This document discusses various pulmonary interventions including non-vascular interventions like thoracentesis, pneumothorax drainage, lung abscess drainage, pericardial effusion drainage, and biopsies. Vascular interventions discussed include bronchial artery embolization and SVC stenting. Specific procedures are described in detail such as lung abscess drainage involving image-guided catheter placement, mediastinal abscess drainage, pericardial effusion drainage, transthoracic needle aspiration, pleural biopsy, endobronchial ultrasound, mediastinoscopy, and transtracheal oxygen therapy. Interventions in bronchoscopy including diagnostic and therapeutic procedures are also summarized.

1. INTERVENTIONS IN PULMONARY
MEDICINE
Dr. Don Gregory
Junior Resident
GMC, Patiala

2. Non vascularinterventions
 THORACOCENTESIS/ ICD
 PNEUMOTHORAX DRAINAGE
 LUNG ABSCESS DRAINAGE
 PERICARDIAL EFFUSION
DRAINAGE
 DRAINAGE OF FLUID
COLLECTIONS
 TTNA/BIOPSY
 PLEURAL BIOPSY
 PLEURODESIS
 USG/EBUS
 MEDIASTINOSCOPY
 TTOT
 INTERVENTIONS IN
BRONCHOSCOPY
 THORACOSCOPY
 VATS
VASCULAR INTERVENTIONS
 BRONCHIAL ARTERY
EMBOLIZATION
 SVC STENTING
 PERCUTANEOUSVASCULAR FB
RETRIEVAL

3. 1) Lung abscess drainage
 Lung abscess represents an infected collection of lung
parenchyma
 It may be primary(due to aspiration) or secondary(due to
adjacent infection/blood spread)
 Image guided PC catheter drainage is used in those who
don’t respond to medical management
 CT is required to assess presence of pleural involvement &
also to plan a safe transthoracic route for catheter
placement
 Procedure is performed under fluoroscopy/CT/USG guidance
 Patient is positioned with the affected side in nondependent
position to avoid spilling of contents to opposite lung.
Smaller(12-14Fr) size catheter is used to avoid air leaks
 Resolution of abscess occur in 73-100% cases aften 10-
15days of drainage. Complete collapse of cavity takes 4-
5weeks.Catheter is removed once resolution occurs

4. 2)Mediastinal abscess drainage
 Mediastinal abscess is a life threatening infection which occus
subsequent to thoracic surgery/endoscopy
 If surgical drainage is not feasible, then its drained
percutaneously under CT guidance by a
parasternal/paraspinous approach to avoid lung injury. Can also
be tried under transesophageal approach.
 Success rate 83-100%, but 30 day morality rate is high
3)Pericardial effusion drainage
 Done when diastolic filling of ventricles is impaired
 Pericardial catheter drainage is done under USG guidance
using a subcostal/subxiphoid approach with/without
fluoroscopy.
 If CT guided,then left anterolateral approach is used

5. 4) Transthoracic needle aspiration/Biopsy
• It should be done when identity of lesion could not be
established using non invasive methods
• TTNB of pulmonary lesions is mainly done under CT guidance
if lesions are adjacent to hilum / mediastinum, for small lesions
& lesions not clearly seen on fluoroscopy
• Fluoroscopy is useful only for biopsy of nodules in lower third of
lung
• USG guidance is limited to masses that are apical, juxta
diaphragmatic or adjacent to chest wall.
INDICATIONS
 SPN
 Confirming metastatic lung disease
 Staging of lung cancer/extrathoracic malignancy
 Sampling of suspected focal infections

6. CONTRAINDICATIONS
 Vascular lesions/hydatid cyst
 Bleeding disorders
 Severe pulmonary HTN
 Emphysematous bullae in planned biopsy route
 Severe pulmonary disease(FEV1 <1ltr)
 Contralateral pneumonectomy
 Ventilator dependence/inability to hold breath
TECHNIQUE
 Smaller guage(20-25G) needles are used for
TTNA & 14-19G are used for TTNB.
 Needles have different angles and bevel of the
tip. Chiba needle has angle of 25degree and
spinal has 30degree.Greene and Franseen
needles have 90degree tips.
 Noncutting type are used for
aspiration(chiba/spinal/greene)and cutting type
for biopsy

7.  Biopsy is performed with 2 techniques
• Single needle technique for large accessible lesions
• Coaxial technique for smaller lesions or lesions that require
lengthy imaging procedures for correct needle placement. Here
an 18/19G needle is 1st advanced to proximal edge of lesion as
guide needle .A 22G needle is then advanced through this
guide needle for aspiration or 20G cutting needle for core
biopsy.
 Postprocedure CXR is taken immediately & 4hrs after
procedure to r/o pneumothorax
Complications
 Pneumothorax(30-60%) ,rarely requiring interventions
 Hemoptysis(5%)usually as blood streaking
 Vasovagal reaction/lobar torsion/needle tract metastases
 Mortality(0.02%) due to tension pneumothorax/air
embolism/pulmonary hemorrhage

8. Results:
 TTNB has a sensitivity of 70-100% for diagnosis of malignancy,
but for benign lesions its 50%
TTNB from other sites
 Anterior mediastinal masses can be assessed by
para/supra/transsternal approaches
 Posterior mediastinal/subcarinal masses by paravertebral
approach.
 A direct mediastinal/extrapleural approach is preferred over
transpulmonary approach to reduce risk of pneumothorax. Also
use of a pleural space approach through an existing
pl.eff/iatrogenically created pneumothorax has been described
 Saline injection(salinoma) can be used to widen
paravertebral/substernal extrapleural space for a direct
mediastinal approach
 For mediastinal masses, bronchoscopic
approaches/mediastinoscopy score over TTNA/B

9. 5)Pleural biopsy
 The main Indication is to establish diagnosis of TB pleuritis
when ADA is not confirmative & in malignancy where cytology is
negative
 Contraindications include bleeding disorders, borderline
respiratory failure, empyema(can form SC abscess),
uncooperative pt,local cutaneous lesions like pyoderma/HZV
infection
 Success rate is 42% when done blindly, 79% when image
guided, 93% under thoracoscopy
 Image guided pleural biopsy is most preferred ,although no
imaging is required if there is moderate to large pleural effusion.
 3 types of needles: Abram’s/Cope/Raja of which Abram’s is
most preferred

10. Technique using Abram’s needle
Stylet is inserted into cannula which is in turn inserted
into trocar.
Under LA, a small skin incision is given, the needle is
inserted at 90° to the ribs.Firm pressure exerted on
stylet & needle pushed inside.
Pop is heard when needle enters pleural space.
Now stylet is removed, syringe attached & cannula
rotated anticlockwise to open notch.
Pl.fluid is aspirated, cannula rotated clockwise to lock
notch and syringe changed.
Now notch is unlocked, entire needle rotated so that
notch points inferiorly.
Needle is slightly withdrawn now until it hooks to
parietal pleura.now cannula is rotated clockwise to lock
the notch and thus a biopsy is obtained.
This is repeated for 3-4times in different
directions.Needle is then withdrawn.biopsy will be at tip
of needle.Wound closed with bandage/suture if reqd

