Bronchial Artery Embolization

Mohammed T. Alshammari

Manraj K.S. Heran

Bronchial artery embolization (BAE) was first reported in 1973 by Remy et al. as a treatment option for massive and life-threatening hemoptysis (1). In 90% of the cases of massive hemoptysis, the culprit vascular bed is the bronchial circulation rather than the pulmonary (5%) or nonbronchial systemic circulations (5%) (1,2,3). BAE is a safe and extremely effective therapeutic option because, unlike surgery, BAE preserves pulmonary function. Most patients with massive hemoptysis have poor pulmonary function, and they tend to be poor surgical candidates. In addition, surgery carries a mortality rate of 7.1% to 18.2%, this increases to about 40% when surgery is performed as an emergency (4).

Indications

1. BAE is considered first-line treatment for most cases of massive hemoptysis.

a. Life-threatening hemoptysis is defined as:

(1) Bleeding of 300 mL in 24 hours, or

(2) 100 mL daily for at least 3 days, or

(3) Minor bleeding with hemodynamic instability (5)

b. Most commonly, these patients suffer from diffuse interstitial lung disease, lung infection, or chronic granulomatous disease.

c. Conditions associated with hemoptysis include:

(1) Cystic fibrosis

(2) Tuberculosis

(3) Bronchiectasis

(4) Interstitial pulmonary fibrosis

(5) Fungal infections such as aspergillosis

(6) Ruptured bronchial artery aneurysm

(7) Arteriovenous fistulae

(8) Neoplasms

(9) Behçet disease

(10) Cryptogenic

Contraindications

Absolute

None

Relative

1. Contraindications to angiography

a. Uncorrectable coagulopathy

b. Renal insufficiency

c. Documented prior serious contrast reaction (see Chapter 64)

2. Presence of a major radiculomedullary artery (i.e., supply to the spinal cord) from the target artery is considered a contraindication by some interventionalists, but others advocate embolization if a microcatheter can be negotiated safely beyond the vessel of concern (6).

3. Congenital pulmonary artery stenosis (CPAS). In patients with CPAS, the bronchial circulation may provide essential pulmonary parenchymal perfusion. Pediatric cardiology consultation is imperative before BAE (3).

Preprocedure Preparation

1. Resuscitation

In the setting of life-threatening hemoptysis, it is essential to stabilize the patient’s condition with measures including:

a. Protecting the airway by keeping the bleeding side dependent, selective intubation of the uninvolved lung, and use of a dual lumen tube to ventilate the lungs separately

b. Optimizing oxygenation

c. Correct underlying hypotension, coagulopathy, and electrolyte imbalance as needed.

2. Preprocedure assessment

a. Chest x-ray (CXR) may help in diagnosing and localizing an underlying source. CXR is a quick, noninvasive, and widely available first step that can be diagnostic in 50% of cases (7).

b. Computed tomography (CT)/computed tomographic angiography (CTA

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