemoptysis, not
the bleeding itself12.
ANATOMY
Bronchial arteries have variable anatomic patterns13. The most consistently
present arterial trunk is the right intercosto-bronchial arterial trunk (ICBT) , c d e
seen in almost 80% individuals (Figure 1). The other patterns, as described
by Cauldwell et al 14 are described in following table . Figure 1 (a-e). Massive hemoptysis in a 50 year male who responded to BAE.
Bronchial arteries originate from the descending thoracic aorta, between the Axial CT lung window section reveals ground glass opacity and nodules in
level of fifth and sixth thoracic vertebrae, around the origin of the left main right upper lobe (a). Flush aortogram reveals an intercostobronchial trunk
bronchus. Bronchial arteries can be distinguished by their branching pattern (arrow) on the right side (b). Selective catheterization of the ICBT revealed
and their anatomical course along the major bronchi. In around 30 % of enlargement and tortuosity of the bronchial artery and parenchymal blush
patients, bronchial arterial origin can be aberrant, i.e., outside the normal (c,d). Embolization was performed using PVA particles (300microns). Post-
origin at T5-T6 level15,16. The common sources of aberrant bronchial arteries embolization image revealed complete embolization of the trunk (e).

Correspondence: Prof. Deep Narayan Srivastava, Department of Radiodiagnosis, All India Institute of Medical sciences, New Delhi, India.
E-mail: drdeepsrivastava@rediffmail.com
 70 JIMSA January-March 2013 Vol. 26 No. 1

embolization of the arteries does not lead to any clinically significant

sequelae.4,5,16 . The anterior medullary arteries are less often visualized but
are of greater concern as they feed the anterior spinal artery. The artery of
Adamkiewicz arises at T9 to T12 levels in most cases and reinforces the
anterior spinal artery, which is the primary source of spinal cord perfusion20.
Inadvertent embolization of the anterior medullary arteries ( identified from
their hairpin loop on angiography) can lead to spinal cord ischemia..