11. • 3 samples should be placed in formalin & sent to pathology dept, one
sample in saline to TB lab for M.tb culture. If mesothelioma suspected, one
sample is sent in glutaraldehyde for EM study
• Post-procedure, CXR is done to r/o pneumothorax
• Complications include pneumothorax(more with Cope needle)
,bleeding(hemothorax), AV fistula, damage to liver, spleen,kidney (when
mistakenly biopsied).
Abram’s needle Cope’s needle
Outer trocar, inner cannula Outer cannula, inner trocar
Larger specimens,more mesothelial cells Smaller specimen, more muscle tissue
More commonly used Less commonly used
Closed system. So less chances of
pneumothorax
Open system, more chances of
pneumothorax
Tip of outer trocar is blunt, so concurrent
thoracocentesis is safe
Tip of outer cannula is square & sharp, so
concurrent thoracocentesis is risky

12. 6)EBUS
• Its an invasive procedure in which physicians use ultrasound
devices inside the airways and the lung for exploration of the
structures of airway walls, the surrounding mediastinum, and
the lungs. It may be linear or radial.
• This procedure may be performed under LA with or without
conscious sedation or under GA by oral approach.
• In radial EBUS the miniaturized catheter probe , bearing a
mechanical transducer at its tip that rotates 360°. is inserted
through a regular flexible bronchoscope with a biopsy channel
of at least 2.8 mm.
• Inside the airways, the balloon is inflated until complete circular
contact is achieved and the structures of the wall and the
surrounding mediastinum become visible.
• In order to add the longitudinal dimension to the cross
sectional image, the probe has to be moved along the axis of
the airways.

13. Indications
• For visualization, tumor invasion, TBNA guidance, and
differentiating of vascular from nonvascular structures.
• In guiding therapeutic procedures such as curative photodynamic
and brachytherapy by assessing tumor volume and other
interventions such as airway recanalization.
Contraindications
• Same as routine bronchoscopy
note: LN that can be located:2,3,4,5,6,7,10,11.
LN specific to EBUS: 2R,2L,3A,5,6
Training Requirements
• Trainees should perform at least 50 procedures in a supervised
setting to establish basic competency .To maintain competency,
dedicated operators should perform at least 20 examinations per
year.

14. 7) Mediastinoscopy
 Mediastinoscopy with biopsy is a procedure in which a
lighted instrument (mediastinoscope) is inserted in the
space in the chest between the lungs (mediastinum),
and tissue is taken (biopsy) from any unusual growth or
lymph nodes.
 Patients with isolated mediastinal lymphadenopathy
(IML) are a common presentation to physicians, and
mediastinoscopy is traditionally considered the "gold
standard" investigation when a pathological diagnosis is
required. Endobronchial ultrasound-guided
transbronchial needle aspiration (EBUS-TBNA) is
established as an alternative to mediastinoscopy in
patients with lung cancer.
 EBUS-TBNA is a safe, highly sensitive, and cost-saving
initial investigation in patients with IML

15. Indications
 Enlarged N1, N2 or N3 lymph nodes on CT
scan to biopsy & staging
 FDG-PET positive mediastinal disease
 Centrally located tumours
 T2-T4 tumours
 certain infections
(tuberculosis, sarcoidosis) and autoimmune
disorders
Procedure
 Its done in the hospital under GA
 A endotracheal tube is placed
 A small surgical cut is made in the neck. A
device called a mediastinoscope is inserted
through this cut and gently passed into the
mid-part of the chest.
 Tissue samples are taken of the lymph
nodes around the airways. The scope is
then removed and the surgical cut is closed
with stitches.
 A chest x-ray is usually taken at the end of
the procedure.
 The procedure usually takes 60 - 90
minutes

16. 8)Transtracheal Oxygen Therapy
 TTOT is a minimally invasive
procedure that is achieved through
percutaneously placed devices that
allow for long term oxygen use.
 The procedure is usually performed
on an outpatient basis. Dedicated
procedure kits including needles,
guidewire, dilators, stents, and
oxygen delivery catheters are
available.
 TTOT provides an additional
means of delivering oxygen.
Advantages are longer life of
oxygen sources and cosmetic
issues.
 Additionally, there is some
evidence that patients experience
improvement of dyspnea and
exercise tolerance.

17. Technique
• It may be performed under LA with or without conscious
sedation or under GA
• Before establishing TTOT, patients and their caregivers need to
undergo appropriate teaching and preparation and demonstrate
motivation to return for multiple postprocedure visits.
• The first step for the procedure is placement of the percutaneous
stent. A small, 1.0- to 1.5-cm vertical incision is made over the
insertion site and a guidewire introduced via Seldinger technique.
• The opening is then dilated and a stent is placed.
• After 1 week of tract maturation, the stent is removed and the
oxygen delivery catheter placed.
• Until the tract is completely mature, all exchanges have to occur
over the wire.
• Regular frequent follow-up is needed for several weeks
postprocedure to allow for patient teaching and early recognition
of complications.

18. Indications
• Any patient receiving long-term oxygen.
• Patient intolerant of nasal cannula oxygen delivery, refractory
hypoxemia, and limited mobility due to high oxygen demands.
Contraindications
• Uncorrectable coagulopathy, terminal illnesses, lack of motivation or
support, inability to return for follow-up, pleural herniation over the
trachea, and upper airway obstruction.
Complications
• Complications are very uncommon and include mucous ball
formation, pneumothorax and subcutaneous emphysema.
• Mortality is exceedingly low, and the most common morbidity is
catheter-induced coughing.
Training requirements
• Trainees should perform at least 10 procedures in a supervised
setting to establish basic competency and maintain it by performing
at least five procedures per year.

19. Interventions in bronchoscopy
THERAPEUTIC
• Endobronchial tumour debulking
• Laser/Electrocautery
• APC/Cryotherapy
• PDT/Brachytherapy
• Displacement Therapy
• Rigid Bronchoscopy
• Balloon Dilatation
• Stent
• Silicon
• Metallic stent
• Percutaneous dilatational
tracheostomy
• Therapeutic Bronchoscopy for
emphysema and asthma
LVRS/Airway bypass
Bronchial thermoplasty
DIAGNOSTIC
• TBNA/TBLB/EBLB
• Autofluorescence
Bronchoscopy
• Confocal microscopy
• Navigational Bronchoscopy

20. Diagnostic interventions in bronchoscopy
1)TBNA
• TBNA is a minimally invasive procedure that provides a nonsurgical
means to diagnose and stage bronchogenic carcinoma by sampling
the mediastinal lymph nodes.
• Applications of bronchoscopic needle aspiration have expanded to
include not only sampling of paratracheal or mediastinal lymph
nodes, but peripheral, submucosal, and endobronchial lesions.
• The procedure allows for sampling tissue through the trachea or
bronchial wall, and sampling of tissue beyond the vision of the
dedicated operator.
• This procedure may be performed under local anesthesia, with or
without conscious sedation, or under general anesthesia
• For submucosal lesions, a similar technique is applied; however,
since the goal is to obtain a specimen from the mucosa, the needle
and catheter are kept in a position of slight angulation rather than the
90° angle used to obtain lymph node aspirate.
• For peripheral lesions, fluoroscopy is used to localize the lesion.

