This document discusses embolotherapy for massive hemoptysis. It defines massive hemoptysis and outlines the evaluation and causes. Bronchial artery embolization is presented as the most effective nonsurgical treatment, with short-term success rates of 77-99% and long-term success possible with repeat embolization and controlling underlying disease. The document reviews bronchial artery anatomy, various embolization agents like particles and coils, the embolization procedure and potential complications.

2. Embolotherapy
In Patients With Massive
Hemoptysis
By
Mahmoud E. Abou El-Magd
Assistant lecturer of pulmonary and critical care medicine

3. Hemoptysis

4. • Hemoptysis is classified as massive or
nonmassive based on the rate of bleeding.
• The most commonly used definition of
massive hemoptysis is 600 mL in 24
hours .
(Ibrahim , 2008).

5. • Life-threatening (massive) hemoptysis was
defined as expectoration of at least 200 mL of
blood per hour in a patient with normal or nearly
normal lung function.
• Production of at least 50 mL of blood per hour in
a patient with a chronic respiratory failure, or
more than two episodes of moderate hemoptysis
within a 24 h period .
• Moderate hemoptysis was defined as more than
or equal to three episodes of 100 mL of bleeding
per day within 1 week.
(Agmy, 2013).

6. • The evaluation of hemoptysis involves a careful
history, physical examination, and a chest
radiograph. Initial studies also include a
complete blood count.
• In the vast majority (90%) of cases the source of
the bleeding is the bronchial circulation.
• Massive hemoptysis may be due to active TB,
prior TB, bronchiectasis, mycetoma, Tight mitral
stenosis, and lung cancer.
(Corder, 2003 )

7. Pathophysiology

8. Hemoptysis
Hypoxic pul . V.C
Direct erosion
Elevated local Bl . Pr
angiogenetic growth factors
(Yoon et al., 2002)

9. • Conservative management of massive
hemoptysis has a 50–100% mortality rate
.
• The diagnostic accuracy of FOB is 0%–
30% in patients with normal chest
radiograph and 10%–43% in all patients
with hemoptysis.
(Yoon et al., 2002)

10. • Two decades ago,surgery was regarded
as the treatment of choice for hemoptysis.
but mortality rates were up to 40%
following emergency surgery .
• The mortality rate in patients who are
incapable of tolerating surgical procedure
was 80%.
(Yoon et al., 2002)

11. Indications
for
Recurrent
hemoptys
-is
Pre-
operati-
ve
Bronchial angiography
Massive
hemoptysis
Undiagnosed
hemoptysis
(Sirajuddin and Lucien, 2008)

12. Pulmonary
vascular Anatomy

13. Bronchial Arteries
supply
trachea
Pulmonary airways
Visceral pleura
esophagus
Vasa vasorum of aorta,
Pul. A & V
(van den Berg, 2006)

14. classical bronchial
artery patterns
40 %
2 left & 1 right
20 %
1 left & 1 right
20 %
2 left & 2 right
10 %
1 left & 2 right
( JC. van den Berg, 2006)

18. Pathologic Features Of
The Bronchial Artery

29. Non-bronchial
Systemic
Artery
Anatomy
brachiocephalic arterythe aortic arch
internal mammary
artery
Pericardiacophrenic
subclavian artery
thyrocervical trunk
(Yoon et al., 2002)

33. Embolization
tools

34. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
( JC. van den Berg, 2006)

35. 1-Polyvinyl Alcohol Particles
• 50 and 2000 µm, the typical size ranges
used clinically are 300 to 500 µm or 500
to 700 µm.
• Irregular shape .
(J. Golzarian et al., 2006 )

36. Polyvinyl alcohol
Focal angio-
necrosis
Thrombus
formation
Plt
aggregation
Slow
flow
Adherence
Mechanism of action
(J. Golzarian et al., 2006 )

37. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
2- Spherical Embolic Agents
( JC. van den Berg, 2006)

