PowerPoint presentation on Bronchial Artery Embolization (BAE) by Dr.Tinku Joseph

1. BRONCHIAL ARTERY EMBOLIZATION
DR TINKU JOSEPH
DM Resident
Department of Pulmonary Medicine
AIMS, Kochin
Email-: tinkujoseph2010@gmail.com

2. contents
 Bronchial circulation
 Bronchial Artery Embolization (BAE)
 Indications
 Procedure
 Complications

3. Two Circulations in the Lung
• Bronchial Circulation
– Arises from the aorta.
– Part of systemic circulation.
– Receives about 2% of left
ventricular output.
• Pulmonary Circulation
– Arises from Right Ventricle.
– Receives 100% of blood flow.

5. ANATOMICAL CONSIDERATION-
Bronchial Artery
 Variable anatomy in terms of origin, branching
pattern, and course.
 Bronchial arteries usually arise as a pair or as a
common trunk, from the descending thoracic aorta
below the origin of left subclavian artery.
 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. BRONCHIAL CIRCULATION
 Sometimes part of blood supply of anterior spinal
artery come from bronchial vessels.
 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 radiculo medullary branches of the
intercostals and lumbar arteries.

7. 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.

8. Topographical Facts:
Normal Anatomy and Variations

9. Bronchial artery branching pattern
Cauldwell et al - four patterns:
 Type I
 Type II
 Type III
 Type IV
Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an
anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395–
412.

10. Type I
• Incidence: 40.6%
• Left:2
• Right:1
{intercostobronchial
trunk (ICBT)}

14. Bronchial Artery- Course
 Leave the aorta at an upward
angle, against the direction of
blood flow.
 Send braches to oesophagus,
mediastinum, lymph nodes and
nerves.
 On reaching the main bronchi
divide into visceral pleural
branches to the mediastinal
pleura and true bronchial
arteries to the bronchial tree.

15. Bronchial Artery- Course
 Spiral course around bronchi, one on either side of
each other but anastomosing frequently with each
other
 The vessels form an arterial plexus in the adventitia
from which branches pierce the muscle layer to enter
the submucosa, where they break up into capillary
plexus.
 Supplies bronchi, nerves, walls of pulmonary vessels
and intra pulmonary lymph nodes.

16. Bronchial Artery- Course
 Arteriolar branches of the
visceral pleural vessels pass
along interlobular septa,
reaching the interstitial tissue of
the lung acinus.
 The true bronchial arteries
reach as far down the airways as
the terminal bronchiole.
 Much of the bronchial arterial
blood, having gone through the
submucosal capillaries, passes
into the venous plexus in the
adventitia.
 Veins from this plexus then join
pulmonary venous system.

17. Bronchial Artery
Embolization
 Minimally invasive alternative to
surgery.
 selective bronchial artery
catheterization and angiography,
followed by embolization of any
identified abnormal vessels to
stop the bleeding.
 Considered to be the most
effective nonsurgical treatment
in the management of massive
and recurrent hemoptysis.

18. Bronchial Artery Embolization
 First by Remy et al. in 1973.*
 Temporary or definitive
 Immediate control: 57–100% of patients**
 Embolization : bronchial and nonbronchial
 Long-term control: 70%-88%
Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann
Radiol (Paris) 1974; 17: 5–16.
**Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries.
Radiology 1977; 122: 33–37.

19. Indications
• Haemoptysis-:Failure
of conservative or
bronchoscopic
treatment to control
bleeding.
ISRN Vascular Medicine
Volume 2013, Article ID 263259, 7 pages

20. Indications
 Managing ruptured pulmonary artery venous
malformation.
 To Stabilize patients before surgical resection or
medical treatment.
 As a definitive therapeutic approach in patients:
-Who refuse surgery
-Who are not candidates for surgery
-Where surgery is contraindicated
Bronchial artery embolization: Managing ruptured pulmonary artery venous
malformation e A case report Dharitri Goswami a,*, Shantanu Das b,1, Ashok
Parida c,2, Joy Sanyal c,3. Respiratory Medicine CME 4 (2011) 160e163
poor lung function, bilateral pulmonary disease, co morbidities.

21. WHY BAE ??
1)Bronchial circulation (90% of cases)
- Pulmonary circulation (5%) .
- Aorta (5%)(eg, aorto bronchial 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%.

22. BAE- TECHNIQUE
 Prior to the procedure, a brief neurological exam is
performed to establish a baseline.
 Femoral route/Trans-Axillary route
 Monitor vitals/spo2
 Sedation optional
 Clean groin with antiseptics.
 Adequate LA
 A preliminary descending thoracic aortogram
(Ionic/non ionic contrast) can be performed as a
roadmap to the bronchial arteries.

23. BAE - TECHNIQUE
 Both bronchial arteries and nonbronchial systemic
arteries are opacified.
 The diagnostic angiographic injections are always
selective into the bronchial, intercostals, subclavian,
internal mammary, intercostobronchial, and inferior
phrenic arteries.
 Under X-Ray machine guidance (Digital cardiac imaging
with digital subtraction facility)
 Reverse curve catheter – mikaelsson, simmons 1,
shepherd’s hook.
 Low arotic arch – forward looking catheters ( cobra or RC
) used.