21. Indications
• Diagnostic and staging information in the presence of malignancy in mediastinal
lymph nodes, submucosal, endobronchial, and parenchymal masses
• Sarcoidosis/ TB
• Fungal disease.
Contraindications
• Most contraindications to TBNA are relative rather than absolute, most common
being Respiratory distress and bleeding disorders.
Risks
• The most common potential complications are bleeding(Significant bleeding
rarely occurs even after a major vessel puncture),pneumothorax, or
pneumomediastinum.
• Fever and bacteremia have been reported following TBNA, although this may
be related to the bronchoscopic procedure itself rather than this specific
technique.
Training Requirements
• Trainees should perform at least 25 needle aspirates in a supervised setting to
establish basic competency. & to maintain competency, dedicated operators
should perform at least 10 procedures per year.

22. 2)Autofluorescence Bronchoscopy
• Its a bronchoscopic procedure in which a blue light rather than a
white light is employed for illumination, and premalignant and
malignant tissue is distinguished by a change in colour from
normal tissue without the need for fluorescence-enhancing drugs.
• Fluorescence techniques used with bronchoscopy have
demonstrated detection of dysplasia, carcinoma in situ, and early
invasive cancers not visible by standard white light bronchoscopy
(WLB) through a specialized bronchoscope. In addition to the
equipment needed for bronchoscopy,
• A dedicated endoscopic system allowing for blue light imaging is
required. Two images of different wavelengths (red and green) are
captured.
• Images are processed such that the image on the video monitor
allows for normal tissue to be visualized as green and abnormal
tissue to be visualized as reddish-brown in color. Inspection is then
performed using a standard bronchoscopic technique.

23. Technique
• This procedure may be performed under LA with or
without conscious sedation or under GA.
• Initial bronchoscopic examination is performed using
conventional WLB.
• Trauma to the mucosa, needs to be avoided, biopsy
specimens are not obtained from abnormalities until
after (or during) autofluorescence inspection.
• Following white light inspection, a detailed
autofluorescence examination is performed and all
abnormalities are graded.
• Biopsies are then performed either under white light
settings of the areas determined to be abnormal, or
after (or during) autofluorescence bronchoscopic
inspection of the areas determined to be abnormal.

25. Indications
• Known or suspected lung cancer by abnormal sputum cytology
findings
• Inspection for synchronous tumors
• Surveillance following cancer resection
• Primary screening among high risk patients.
Contraindications
• Same as routine bronchoscopy
Training Requirements
• Trainees should perform at least 20 autofluorescence
bronchoscopies in a supervised setting to establish basic
competency.
• To maintain competency, dedicated operators should perform at
least 10 procedures per year.

26. 3)FCFM
• Fibered confocal fluorescence microscopy (FCFM), also referred to as Cell-
Vizio® (MaunaKea Technologies, France) is a new technique that produces
microscopic imaging in a living tissue, through a 1 mm fiberoptic miniprobe
that can be introduced into the working channel of the bronchoscope.
• The principle of confocal imaging was patented in 1957 by Marvin Minsky
and aims to overcome some limitations of traditional wide-field fluorescence
microscopes
• The system produces real-time ,high-resolution, microstructural images of
lobular and alveolar lung structures in living humans with a 5 µm lateral
resolution and a field of view of 600 x 600 µm.
• FCFM is able to produce dynamic, high-resolution microimaging of the
respiratory bronchiolar walls, alveolar ducts and sacs in vivo during
endoscopy (a procedure termed as alveoscopy).
• The hypothesis of this study is that an alveoscopy makes it possible to
analyze the microstructure of the distal airways in vivo and to collect specific
morphologic information in patients with interstitial lung diseases.
• The main advantages of this design are the very small size and the flexibility
of the probe that can reach the more distal part of the lungs , as well as the
fast image collection speed that helps to avoid artifacts due to tissue
movement.
• The french model is in phase 2 trial as of now

27. Conventional fluorescence
microscope
• The entire specimen is
flooded evenly
• Less optical resolution
• High signal intensity, so
less exposure required
FCFM
• Uses point illumination
and a pinhole in an
optically conjugate plane
• Better
• Decreased signal
intensity , so
long exposures are often
required.

28. • Specific miniprobes for bronchial and alveolar imaging have a
diameter of 1 mm that can enter the working channel of any adult
bronchoscope. These miniprobes are devoid of distal optics and
have a depth of focus of 0 to 50 μm and a lateral resolution of 3
μm, for a field of view of 600 × 600 μm. The system produces
endomicroscopic imaging in real time at 9 to 12 frames/second.
• Two different wavelengths are available. The Cellvizio 488 nm is
used for autofluorescence imaging of the respiratory tract as well
as for fluorescein-induced imaging of the GI tract (7, 8, 22).
Another device at 660 nm excitation can be used for epithelial cell
imaging after topical application of exogenous fluorophores such
as methylene blue (23–25).
• The main limitations of the system are related to its maximal
imaging capabilities (30,000 pixels), which restrict the lateral
resolution to the fiber intercore distance (3 μm), and the fact that
the focus point of the system cannot be adjusted. As discussed
later, interpretation of the data also relies on the fluorescence
properties of the imaged tissue.

29. FCFM showing the elastin network of
the basement membrane zone. (A)
Opening of a bronchial gland (star). (B)
Elastic fibered network oriented along the
longitudinal axis of the airways. (C) Distal
bronchiole showing helicoidal imprints of
smooth muscles (arrow). (D) Transitional
bronchiole showing an alveolar bud

30. Representative data of HRCT and alveoscopy in the corresponding segments
before(A, B) and 3 months after the treatment (C, D). Total disappearance of
"crazy paving" and "ground glass opacity" symptoms on СT, but the floating
complexes in alveoli at endomicroscopy are partially saved

31. FCFM acinar imaging (488 nm). (A and B)
Nonsmoking subject. Elastin framework of
an alveolar duct (A, arrowhead), and of an
extra-alveolar microvessel (B, arrow). (C
and D) FCFM imaging of smoker alveoli,
showing alveolar walls (arrowhead) and
alveolar macrophages (asterisk).
FCFM (660 nm excitation) after topical
application of methylene blue (0.1%). (A)
regular normal bronchial epithelium. (B)
Peripheral lung nodule (adenocarcinoma)

