A 44-year-old man with hemoptysis: A review of pertinent imaging studies and radiographic interventions

Cleveland Clinic Journal of Medicine. 2008 August;75(8):601-607

August 1, 2008|Cleveland Clinic Journal of Medicine

Arlene Sirajuddin, MD;Tan-Lucien H. Mohammed, MD

ABSTRACTChest radiography, conventional computed tomography (CT), multidetector CT angiography, and conventional thoracic angiography are all useful in assessing patients with hemoptysis. In this paper we outline our approach to assessing and treating these patients.

KEY POINTS

We recommend chest radiography in the initial stages of evaluation of hemoptysis, whether the hemoptysis is massive or nonmassive.
In cases of hemoptysis that is intermittent (whether massive or nonmassive) in patients whose condition is stable, CT, multidetector CT angiography, and bronchoscopy are all useful.
In cases of hemoptysis that is active, persistent, and massive, multidetector CT angiography, bronchoscopy, and conventional bronchial angiography are all useful, depending on the hemodynamic stability of the patient.
Bronchial artery embolization is the preferred noninvasive first-line treatment for hemoptysis and offers an excellent alternative to surgery for patients who are poor candidates for surgery.

BRONCHIAL ARTERY EMBOLIZATION: AN ALTERNATIVE TO SURGERY

After a cause of the hemoptysis has been established by radiography, CT, or bronchoscopy, bronchial artery embolization is an effective first-line therapy to control massive, life-threatening bleeding.⁶ It is an alternative in patients who cannot undergo surgery because of bilateral or extensive disease that renders them unable to tolerate life after a lobectomy.⁶^,¹²^,¹⁸

Indications for bronchial artery embolization include failure of conservative management, massive hemoptysis, recurrent hemoptysis, and poor surgical risk. It is also done to control bleeding temporarily before surgery.¹

Another indication for this therapy is peripheral pulmonary artery pseudoaneurysm, which is found in up to 11% of patients undergoing bronchial angiography for hemoptysis. These patients typically present with recurrent hemoptysis (sometimes massive) and occasionally with both hemoptysis and clubbing. Most of these patients have either chronic active pulmonary tuberculosis or a mycetoma complicating sarcoidosis or tuberculosis. Occlusion of the pulmonary artery pseudoaneurysm may require embolization of bronchial arteries, nonbronchial systemic arteries, or pulmonary artery branches.²⁰

Surgery, however, is still the definitive treatment of choice for thoracic vascular injury, bronchial adenoma, aspergilloma resistant to other therapies, and hydatid cyst.⁶ A cardiothoracic surgeon should be consulted in these cases.

Outcomes of embolization

Figure 5. A pathologic bronchial artery to a mediastinal tumor before (left) and after (right) embolization with polyvinyl alcohol particles.

Aside from the cases in which surgery is indicated, bronchial artery embolization (Figure 5) is a very successful minimally invasive therapy that controls bleeding immediately in 66% to 90% of patients.¹^,⁷^,²¹ It is the preferred emergency treatment for massive hemoptysis, as the death rate is 7.1% to 18.2%, which, though high, is considerably less than the 40% seen in emergency surgery for massive hemoptysis.⁶

If a patient with massive hemoptysis undergoes successful bronchial artery embolization but the bleeding recurs 1 to 6 months later, the cause is likely an undetected nonbronchial systemic arterial supply and incomplete embolization.¹^,²² Late rebleeding (6–12 months after the procedure) occurs in 20% to 40% of patients and is likely to be from disease progression.¹^,⁷

Common complications of bronchial artery embolization are transient chest pain and dysphagia. Very rare complications include subintimal dissection and spinal cord ischemia due to inadvertent occlusion of the spinal arteries.⁶ Another complication in patients with renal failure is contrast nephropathy, the risk of which must be weighed against the possible consequences—including death—of not performing bronchial artery embolization in a patient who cannot undergo surgery.

CASE REVISITED: CLINICAL COURSE

In the patient described at the beginning of this article, a chest radiograph obtained in the emergency room showed an area of nonspecific consolidation in the left upper lung. Conventional chest CT was then ordered (Figure 4), and it revealed a cavitary lesion in the left upper lobe, consistent with aspergilloma. Bronchoscopy was then performed, and it too indicated that the bleeding was coming from the left upper lobe. Samples obtained during the procedure were sent to the laboratory for bacterial and fungal cultures.

In the meantime, family members were contacted, and they revealed that the patient had a history of sarcoidosis.

The patient went on to develop massive hemoptysis. Although the treatment of choice for mycetoma is primary resection, our patient’s respiratory status was poor as a result of extensive pulmonary sarcoidosis, and he was not considered a candidate for emergency surgery at that time. He was rushed to the angiography suite and successfully underwent emergency bronchial artery embolization.

References

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