38. 2-Spherical Embolic Agents
• Trisacryl Gelatin Microspheres
40–120, 100–300, 500–700, and 700–900 mm,
In its original form, these spheres are clear.
• Polyvinyl Alcohol microspheres (Contour
SE particles)
100–300,300-500, 500–700, 700–900, and 900–1,200
m m.
(Avritscher and Wallace, 2012 )

42. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
2- Spherical Embolic Agents
3- Gelfoam
( JC. van den Berg, 2006)

43. 3-Gelfoam
• Gelatin sponge (Gelfoam) is a white,
water-insoluble, prepared from purified
pig skin gelatin.
• Temporary.
• 4w to 4m
(Golzarian et al., 2006 )

45. B - Liquid Agents
1- Ethanol or Absolute Alcohol
not radiopaque and highly diffusible ,Severe
complications such as cardiac arrest and pulmonary
embolism have been reported.
2- Cyanoacrylate
(Burrows and Mason, 2004)

46. C- Coils and Metallic Embolization
• The metallic coils range in size from 0.018 in.
(microcoils) to the standard 0.035–0.038 in.
sizes. made from either stainless steel or
platinum , all coils are permanent Devices.
• Coils should not be used in combination with
particulate embolization for the treatment of
tumors .
• Gugliemi detachable coil (GDC) system
(Golzarian et al., 2006 )

52. D – Balloons
E – Microcatheters
come in a variety of sizes from the larger bore
(outer diameter 3 F) to standard size (2.7 F) to
very small bore (2 F).
(Golzarian et al., 2006 )

55. Chylothorax 55

56. Embolotherapy
Technique

57. PREPARATION
• consent .
• sedatives or narcotic analgesics .
• monitoring .
• contrast .
• Fasting 4h before examination, except diabetic
patient.
• Stop
(Aspocid, Clexane) 1 day before examination.
(Marivane) 3 days before examination.
• Control of hypertension.
(Bader et al., 2004 )

58. Contra-indications

59. • absolute contraindication
spinal artery !!
• relative contraindication
- Contrast allergy.
-Uncontrolled (Hypertension)
-Coagulopathy Problems.
-Renal dysfunction.
-Uncontrolled (arrhythmias).
-Pregnancy !
(Chun and Belli, 2009)

61. Complications

62. 1. (transient) chest pain, in 24% up to
91% of cases .
2. dysphagia, 0.7% to 18.2%.
3. spinal cord ischemia, 1.4%–6.5%
4. “post-embolization syndrome”.
5. Non-target embolization (colon,
coronary and cerebral circulation).
(McPherson, 2010 )

63. 6. Rare complications as Aortic and
bronchial necrosis .
7. Other complications related to
angiography in general as
-Bleeding, False aneurysm ,Reactions to the
dye and Kidney damage .
(Wong et al., 2002)

64. Recurrence

65. Recurrence of hemoptysis may
occur due to:
• Recanalization
• Incomplete embolization.
• Revascularization
• anomalous bronchial arteries .
• The underlying disease.
(Chun and Belli , 2009)

66. Results

67. • Active and old TB had the best results .
• Patients with malignancy were the most
difficult to manage … Why ?
• Poor outcomes have been observed in
patients with aspergilloma .
(Mauro et al ., 2006 )

68. • We recommend use of bronchial
arteriography as a routine investigatory
tool for patient with hemoptysis .
• Future researches regarding other uses of
radiological bronchial and pulmonary
arteries intevention .

81. Home takeaways

82. • Bronchial artery embolization is highly effective in the
treatment of acute hemoptysis. Short-term non
recurrence rates (with follow-up up to 1 month) range
from 77% to 99% .
• success rates of 100% can be achieved using repeat
embolization and control of underlying disease either
pharmacologically or surgically .
• The most effective nonsurgical treatment for massive
hemoptysis is bronchial artery embolization (BAE) .
(Chun and Belli , 2009)