32. Clinical application of FCFM
• In vivo diagnosis of early malignant and premalignant conditions of the bronchial
tree, allowing the analysis of both the epithelial and subepithelial layers during the
same procedure.
• Nonmalignant bronchial diseases like tracheomegaly(the complete disappearance
of the bronchial wall fibered connective network), bronchial sarcoidosis, PAP, to
study specific basement membrane remodeling alterations, such as in chronic
bronchial inflammations, asthma and COPD.
LIMITATIONS
• First, because of the orthogonal branching and the small caliber of the terminal and
respiratory bronchioles in humans compared with the probe size, alveolar imaging
regularly bypasses the transitional respiratory bronchioles. This could represent a
limitation for the study of the distal membranous and respiratory bronchioles,
unless thinner probes, currently devoted to experimental animal imaging, become
clinically available in the future.
• Second, the probe progression into the lobule supposes the disruption of alveolar
walls, followed by a compression effect on the more resistant ductal structures.
Minimal imaging distortion is observed when the probe is applied on the axis of the
duct, resulting in the visualization of more details in the background planes than
theoritically allowed by the 50-μm depth of focus of the system . This compression
effect may be difficult to control in vivo. the more reproducible results were
obtained in gently pulling back the probe once the alveolar imaging is obtained and
analyzing the last images before the contact is lost.

33. • Third, fluorescence microimaging by itself has some advantages and
limitations. In contrast to reflectance imaging, fluorescence microimaging is
devoid of interference with the reflected and refracted light at the air–liquid
interface, because the backscattered excitation light is filtered out by the
detection system. This merely produces a small decrease in the signal
intensity at the air–liquid interface, without any other optical artifact. This
property allows the visualization of bubble-like structures as well as the
presence of fluorescent cells within this liquid phase.
• On the other hand, FCFM exclusively records the signal coming from
fluorescent structures in response to appropriate excitation wavelengths. In
this regards, in vivo FCFM in nonsmokers only images the elastin of the
peripheral and axial connective tissues. Data from the literature indicate that
such information might be helpful for the exploration of several peripheral
lung diseases. However, as the confocal fluorescence imaging of the distal
lung is likely to appear very different from the corresponding histopathology,
the semeiology of the FCFM elastin lung network imaging will have to be
characterized in pathological conditions. In this regard, in vivo comparative
studies on confocal alveolar imaging in patients with peripheral lung
diseases and healthy volunteers appear mandatory, before the place of
FCFM in the routine exploration of the peripheral lung could be appreciated.

34. • Electromagnetic navigation bronchoscopy provides the ability to
detect lung cancer and lung disease earlier, even before
symptoms are evident, enhancing treatment options for patients
• Similar to Global Positioning System technology,
electromagnetic navigation bronchoscopy creates a three-
dimensional virtual “roadmap” of the lungs from the patient’s
CT-Scan that enables a physician to steer a unique set of
catheters through the lungs to reach the targeted lesion in a
minimally invasive manner.
• It can be used with a wide-range of patients including those
who suffer from poor lung function or have had cancer surgery,
chemotherapy, or radiation therapy
4)Electromagnetic Navigation Bronchoscopy

35.  An experienced lung specialist locates one
or more lesions deep in the lungs on a CT-
Scan. That CT-Scan of the lungs is loaded
onto a computer and a virtual three-
dimensional “roadmap” of the lungs is
generated. The physician marks anatomy
points of the lungs and the target lesions
on the three-dimensional image to map a
route for navigation and steerable catheters
to travel through the lungs.
 A unique set of catheters is then loaded
into the bronchoscope before the
procedure begins. These catheters have
360-degree steering capabilities to reach
lesions as well as an electromagnetic
sensor that allows the physician to track
the exact location of the catheters in the
lungs.

36.  Bronchoscopy is performed with pt lying on a electromagnetic board.Tip of
the bronchoscope has a electromagnetic tracker& this indicates its position.
This allows the electromagnetic sensor to be viewed in real-time on the
virtual three-dimensional “roadmap” of the lungs to assist the physician in
reaching the target lesions.
 Once the target lesions are reached, the steering catheter is removed and
tiny surgical instruments are passed through the bronchoscope to collect a
biopsy from the lesion for testing and diagnosis.
 Latest iLogic software has six possible screen modes which creates a
bronchial tree diagram with a route map to target
 Indications of EMN
 Sampling of peripheral nodule
 Guidance for transbronchial FNA of mediastinal LN/peribronchial masses
 Targeted transbronchial cryobiopsy
 Insertion of markers for stereotactic RT or VATS biopsy

38. THERAPEUTIC BRONCHOSCOPY
Endobronchial tumour debulking
1)Laser Therapy
 The wavelength of the laser( light amplification of stimulated
emission of radiation) determines the characteristics of each
type. Tissues absorb the intense light of the laser, and energy is
dissipated, mainly in the form of heat. This tissue/light
interaction is used for tissue destruction and coagulation.
 Laser therapy can be used alone or in association with other
ablative techniques or stenting
 Laser therapy may be performed with either flexible or rigid
bronchoscopic instruments.
 The Nd-YAG laser is the most commonly used laser. The
wavelength is 1064 nm, yielding invisible light in the infrared
range.
 Other lasers include the potassium titanyl phosphate laser, the
carbon dioxide laser, and diode lasers. The specific laser fibers
are usually accompanied with the appropriate power generator
and specific protective eyewear.

39. Nd-YAG laser
 Nd: YAG laser is used to shrink
or destroy tumors and/or to
relieve symptoms in difficult-to-
reach areas of the body, such as
the lungs, esophagus or colon.
 The Nd: YAG (neodymium:
yttrium-aluminum-garnet) laser
uses a high power laser beam
that literally burns, or
“vaporizes,” the tumor which is
then suctioned out through an
endoscope or bronchoscope.
 The Nd: YAG laser is often used
to treat large obstructive masses
that can’t be removed surgically,
but are causing symptoms, such
as bleeding or obstruction
 Efficient photocoagulation, good
penetration and excellent
hemostasis,less infection at
surgical site,early healing
Nd Yag laser therapy. Laser fibre (A)
to be inserted through the working
channel of the flexible bronchoscope
(B), passed through the lumen of the
rigid bronchoscope (C). Laser fume
extraction device (D), protective
curtain (E) and eye wear (F) can be
seen.

40. Technique
• Rigid bronchoscopy is usually preferred over the flexible technique
as a delivery mechanism for laser therapy. This provides easy
access for suction and grasping of large debris. The rigid scope can
be used to tamponade bleeding. Airway strictures can be dilated
using rigid bronchoscopes of increasing diameter.
• All personnel in the operating room should wear protective
eyewear. Flammable material should be kept away from the
operating field.
• After intubation under GA/LA, a suction catheter and the laser
fiber are inserted. While the laser is fired, the fraction of inspired
oxygen should be kept at 40% to avoid combustion. This is more
important if gaseous anesthesia is being delivered.
• Continuous suction should be applied.
• Once a certain amount of charring has occurred and tissues
become softer, direct mechanical debulking should be done to
expedite the procedure.

