1. BRONCHIAL ARTERY
EMBOLISATION IN
HAEMOPTYSIS
DR.P.SABHARISUNDARAVEL
JUNIOR RESIDENT( RADIODIAGNOSIS)
MEDICAL COLLEGE, KOLKATA

2. INTRODUCTION
•
Massive hemoptysis or chronic recurrent hemoptysis are potentially
life-threatening conditions.
•
Despite advances in medical and intensive care unit management,
massive hemoptysis remains a serious threat. Mortality rate for
patients with massive hemoptysis can be as high as 75% .
•
Superselective catheterization of the bronchial arteries feeding the
affected areas followed by particulate embolization has proven to be
an effective treatment for the control of bleeding.

3. WHY ??
1) Bronchial circulation (90% of cases)
- Pulmonary circulation (5%) .
- Aorta (5%)(eg, aortobronchial fistula, ruptured aortic aneurysm).
2) Surgery
- Mortality ~18% when performed electively, rising to 40% when performed emergently.
- conservative approach , mortality risk of at least 50%.
3) Minimally invasive
- clinical success - 85% to 100%,
- recurrence of hemorrhage – 10%.

4. ANATOMICAL CONSIDERATION
•
Variable anatomy in terms of origin, branching pattern, and course.
•
The standard or orthotopic origin is from the aorta between the
levels of T5 and T6 (80%).
•
ANOMALOUS – Outside the levels of T5 and T6 .
•
ANOMALOUS - Aortic arch, Internal mammary artery, Thyrocervical
trunk, Subclavian, Costocervical trunk, Pericardicophrenic artery,
Inferior phrenic artery.

6. BRANCHING PATTERN (CAULDWELL)
Type 1 (40.6 %)
. one right bronchial
artery
from ICBT
.Two left bronchial
arteries
Type 2(21.3 %)
.one on the right from ICBT
.One on the left
Type 3(20.6 %)
.Two on the right
(1 from ICBT &
1 bronchial artery)
. Two on the left.
Type 4(9.7 %)
.Two on the right (1
from
ICBT & 1 bronchial
artery).
.one on the left.

10. SPINAL ARTERIES
•
When bronchial artery embolization is performed, consideration
must be given to the arterial supply to the spinal cord.
•
Most important is Anterior Spinal Artery.
•
Anterior spinal artery receives contributions from the anterior
radiculomedullary branches of the intercostals and lumbar
arteries.
•
6-8 , hairpin loop course.

11. ARTERY OF ADAMKIEWICZ
•The largest anterior medullary
branch.
•Has variable origin from T5 –L5 level, but
most commonly from T8 – L1 level.
•In 5 % of population Rt. IBT contributes to
artery of Adamkiewicz.
•The left bronchial arteries very rarely
contribute the anterior spinal artery.

12. Source : internet.

13. TECHNIQUE
•
Prior to the procedure, a brief neurological exam is performed
to establish a baseline.
•
Femoral route.
•
A preliminary descending thoracic aortogram can be
performed as a roadmap to the bronchial arteries.
•
Reverse curve catheter – mikaelsson, simmons 1, shepherd’s
hook.
•
Low arotic arch – forward looking catheters ( cobra or RC )
used.

14. The left main stem bronchus
serves as a convenient
fluoroscopic landmark for the
general location of the bronchial
arteries
 The catheter is directed lateral
or anterolateral for the right
bronchial and more anterior for
the left.
Bronchial arteries – course of
main stem bronchi towards hila.
Intercoastal arteries – initial
cephalic course , then laterally
along undersurface of rib

15. REVERSE CURVE
COBRA HEAD

16. COMPLICATIONS
•
Chest pain is the most common complication.
•
Dysphagia due to embolization of esophageal branches may also be
encountered.
•
The most disastrous complication is spinal cord ischemia due to the
inadvertent occlusion of spinal arteries. When the artery of
Adamkiewicz is visualized at angiography, embolization should not be
performed.
•
Other rare complications include aortic and bronchial necrosis,
bronchoesophageal fistula, non–target organ embolization (eg, ischemic
colitis), pulmonary infarction.

17. REPORT
•
9 cases (march-september).
•
All electively.
•
Prior HRCT – all cases.

Bronchiectasis with alveolar opacities .

Mass like lesion – two cases.

Tuberculosis.
•
Right -6
•
Left – 2
•
Bilateral - 1

18. Embolisation
•
Polyvinyl alcohol (PVA) particles- 300 to 500 μm.
•
1mm PVA – one case .

Right bronchial artery alone – 3

Left bronchial artery alone – 1

B/L Bronchial artery – 2

Left Bronchial and LIMA – 1.

Left Axillary , Left LIMA and B/L Bronchial – 1

Incomplete – 1.

19. 60 YR MALE
C/O HEMOPTYSIS - 3YRS.
KNOWN TUBERCULAR AND SMOKER

21. 25 YR/FEMALE
C/O HEMOPTYSIS – 2YRS.
K/C/O TUBERCULOSIS

24. 47YR/MALE
HEMOPTYSIS – 6 MONTHS
K/C/O TUBERCULOSIS

26. REPORT
•
INCOMPLETE EMBOLISATION – 1.

SURGERY
•
SUCEESFUL EMBLOISATION – 8.
•
FOLLOW UP – 7

clinical success

27. “NO COMPLICATIONS”

28. CONCLUSION
1.
The development of bronchial artery embolization techniques has
revolutionized the approach to hemoptysis patients.
2.
Bronchial artery embolization possesses high rates of immediate clinical
success coupled with low complication rates.
3.
When bronchial artery angiography and embolization is performed,
consideration must be given to the arterial supply to the spine.
4.
Surgery should be considered only in case where embolisation not
possible due technical difficulty and in case of embolisation failure.
Otherwise bronchial artery embolisation is considered as the mainstay
treatment for hemoptysis.

29. REFERNCES
•
1) Haponik E F, Fein A, Chin R. Managing life-threatening hemoptysis: has anything really
changed? Chest. 2000;118(5):1431–1435.
•
2)Shigemura N, Wan I Y, Yu S C, et al. Multidisciplinary management of life-threatening
massive hemoptysis: a 10-year experience. Ann Thorac Surg. 2009;87(3):849–853.
•
3)Marshall T J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization
for haemoptysis. Eur Radiol. 1997;7(8):1221–1227.
•
4)Yoon W, Kim J K, Kim Y H, Chung T W, Kang H K. Bronchial and nonbronchial systemic artery
embolization for life-threatening hemoptysis: a comprehensive review. Radiographics.
2002;22(6):1395–1409.
•
5)Fernando H C, Stein M, Benfield J R, Link D P. Role of bronchial artery embolization in the
management of hemoptysis. Arch Surg. 1998;133(8):862–866
•
6)Ramakantan R, Bandekar V G, Gandhi M S, Aulakh B G, Deshmukh H L. Massive hemoptysis
due to pulmonary tuberculosis: control with bronchial artery embolization. Radiology.
1996;200(3):691–694.