24. Angiographic signs of haemoptysis
ISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pages

25. BAE - TECHNIQUE
 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.
 Intercostal arteries – initial
cephalic course , then
laterally along undersurface
of rib

26. BAE - TECHNIQUE
 The embolization materials commonly used
are non-absorbable particles of polyvinyl
alcohol (PVA) (Ivalon; Nycomed SA; Paris,
France), 355–500 𝜇m in size (some larger
vessels required particles as large as 2 mm),
and fibred platinum coils of 2 and 3mm in size
(MicroNester Embolization Coils; Cook,
Bjaeverskov, Denmark).

27. Catheters:
 Reverse-curved catheters
(Mikaelson, Simmons I,
SOS Omni)
 Forward-looking
catheters (Cobra, HIH,RC)
 Sizes: 4, 5, or 5.5 Fr are
routinely used.
Mikaelson catheter

28. Cobra type: curved catheter
 Most commonly used
 Microcatheter
 Superselective
catherization
 Less complications

29. Embolizing materials:
• Absorbable gelatin
sponge
• Gelfoam
• Pledgets (1 to 2 mm)
• Thrombin
• Glue
• Recently approved
-Embospheres,
-Spherical Poly vinyl
alcohol(PVA) particles
Permanent occlusive agents
Polyvinyl alcohol (PVA), Trisacryl gelatin microspheres (TGM), Gelfoam

30. Embolizing materials:
 PVA particles (350-500 mic)
 Most common & Safe
 Liquid embolic agents
 -ischemic necrosis
 Stainless steel platinum coils
 -occlude more proximal
vessels.

31. Embolization coils: Platinum Microcoils

32. Embolizing materials:
 Particles > 200 to 250 micr.m should be used
 No ischaemia and no neurologic damage
 Isobutyl-2 cyanoacrolate, Absolute alcohol
Used in pulmonary artery aneurysms
to avoid tissue ischemia and neurologic
damage

33. Embolizing materials:
 Distal embolization : ideal
 Proximal occlusion: temporary relief
 particles < 200 micr.m :avoided
-Tissue infarction
 Liquid embolic agents should always be
avoided because these cause tissue
infarction

34. Clues to bronchial artery as the source of
bleeding:
34
Parenchymal hypervascularity
Vascular hypertrophy
aneurysm

35. 35
The identification of extravasated
dye --INFREQUENT
Bronchopulmonary shunting
Neovascularisation

36. Left upper lobe bronchial artery
After Embolization
Decreased vascularity & hypertrophyTortous and hypertrophied vessel
Before Embolization

37. Right
Left
Abnormal circulation
Pre-embolisation bronchial angiogram
No abnormal circulation
Post embolisation

38. Bronchial artery aneurysm
Hypervascular lesion with aneurysm
Pre embolisation Post embolisationPVA particles
No hypervascular lesion & aneurysm

39. Super selective Embolization of
intercostal artery
Hypervascular areas and a small amount of
pulmonary arterial shunting
Decreased vasularity
POST EMBOLIZATIONPRE EMBOLIZATION
Radicular arteries
INTERCOSTAL ARTERY
Micro catheter passed
beyond radicular artery

40. Bronchial Artery Embolization
 Success rates : 64% to 100%.
 Recurrent non-massive bleeding :16–46%
• Recurrence of haemoptysis may be due to:
 Incomplete embolization of the bronchial
vessels
 Recannalization of the embolized arteries.
 Presence of non-bronchial systemic arteries.
 Development of collateral circulation in
response to continuing pulmonary
inflammation.

41. Bronchial Artery Embolization
 Technical failure: 13%
 Technical failure is caused by non-bronchial artery
collaterals from systemic vessels such as the phrenic,
intercostal, mammary,(PLEURA) or subclavian
Arteries.

42. Complications of BAE
• Transversemyelitis
 The most feared complication
due to non target occlusion of
branches.
When the anterior spinal
artery is identified as
originating from the bronchial
artery, embolisation is often
deferred owing to the risk of
infaction and paraparesis.

43.  The anterior spinal artery is the blood vessel that
supplies the anterior portion of the spinal cord.
 It arises from branches of the vertebral arteries and is
supplied by the anterior segmental medullary arteries,
including the artery of Adamkiewicz, and courses along
the anterior aspect of the spinal cord.
 Disruption of the anterior spinal cord leads to bilateral
disruption of the corticospinal tract, causing motor
deficits, and bilateral disruption of the spinothalamic
tract, causing sensory deficits in the form of
pain/temperature sense loss
Complications of BAE

44. Complications of BAE

45. Complications of BAE
 Chest pain is the most common
complication.
 Dysphagia due to embolization of
esophageal branches may also be
encountered.
• Rare complications
 Aortic and bronchial necrosis
 Bronchoesophageal fistula
 Non–target organ embolization (eg,
ischemic colitis)
 Pulmonary infarction.

46. References
 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.

47.  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.
References

48. 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.

49. 4) Surgery should be considered
only in case where embolisation
is not possible due technical
difficulty and in case of
embolisation failure. Otherwise
bronchial artery embolisation is
considered as the mainstay
treatment for hemoptysis.
CONCLUSION