41. Indications
• Relief of obstruction by tumor or benign exophytic lesion, and
intraluminal disease involving the central airways.
• Central or segmental airway strictures or scarring from
tuberculosis, prior lung resection, trauma, radiation therapy,
tracheotomy, tracheostomy, inhalation injury, endotracheal
intubation, previous laser surgery,
• Foreign body obstruction causing intractable cough,
hemoptysis, severe dyspnea, or postobstruction pneumonia
• Treatment of in situ bronchogenic carcinoma or in
conjunction with photodynamic therapy
Contraindications
• Tracheoesophageal fistula
• Uncorrected coagulopathy,
• Total airway obstruction with little if any functional distal
airway open, and little or no exophytic lesion visible
• Extrabronchial disease.

42. COMPLICATIONS
• Hypoxemia can occur both intraoperatively and
postoperatively.
• Hemorrhage can occur immediately after laser ablation
• Perforation and fistulae formation(use power <40watts)
• Fire in the airway(keep FiO2 <0.4)
• Pneumothorax.
Training Requirement
• Trainees should perform at least 15 procedures in a
supervised setting to establish competency. To maintain
competency, dedicated operators should perform at
least 10 procedures annually.

43. 2)Electrocautery /Diathermy
EC uses high frequency AC(10-5 TO 10-7Hz) which generates
local heat causing necrosis & coagulation.
Low frequency current stimulates muscles & nerves. Hence
not used.
For patient and staff protection, proper insulation precautions
need to be observed. Insulated FOB is reqd.
Pt has a plate at back of thigh to ground & complete circuit.
Low V, high I=>coagulation
High V,low I=> cutting
Trainees should perform at least 15 procedures in a
supervised setting to establish basic competency in
endobronchial electrocautery and APC. & perform 10
procedures /yr to maintain competency

44. • Accessories required include coagulation probe, snare,
biopsy forceps & cutting knife.
• Probe is used for cutting tumours, snare for polyps & knife
for tracheal & endobronchial web

45. 3)ARGON PLASMA COAGULATION
 APC is a noncontact form of electrocautery
 Ionised argon gas created by a high frequency generator
flows through a teflon catheter & the tungsten tip converts
argon to ionised plasma.
 Once gas is released through the catheter tip, it is ignited
through electrical current; an arc is formed if the probe is
close enough to the mucosal surface, causing heat
destruction and desiccation of the tissue.
 The arc can be moved back and forth (painting) and can
even be aimed around bends, making it very suitable for
hard to reach lesions.
 It has a penetration depth of just a few millimeters (3-
5mm),hence its more suitable for the treatment of
superficial and spreading lesions.
 Argon flow is set at 0.3-2ltr/min & power 30-40W

46. Indications of EC/APC
• Any benign or malignant tissue destruction responsive to heat delivery.
Endobronchial malignancy, benign tumors, and relief of postintubation
stenosis, and, in the case of APC, treatment of stent-induced granuloma.
Contraindications
• contraindications for rigid or flexible bronchoscopy,
• pacemaker/metal things susceptible to electrical interference.
Complications
• Risks associated with the rigid or flexible bronchoscopy
• Airway fire
• Hemorrhage
• Airway perforation, and stenosis.
• Pneumothorax/pneumonia/Respiratory failure/Arrythmia
Note: Endobronchial electrocautery is frequently seen as a less expensive
alternative to laser therapy with similar effects and as such similar
indications. Similar to laser, electrocautery cannot be used for extrabronchial
disease

47. 4)Brachytherapy
• Its a minimally invasive procedure that allows
localized delivery of radiation therapy within the
body.
• Methods of brachytherapy delivery include direct
implantation of radioactive seeds into the tumor
area; image-guided implantation of radioactive
sources; transbronchial source implantation with a
bronchoscope; and, most commonly, delivery of a
radioactive source through a transnasal catheter
placed via the lumen of a bronchoscope(M/C).
• 192Ir is the preferred radiation source at this time.

48. Technique
• It may be performed under LA/GA
• FOB is performed via nasal approach. Polyethylene
catheter is introduced into the desired airway .The
involved portion of the airway should have a visible
lumen through which to pass the catheter.
• FOB is withdrawn while catheter is advanced. Then FOB
is introduced through oral approach to confirm correct
placement of catheter. Catheter position is confirmed
radiographically.
• The radioactive source is then afterloaded in a shielded
room using a remote device in the case of high-dose
rate treatment.
• Several treatments at weekly intervals are usually
required for maximal response, but there is no
consensus on optimal dose or frequency.

50. Indications
• Palliation of symptomatic malignant airway obstruction,
• Curative modality in some patients with carcinoma in situ or very
limited early stage lung cancer within the central airways.
Improvement in postobstructive symptoms and hemoptysis is
achieved in most patients.
Contraindications
• Contraindications for rigid or flexible bronchoscopy,
• Malignant tracheoesophageal fistula,
• Prior brachytherapy in the same area.
Complications
• Catheter displacement, which may even penetrate the airway wall
and cause pneumomediastinum and pneumothorax.
• Complications due to the actual radiation effects include fatal
hemoptysis, bronchial necrosis, airway fistulas to neighboring
structures, fibrotic stenosis, and radiation bronchitis
training requirements
• Trainees should perform at least five procedures in a supervised
setting to establish basic competency &perform at least five
procedures per year to maintain competency,

51. 5)Photodynamic Therapy
 Its a minimally invasive procedure that is done using a bronchoscope
and targets tissue destruction using a selectively retained
photosensitizer, which, when exposed to the proper amount and
wavelength of light, produces an activated oxygen species that
oxidizes critical parts of neoplastic cells.
 The photosensitizer is administered IV, and the light source, in the
case of endobronchial treatment, is delivered endoscopically via a
quartz fiber. Direct interstitial delivery of light energy is also possible.
Repeated injections and treatments can be performed.
 In addition to the equipment needed for flexible and rigid
bronchoscopy, a dedicated operator should have available a
photosensitizer, facilities for IV administration, a laser light source
(630 nm with current agents), and an optical fiber. Laser safety
equipment and precautions are also necessary, such as appropriate
eye protection and signage.
 Trainees should perform at least 10 procedures in a supervised
setting to establish basic competency. To maintain competency,
dedicated operators should perform at least five procedures per year

52. Technique
• It may be performed under LA with or without conscious
sedation or under GA
• The photosensitizer (photofrin)is administered IV at a dose
recommended for the specific agent. After an appropriate
interval (usually 1 to 2 days, but within 7 days), a flexible or
rigid bronchoscopy is performed, and the area of abnormality
is illuminated with nonthermal laser (KTP/Argon pumped) of
the proper wavelength (630nm)and dose(200J for 8mins)
• The light is delivered in a superficial or interstitial manner as
required for uniform delivery to the target tissue. Penetration
is limited to 5 to 10 mm from the tissue surface.
• Immediate effects are not seen, but within 48 h, necrosis
becomes apparent. Necrotic tissue must be debrided with
repeat bronchoscopy 1 to 2 days after treatment. Any residual
tumor can be immediately retreated.