a INDICATIONS
b
Figure 2 (a,b). Hypertrophied left bronchial artery as a cause of massive
hemoptysis on a selective angiographic image (a). Note the parenchymal
staining and early venous shunting (arrow) in subsequent fluoroscopic image
(b).
Figure 3. Selective angiogram Figure 4. Aberrant bronchial
of the hypertrophied right artery originating from right
bronchial artery in a patient internal mammary artery as a
with recurrent hemoptysis. cause of massive recurrent
Note the parenchymal staining hemoptysis.
and early venous shunting. He
was treated successfully using
PVA particle embolization.
include the aortic arch, internal mammary artery ( Figure 4), subclavian artery,
intercostal artery, costocervical trunk, brachiocephalic artery,
pericardiophrenic artery, inferior phrenic artery and even the abdominal
aorta17. Normal calibre of the bronchial arteries range from 1.5 mm at the
origin to 0.5 mm at the point of entry in a bronchopulmonary segment 18 The
arteries are defined as being enlarged when the diameter measures more
than 2 mm in size19.
Non bronchial systemic collaterals differ from the aberrant bronchial arteries
in their course not parallel to the bronchi. Non bronchial systemic collaterals
can originate from the descending thoracic aorta, intercostals (Figure 5),
subclavian and brachiocephalic artery, internal mammary artery or axillary
artery. They are considered abnormal and as a source of hemoptysis when
dilated tortuous artery is seen within extrapleural fat in association with pleural
thickening and/or lung parenchymal abnormalities.
Figure 5: Non- bronchial systemic
collateral arising from intercostals
artery with venous shunting (arrow).
The patient presented with recurrent
hemoptysis after successful BAE. The
artery was successfully re-embolized.
While performing BAE, the interventional radiologist should be well versed
with the anatomy of bronchial arteries and the origin of vertebral and spinal
arteries. Two types of arterial supply to the spine are visualized to arise from
the intercostals arteries- the radicular and the anterior medullary arteries.
The radicular arteries are small branches supplying the ventral and dorsal
spinal nerve roots. They are often visualized during BAE and inadvertent
The common causes of massive hemoptysis requiring BAE in the developing
nations include bronchiectasis secondary to tuberculosis or chronic infections,
active tuberculosis, chronic bronchitis, lung abscess, pneumonia or
aspergilloma21. However, in In the western countries BAE is done in cystic
fibrosis, lung abscess, tuberculosis, aspergilloma and lung cancer. Uncommon
causes of massive hemoptysis treatable by BAE include bronchial adenoma,
endobronchial metastases or bronchial artery aneurysm 22,23.
PRE-PROCEDURE IMAGING
The preliminary investigations in hemoptysis include plain radiograph,
computed tomography (CT) and CT angiography of the chest and
bronchoscopy whenever possible. The role of the imaging includes the
evaluation of the lungs and localization of the bleeding (Figure 6). CT is
helpful in localizing the site of bleed in 63-100% of patients24,25. CT is
particularly helpful in cases with tuberculosis, bronchiectasis, bronchogenic
carcinoma. Bronchoscopy, once considered as the primary method to localize
the bleeding source in hemoptysis, has been shown to have a less chance of
localizing the source compared to CECT. In addition to the parenchymal
pathology, CECT is also helpful in detecting the enlarged bronchial and non-
bronchial arteries. 25 With the advent of MDCT, detailed CT angiographic
evaluation of the thoracic aorta, the bronchial and systemic arteries prior to
the procedure is proven helpful. MDCT allows quick evaluation of the lung,
airway and the bronchial arteries; whereas fibreoptic bronchoscopy requires
sedation and is time-consuming. The current suggestion is to perform CT
prior to a bronchoscopy; and the combined use of both the modalities increases
the diagnostic yield. MDCT can also evaluate pulmonary vasculature as a
cause of hemoptysis.
a b c
Figure 6 (a-c). Hemoptysis in a case of active tuberculosis. CT angiogram
axial section maximum intensity projection (MIP) images (a) reveal an area
of consolidation in the right lower lobe superior segment with prominent
arterial branches leading to the consolidated segment. Axial Lung window
section(b) reveal the area of consolidation with surrounding ground glass
opacity and acinar nodules with tree-in-bud pattern ( suggestive of active
infection). Coronal Reformatted MIP image (c ) reveals hypertrophied and
tortuous right bronchial artery (arrow). The patient underwent successful
BAE.
ANGIOGRAPHY TECHNIQUE AND
EMBOLIZATION
Before BAE, a preliminary evaluation of bronchial and nonbronchial arterial supply
is essential. For this a thoracic flush aortogram is acquired using a 5 F pigtail
catheter. This is followed by selective bronchial artery catheterization using a 4F
pre-shaped catheter like Celiac, Picard or renal double curve or Simmons. The
coaxial microcatheter is also used sometimes. Abnormal angiographic findings
JIMSA January-March 2013 Vol. 26 No. 1
include enlargement and tortuosity of the artery, parenchymal blush, shunting to
pulmonary artery or vein, aneurysm and contrast extravasation.(Figure 2-5). These
abnormal bronchial and nonbronchial arteries are embolized depending upon their
supply to the lesion. Careful evaluation of bronchial arterial anatomy is essential
to avoid embolization of any spinal artery. While catheterizing an aberrant bronchial
artery originating from the subclavian artery, the origin of vertebral artery should
be carefully evaluated to avoid any inadvertent passage of particles in the vertebral
artery. Microcatheter is useful in such situation to avoid non-target embolization.
Detailed evaluation of the bronchial and nonbronchial systemic arteries is essential.
The most common embolizing materials used are gelatine sponge (gelfoam) and
polyvinyl alcohol (PVA) particle. Gelfoam, being a temporary embolizing material,
has the disadvantage of recurrence of hemoptysis. PVA particles are permanent
embolizing materials. The particle size commonly used in BAE is 300-
500microns26. Use of a smaller sized particle leads to passage of particle through
bronchopulmonary anastomosis, pulmonary infarct and nontarget embolization27.
The particles are usually mixed with iodinated contrast material in order to make
the mixture radio-opaque. The particles are injected manually in small aliquots (1
ml) in a controlled manner under direct fluoroscopic visualization . Injection
should be stopped immediately once there is stasis of the particles to avoid reflux
into the aorta and non-target embolization. Compared to gelfoam, PVA particles
have less chance of recanalization and hence recurrence of hemoptysis.
Absolute alcohol and N-butyl cyanoacrylate glue are other liquid embolizing
materials which are not routinely used because of the extensive tissue necrosis
associated with them. Metallic coils are not the preferred embolizing agents as
they lead to more proximal occlusion and loss of subsequent access to the bleeding
vessel.
SAFETY AND EFFICACY
BAE is commonly used for treating massive hemoptysis; though chronic recurrent
mild and recurrent hemoptysis which disturbs lifestyle of the patient and is not
amenable to surgical treatment is also increasingly being treated with BAE. BAE
is very effective in acute control of hemoptysis (73-98% initial nonrecurrence
rates). Superselective catheterization and complete embolization improved the
initial success rate. The long term success of this procedure is limited by recurrence
of hemoptysis in a significant number of patients (10-52%) 28. The recurrence rate
depends on several factors including the primary disease condition, adequacy of
the procedure and presence of non-bronchial systemic collaterals. The causes of
delayed recurrence includes incomplete embolization, recanalization of the
embolized vessel, development of other systemic collaterals and progression of
the underlying disease28. In several reports, the major conditions in which recurrence
has been noted include tuberculosis, aspergilloma and lung cancer 28,29. Definitive
treatment of the underlying condition is essential to provide cure of the disease. In
cases of recurrent bleed, repeat BAE has proven useful.
COMPLICATIONS
Bronchial artery embolization is a safe procedure. Transient chest pain is the most
common complication.Subintimal dissection of the bronchial artery or the aorta
has been reported in up to 6.3% of patients 4,5, 30-32. Usually this is inconsequential.
Non target embolization of the anterior spinal arteries leading to spinal cord ischemia
is the most dreaded complication of the procedure. The reported incidence of such
complications range from 1.4-6.5% 33,34 Dysphagia can occur secondary to
embolization of the esophageal branches; which usually resolves spontaneously.
Rare complications of BAE include bronchoesophageal fistula, aortic and
bronchial necrosis, pulmonary infarction, pericarditis, transient cortical
blindness ( possibly due to collateral vessel between the bronchial and vertebral
arteries) 35-39.
CONCLUSION
BAE is a safe and effective treatment modality which can be life saving in massive
hemoptysis. In chronic recurrent nonmassive hemoptysis also its utility has been
established. Though long term efficacy of BAE is limited in chronic diseases, it
can be repeated in cases of recurrent hemoptysis. Imaging, in the form of MDCT
and CT angiography, is useful in the identification of abnormal bronchial and
nonbronchial systemic arteries before performing BAE.
71
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