ARTERIAL EMBOLIZATION

BRONCHIAL ARTERY EMBOLIZATION

Introduction

Last updated: apr 5, 2023

Massive hemoptysis is a frightening and potentially life-threatening clinical event. Patients with chronic inflammatory lung diseases such as bronchiectasis, sarcoidosis, tuberculosis, and cystic fibrosis develop markedly hypertrophied and fragile bronchial arteries that may lead to clinically significant hemoptysis.

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Anatomy

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 Variations of bronchial artery origin pdf 0644 2025070109252601-Jul-2025 09:25 2023031711052217-Mar-2023 11:05 762 KB Preview Print Download

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Indications

  • Massive hemoptysis (defined as bleeding greater than 240 to 300 mL/24 hours) carries a 50 to 85% mortality rate when treated conservatively. Death is most often due to asphyxiation from the aspiration of blood, leading to airway obstruction.
  • Recurrent bouts of moderate hemorrhage (three or more bouts of 100 ml of blood per day within a week) are now also considered a major hemorrhagic event.
  • In addition, chronic or slowly increasing hemoptysis is considered an indication for transcatheter therapy.

 

Contra indications

Absolute

  • The only absolute contraindication is a supplying branch to the heart, brain or spinal cord.
  • And of course are the usual contraindications, absolute or relative, for angiography in general

Relative

 

Workup

  • Bronchoscopy (BC)
    • lateralisation
    • clot extraction
    • direct instillation of medications
    • tamponade
    • ablation of haemorrhagic arteries
    • supports selective intubation
    • The source is most likely to be located during active haemoptysis (in 73–93% of cases) or within 24–48 h of cessation

 

Pre procedural

  • Stop any anti-coagulation medication
  • Correct any coagulopathy before embolization, (achieving hemostasis depends on ability to clot).
  • Computed tomography angiography (CTA)

 

Materials

Essentials

Diagnostic Catheters

  • reversed curved shapes
  • forward-looking shapes
Microcatheter
  • 2.7–2.9 Fr. preferred
Microwires
  • 0.014 00or 0.016 00in diameter, hydrophilic coating preferred
Non-ionic contrast
Embolic agents
  • spherical or non-spherical particles (300–900 lm)
  • non-spherical, PVA particles, 355–500 micronrecommended for BAE.
  • never use particles with a diameter <300 lm for BAE
  • liquid embolic (NBCA, non-adhesive, high-viscous polymers)
  • gelfoam (only as supplementary agent)
  • microcoils (in specific situations)

Non-Essentials

 

Positioning the patient

  • Supine

 

Tips and tricks

  • Where clinical or imaging lateralisation of the bleeding site is uncertain, treat any enlarged bronchial arteries at the first session.
  • Carefully scrutinize angiography for any signs of non-target vessels leading to brain, spine cord and heart before starting the embolisation procedure
  • At all times embolisation is performed with a small (1 ml) Luer-lock syringe under active fluoroscopy to ensure any sign of reflux is picked up as early as possible.
  • Use the left main bronchus as a reliable reference point for catheterisation of the right or left bronchial arteries
  • In case of bronchial-to-pulmonary shunts, use larger particles and coils
  • Actively search and embolise as many non-bronchial systemic collaterals in the first BAE procedure as possible to decrease recurrence rates of haemoptysis. Angiography of the subclavian arteries should be considered, to determine the origin of ectopic BA supplied by internal thoracic arteries or thyrocervical trunks, in apical- predominant disease

 

Complications

  • Chest pain and dysphagia common within the first week (>30%)
  • Post-embolization syndrome (2-30%)
  • Spinal cord ischemia (<1%)
  • Bronchial artery dissection or perforation (3-10%)
  • Transverse myelitis (based on non-ionic contrast)
  • Rare reported major complications include bronchial infarction, oesophago-bronchial fistula, myocardial infarction, ischemic colitis, transient cortical blindness, phrenic nerve injury, and stroke all of which can be attributed to non-target embolisation.
  • Death

 

Post-op

  • Observe for signs of neurological deficit.
  • Provide supplemental oxygen, IV fluids, and blood pressure maintenance (mean arterial pressure above 80 mmHg) if spinal cord damage occurs.
  • A spinal drain should be inserted if spinal cord infarction cannot be immediately confirmed

 

Report

Time out akkoord. Patient in rugligging. Wassen met chloorhexidine en steriel afdekken. Echografisch geen stenose in de AFCD. Retrograde toegang, met 6F sheath. 5000 IE Heparine.

Superselectieve katheteisatie van de ... bronchiaal arterie, afgaande van ... Angiografie toont geen voorziening van de spinalis anterior. Embolisatie met ... micron partikels.

Angioseal

 

Literature

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