53. Indications
 Superficial cancers in patients ineligible for surgery or EBRT.
 palliation of malignant endobronchial obstruction.
 Photodynamic therapy response is not dependent on the tumor cell type. It can be
applied in patients who have already undergone surgery, radiation, or chemotherapy.
Photodynamic therapy produces complete response rates in 60 to 80% of early stage
mucosal carcinomas, and has been shown to palliate airway obstruction in 80% of
patients.
Contraindications
 patients with critical central airway obstruction (because of the delay in
improvement),
 tumors invading the esophagus or major vessels,
 patients with porphyria or an allergy to components of the photosensitizer.
Risks
 skin photosensitivity which may last for up to 6weeks after injection of the
photosensitizer.pts are advised to cover body fully for 6weeks & not get exposed to
light
 Local complications from the treatment include airway edema, necrosis, and
stricture. Tumor lysis can result in bronchovascular fistula or tracheoesophageal
fistula.
 Hypoxia, infection, Fatal hemoptysis

54. 6)Cryotherapy
 It can be used in traditional format or by cryoextraction
 Cryoprobe is passed through bronchoscope till it protrudes 2cm
distally. probe is applied to tumour & freezed (below -20 to -
40℃) for 10 seconds using a foot pedal. Multiple freeze thaw
cycles are given to ensure adequate treatment.
 Freezing causes vasoconstriction,microthrombi formation,
protein & enzyme damage, all leading to tumour necrosis.
 Its safe,easy but effects are delayed. Need repeat
bronchoscopy after 72hrs-1week to remove tumour.
 Its clinical uses are primarily in treating patients with inoperable
obstructive central lung cancers.
 In cryoextraction, a modified cryoprobe from erbe is used which
can withstand forces upto 50N. Probe cooled to -90deg and
applied on tumour for 3-6sec. Then bronchoscope reinserted
after some time & tumour removed.

55. pic

56. Displacement therapy
1)Airway Stents
 Airway stents, similar to vascular stents, are devices designed
to keep tubular structures open and stable,mainly in extrinsic
compression of airways by tumours
 Stents can be metallic or nonmetallic.
 Metallic stents can be covered(with silicon) or uncovered. They
are usually made from nitinol( nickel titanium alloy)
 Depending on the design, they may be placed with either
flexible or rigid bronchoscopes(nonmetallic) directly or through
fluoroscopy guidance
 Delivery devices specific for the individual stent are necessary
and frequently accompany the actual device (such as delivery
catheters).
 In case of airway obstruction, an appropriate lumen is
reestablished before placing a Stent by a variety of methods
depending on the type of obstruction.

57. The choice of stent depends on the underlying lesion to be
treated, dedicated operator preference and resource
availability. Covered metallic stents are most commonly used
for malignant obstructions.
Silicone stent
Require RB
Easily removed
Migration
Can be used in both
malignant and benign
stenosis
Metal stents
Easy to insert
Difficult to remove
Granulation tissue
Not recommended for
most benign stenosis

58. Technique
• It may be performed under LA /GA
• The stent length should exceed the length of the lesion to
some degree to ensure patency.size & length of stent is
determined by CT scan
• If stents are chosen too small in diameter, they may migrate;
if they are chosen too large, they may not open or may cause
stress on the airway wall.
• ET tube is inserted.FOB is inserted orally and a guide wire
passed through instrument port to desired location.
• Now FOB is withdrawn & reinserted through ET tube. stent is
passed through the guidewire, and deployed at desired site.
• Fluoroscopic guidance is used when distal aspect cant be
visualised through FOB
•

60. Indications
• Intrinsic airway obstruction from benign or malignant diseases,
• Extrinsic airway compression such as tumors or other
structures within the chest, sealing of airway fistulas and, in
selected cases tracheobronchomalacia.
Contraindications
• Nonviable lung is present beyond the obstruction.
Complications
• Stent migration ,biofouling of stent & halitosis,
infection,Granuloma formation, stent fractures, hemoptysis, and
airway obstruction due to impaction, pain
• Mortality due to stent placement is rare.
Training Requirements
• Trainees should perform at least 20 supervised procedures in a
supervised setting to establish basic competency & 10
procedures/yr to maintain competency

61. 2)Balloon Dilatation
 Benign tracheobronchial stenosis of the proximal airways can
result from a variety of conditions and can cause dyspnea,
cough, wheeze, stridor, or recurrent pulmonary infections.
 A variety of modalities may be used to manage benign airway
strictures, but none is documented to be uniformly effective
 In some patients with extrinsic narrowing/circumferential
submucosal disease causing airway obstruction,airway
dilatation is 1st reqd before stent insertion
 Balloons used for intravascular procedures can also help to
manage endobronchial stenosis secondary to both malignant
and benign disease. Cordis PTA Dilatation Catheter(Cordis
Europa N.V., The Netherlands) are most commonly used for
endobronchial narrowings.

62.  The Cordis balloon comes in a variety of diameters and lengths
to help dilate areas of bronchial compromise. Occasionally,
strictures are dilated prior to the placement of a stent or even
used to fully expand a stent already in place.
 The balloon is passed endobronchially via either a rigid or
flexible bronchoscope(2.8mm).
 The appropriate diameter and length of the balloon are chosen
for the particular lesion. Ideally, 5-10 mm of balloon should
extend beyond the lesion both proximally and distally.The
treatment should be performed as a series of dilatations with
gradual increase in the balloon diameter to minimize the risk of
tracheobronchial rupture.
 Once inflated to the prescribed pressure, this dilatation
pressure should be maintained for 1-2 minutes. Two minutes is
preferable if the patient can tolerate this without discomfort or
hypoxia.

64. 3)Percutaneous Dilatational Tracheostomy
• PDT is an invasive procedure in which the
placement of a tracheostomy tube is achieved
after establishing a tracheal stoma through
dilation, rather than surgical creation of a
stoma.
• The procedure may be performed in the
operating room or at the bedside. Dedicated
procedure kits including needles, guidewire,
and dilators are available..
• Two dedicated operators along with a nurse
need to be present for this procedure; one
dedicated operator performs the procedure,
and the other manages the airway and
endotracheal tube.
• This second dedicated operator should be
prepared to perform bronchoscopy if
necessary.

65. Technique
 It may be performed under LA /GA
 Patient is placed in supine position with the neck slightly extended.
Ventilation should be controlled and FiO2 changed to 1.0.
 A 1.0- to 1.5-cm superficial incision is made over the intended entry site,
which usually is below the first and above the third tracheal ring.
Depending on the neck anatomy, higher or lower entry points may need
to be chosen.
 Alternatively, the endotracheal tube may stay in place during the
procedure.
 A needle is introduced into the chosen interspace in the midline and a
guidewire inserted. Once the needle is removed, the space is
sequentially dilated to a size appropriate for the desired tracheostomy
tube. The tracheostomy tube is then placed over the guidewire on an
obturator. Once placement is confirmed, the endotracheal tube is
removed.
 Bronchoscopic guidance may be beneficial for the novice and in
complicated cases, and therefore should be readily available. It is not
required for routine use.

66. Indications
 Long-term artificial airway for prolonged ventilator dependence or
management of secretions.
Contraindications
 Absolute contraindications are uncontrollable coagulopathy,
infection over the site, extreme ventilatory and oxygenation
demands, and tracheal obstruction.
 Relative contraindications pertain to unfavorable neck anatomy
and emergency airway management.
Complications
 Airway injury, respiratory depression, pneumothorax, bleeding,
cardiorespiratory arrest, arrhythmia, infection, and death are
potential complications.
Advantage of PDT over conventional tracheostomy
 Lesser incidence of bleeding and infection.
 If performed as a bedside procedure, the risk of patient
transportation and operating room costs are foregone.

67. Selection of Therapy for Airway
obstruction
 For Urgent Therapy
– Laser, Stent, Rigid Bronchoscopy
 For Semi-urgent Therapy
– Cryotherapy, Electrocautery, APC, PDT, Balloon
 For Prolonged Therapy
– PDT, Stent, Brachytherapy

68. Therapeutic interventions for COPD
• Bullectomy ,Bronchoscopic techniques & Lung transplant are
available options
• Bronchoscopic techniques are beneficial in pts with severe end
stage emphysema who are symptomatic despite maximal
medical therapy & pulm.rehabilitation.
• Procedure used depends upon the type of emphysema
• Heterogenous emphysema is defined as greater than 10%
variation in emphysematous destruction (CT attenuation value
<910HU on 10mm CT sections when a density mask is
applied)between upper & lower lobes .Here LVRS is helpful
• Valves(Zephyr or intrabronchial) or coils(PneumRx) are used in
Bronchoscopic LVRS
• In homogenous emphysema, airway dynamics are improved
by airway bypass rather than LVRS

69. Zephyr valve
• Its a 3rd generation valve. Inserted through instrument channel of FOB &
deployed into the desired segment using a delivery catheter to achieve lobar
atelectasis.
• Comes in 2 sizes :4-7mm & 5.5-8.5mm.
• Complications include Acute Exacerbation, pneumothorax, granulation
tissue formation, infection
Endobronchial valve
• Its an umbrella shaped device. Avail in sizes of 5,6,& 7mm
• Undersizing causes lack of seal & oversizing causes ruffling. Hence exact
sizing is done using balloon sizing kit
• Using a delivery catheter passed through a bronchoscope, a synthetic valve
is placed in the target location and fixed to the bronchial wall. The valve is
designed to prevent air inflow during inspiration but to allow air and mucus to
exit during expiration. Several valves may be needed (one or more for each
segment of the lung to be treated). Patients may sometimes be given
antibiotics and/or steroids
• One way valve blocker at airway  shrinkage of emphysematous segment /
lobe (50%)  increasing FEV1 (50%), life quality (most), decreasing O2
dependent (most)

71. Intrabronchial valve (Spiration Inc.) with delivery system deployed
via working channel of bronchoscope.

72. Indications of Intrabronchial Valve removal
Incorrectly positioned/incorrect size
No improvement
Develop complications
While removing, remove FOB unit as a whole, and not
through instrument channel(to avoid damage to FOB)
Complications of EB valve
Exacerbation of COPD(10%):Rx is steroids & antibiotics
Pneumothorax :Conservative Management
Hemoptysis & Hemorrhage
Valve displacement
Granulation tissue
Infections: Rx is remove valve

73. PneumRx LVR coils
 These are memory coils made from
nitinol.Avail in various sizes
 It is delivered STRAIGHT into the
desired airway using delivery system
(cartridge,catheter,guidewire &
forceps)through FOB under
fluoroscopic guidance using a
guidewire.
 Once placed, it recoils into its original
shape & pulls the portion of the lung.
target lobe is treated systematically
with around 10coils, one in each
subsegment

74. Airway bypass
 It relies on creation of collateral channels which allow airways
of destroyed lung to empty more effectively during
expiration,hence reduce hyperinflation.
 Under LA/GA, doppler probe is inserted into FOB to locate an
avascular area in airways. probe is removed & a needle with a
balloon dilator is inserted. Dilator is inflated creating a 3mm
hole between airway segment & parenchyma.
 Then a drug eluting stent on the balloon catheter is inserted &
placed in location such that mid portion of stent is just through
the bronchial wall. Balloon is inflated for 10sec to deploy stent &
maintain airway.
 3stents are inserted in each lung, with a max of 2 in each lobe.
 Complications include AE of COPD(MC), occlusion(usually
within 3months), hemorrhage & pneumomediastinum/thorax

76. BRONCHIAL THERMOPLASTY
• In asthma, increased airway smooth muscle mass leads to
airway hyperresponsiveness and constriction in response to
external stimuli, such as dust, allergens, cold air or stress.
• some patients with severe persistent asthma continue to suffer
from excessive bronchoconstriction that is integral to an asthma
“attack” (exacerbation) despite medical management.
• Reduction of airway smooth muscle helps reduce the ability of
the airways to narrow in response to a trigger, thereby providing
a therapeutic benefit for patients with severe asthma.
• The Alair® Bronchial Thermoplasty System was approved in
April 2010 by the Food & Drug Administration (FDA) for the
treatment of severe asthma in adults.

77. Procedure
 Bronchial thermoplasty is delivered by the Alair® system , which is
comprised of an Alair® catheter and an Alair® controller.
 Its performed in three outpatient procedure visits, each scheduled
approximately three weeks apart. The first procedure treats the
airways of the right lower lobe, the second treats the airways of the
left lower lobe and the third and final procedure treats the airways in
both upper lobes. After all three procedures are performed the
bronchial thermoplasty treatment is complete.
 Preop:patient will be on a 50-mg oral steroid pill for 3 days before the
procedure, 50-mg steroid pill on the day of the treatment. On each BT
treatment day, pulmonary function test must be done.
 The patients prepped and placed under moderate/conscious sedation
 A standard flexible bronchoscope is introduced into the bronchial tree
through either nose or the mouth, and the alair® catheter is
introduced into airways through the bronchoscope.
 The bronchoscope is then navigated to the first target treatment site,
typically the most distal airway in the targeted lobe.

78. The Alair Catheter is a single-use
device designed to be delivered
through the working channel of a
standard bronchoscope.
Expandable electrode array with four
5 mm electrodes that deliver RF
energy to airways main stem bronchi
Alair system delivers the correct
intensity and duration of thermal
energy sufficient to reduce excess
ASM, while limiting long-term
impact to surrounding tissues

79. • Once the Alair® Catheter is positioned at the
desired location of airway, the electrode
array at the tip of the Alair® Catheter is
expanded to contact airway wall; the
physician activates the Alair® Radiofrequency
(RF) Controller to deliver RF energy through
the Alair® Catheter to airway wall.
• The Alair® RF Controller delivers low-power,
temperature-controlled RF energy to the
airway for a maximum of 10 seconds per
activation. The RF energy heats the wall of a
portion of airways in a controlled manner.
• The application of heat to the airway wall is
intended to reduce the amount of excessive
airway smooth muscle present in the airways
and limit its ability to contract and narrow the
airway.

80.  A single activation of the Alair® catheter delivers RF energy
over a distance of 5 mm (the length of the exposed electrodes
within the electrode array). Audible and visual cues from the
Alair® RF controller signify proper delivery of RF energy.
 After each activation the Alair® catheter is repositioned and
subsequent activations are performed contiguously (adjacent
but not overlapping) along airway.
 This technique is used in all of accessible airways distal to the
mainstem bronchi and ≥ 3 mm in diameter. The Alair® catheter
is deployed from the distal to the proximal end of airway being
treated. This process is repeated in all of airways that are
accessible and planned for that bronchoscopy session.

81. INDICATIONS
 Severe persistent asthma in patients 18 years and older.
 Patients whose asthma is not well controlled with inhaled corticosteroids
and long acting beta agonists.
CONTRAINDICATIONS
 Have had this treatment before.
 Patients younger than 18 yrs
 An active respiratory infection
 Have had an asthma attack or changed oral CS dose in the last 2 weeks
 Coagulation defects
BENEFITS
• 32% reduction in asthma attacks
• 84% reduction in emergency room visits for respiratory symptoms
• 66% reduction in days lost from work, school, or other daily activities due to
asthma symptoms
• 73% reduction in hospitalizations for respiratory symptoms

82. VASCULAR INTERVENTIONS
These are mainly done by intervention radiologists
1)BRONCHIAL ARTERY EMBOLIZATION
 Minimally invasive alternative to surgery
 Considered to be the most effective nonsurgical treatment
in the management of massive and recurrent hemoptysis
Indications:
 Failure of conservative or bronchoscopic treatment to
control bleeding
 Massive hemoptysis (300 mL or more of expectorated
blood within a 24-hour period)
 Moderate hemoptysis: three or more episodes of 100 mLor
more within 1 week
 Mild hemoptysis: chronic or slowly increasing episodes
 Recurrent hemoptysis

83. Pre-intervention
• CT angiography (MRI) :to localise site
• Sedation/antitussive
medication/anaesthesia
Procedure
• Interventional suite should be equipped
with digital subtraction technology (DSA)
• Selective catheterization of bronchial
artery of affected side is done by Cobra/
Sidewinder/ Headhunter/ Sos-Omni
catheter.
• Reduce perfusion pressure to fragile
vessels in pathological areas by
occluding the systemic arterial inflow.
• Embolize as close to the site of the
abnormal area as possible, to prevent
recurrence from nonbronchial systemic
collateral vessels
• Final check via guiding catheter
• If the initial embolization proves clinically
unsuccessful within 6-12h extensive
search for collateral blood supply should
be done

84. Embolization Material
1)Permanent occlusive agents
• Polyvinyl alcohol (PVA)/Trisacryl gelatin microspheres
(TGM)/Gelfoam
• Particle size: 100 –1200 m
• The smaller the particles the greater the likelihood of tissue
necrosis
2)Embolization coils
• normal/microcoils (<3F)
• Various shapes &sizes
• High radio-opacity
• Synthetic fibers to maximize thrombogenicity.
• Delivery into the target vessel by saline flush or by push
technique

85.  Immediate control of hemoptysis occur in 73-99% cases.
 Recurrence occur in 10-55% cases
 Poor outcomes have been observed in patients with
aspergilloma.
 Bronchial arteries also supply esophagus,diaphragmatic &
mediastinal visceral pleura &spinal cord. Complications result
from inadvertent occlusion of these branches. most common
side effects: Chest pain 24–91% Dysphagia1–18%
 Most serious complication: Transverse myelitis due to spinal
cord ischemia

86. 2) PULMONARY ARTERY EMBOLIZATION
 Done for pulm.artery aneurysm/AVM
 Main pulm artery Aneurysms are
caused by congenital
disorders/vasculitis. Multiple
aneursms by infection.
Pseudoaneursms mainly occur in
right middle/lower lobe arteries.
Present with hemoptysis,chest pain
or dyspnoea or may be incidental
finding in CXR/CT
 PAVM occur sporadically/due to
trauma/osler weber rendu
syndrome.cause rt-lt shunting
leading to
dyspnoea,fatigue,hemoptysis,stroke
or brain abscess
a)Right pulmonary angiography shows a
big pulmonary arteriovenous
malformation (PAVM) in the middle lobe
and a small one in the lower lobe with a
feeding artery of 1.6 mm (arrows). (b)
Left pulmonary angiography shows a
very small PAVM in the upper lobe with
a feeding artery of 1.5 mm (arrow)

87.  CT angiography is done to
identify all feeding arteries f/b
embolotherapy with coils(should
be 1-2mm larger than artery) or
balloons(if artery <5mm)
 Procedure Successful in 90%
cases
 Postembolization syndrome with
fever & chest pain can occur
 Complications occur in 10-20%
cases.paradoxical air
embolization can occur. To
avoid this, all catheter &
guidewire exchanges & coil
introduction should be done
“under water”
Same case after embolization of the big
PAVM in the middle lobe with use of a
detachable balloon (arrow)

88.  3)SVC STENTING
 SVC obstruction can be due to luminal
cause(thrombus/tumour), extrinsic compression(tumour/LN) or
mural disease
 C/F include marked facial & neck swelling, B/L arm swelling,
cyanosis, dyspnoea,hoarseness& headache.
 Most patients die due to malignancy rather than SVC
obstruction. So aim of stenting is only short term palliation who
fail other aggressive measures.
 In benign lesions, Percutaneous Transluminal Angioplasty is
done before stenting to assess degree of stenosis & localization
of max resistance in stenosed segment. In malignancy,PTA is
done after stenting to establish optimal venous return.
 C/I include preterminal pts with malignancy,chronic venous
thrombosis,endoluminal tumour growth,upper limb paralysis
 Complications :stent migration, denovo thrombosis, pulmonary
embolism

89. 4)PC vascular FB retrieval
FB needing retrieval include lost central venous line, swan ganz
catheters,ventriculoatrial shunts, port-a-caths,cardiac stimulator lines &
pacemaker electrodes
This procedure avoids thoracotomy and open heart surgery
Extraction is done by loop snare technique, helical basket entrapment or
grasping forceps technique or combination of above
Success rate >90%