Imaging in haemoptysis

Definition
• Hemoptysis (Gr. haima=blood; ptysis=spitting )
 The spitting of blood derived from the lungs or bronchial
tubes as a result of pulmonary or bronchial hemorrhage.
• Hemoptysis, defined as bleeding that originates from the lower respiratory
tract, is symptomatic of potentially serious or even life-threatening thoracic
disease and warrants urgent investigation
(Stedman TL. Stedman’s Medical dictionary. 27th ed. Philidelphia: Lipincott Williams & Wilkins, 2000.)
2

Pathophysiologic Features
and Causes of Hemoptysis
• The lungs are supplied by a dual arterial vascular system composed
of
– (a) the pulmonary arteries, which account for 99% of the arterial
blood supply to the lungs and take part in gas exchange; and
– (b) the bronchial arteries, which are responsible for providing
nourishment to the supporting structures of the airways and of the
pulmonary arteries themselves (vasa vasorum) but do not normally
take part in gas exchange.
• The bronchial vasculature feeding the intrapulmonary airways is
situated close to the pulmonary arteries at the level of the vasa
vasorum, and histologically the two systems are connected by
anastomoses between the systemic and pulmonary capillaries .
• This communication between the bronchial and pulmonary arteries
contributes to a normal right-to-left shunt that accounts for 5% of
cardiac output.

• Conditions causing reduced pulmonary arterial perfusion
such as chronic thromboembolic disease and vasculitic
disorders, in which there is a reduction in pulmonary
arterial supply distal to the emboli, can lead to a gradual
increase in the bronchial arterial contribution, thereby
increasing the importance of bronchial-to- pulmonary
artery anastomoses in regions of the lung that are
deprived of their pulmonary arterial blood flow.
• Experimental studies have suggested that the increased
bronchial arterial blood flow is due to neovascularization.
• Neoplastic disease can also be responsible for such humor-mediated
neovascularization
• Such newly formed collateral vessels are usually fragile and
“leaky” and prone to rupture.

• Blood Circulation in the lungs :
Low pressure
2 Components
Pulmonary Circulation
SBP = 15-20 mmHg
DBP = 5-10 mmHg
Patients with normal PAP ( no
PAH) rarely bleed: only 5% of
massive hemoptysis
High pressure
Bronchial Circulation
= systemic pressures
Bronchial arteries & collaterals
originate from the aorta
The source of bleeding in most cases
Bleeding mechanisms
• Inflammation  Erosion of the vessel wall
• Increased pressure in the vessel  Increase vessel size  Rupture
Aneurysm formation

Etiology: Classification by site
Tracheobronchial source
Bronchitis
Bronchiactasis
Neoplasm
Broncholithiasis
Airway trauma
Foreign body
Pulmonary Parenchymal
Source
Lung abscess
Pneumonia
TB
Mycetoma (Fungus Ball)
GPS
Idiopathic pulmonary hemosederosis
WG
Lupus pneumonitis
Lung contusion
Pulmonary Vascular source
Pulmonary embolism
Arteriovenous malformations
Pulmonary arterial hypertension
Pulmonary venous hypertension
(Mitral stenosis)
Pulmonary artery rupture
Miscellaneous/rare causes
Pulmonary endometriosis
Systemic coagulopathy
Use of anticoagulants or thrombolytics

INFECTION
It is the most common cause of hemoptysis worldwide
with 2 billion people infected worldwide with 5-10% developing disease
(Public Health Reports. Vol. 3. New York: World Health Organization; 1996: p. 8–9.)

GRADE AMOUNT /24 HRS
Mild < 50 ml
Moderate 50 - 200 ml
Severe**/Major* > 200 ml * 150 ml per 12 hrs or**
9
>400 ml per 24 hrs
Massive > 600 ml
Exsanguinating# #1,000 ml total or 150
ml/h
Life-threatening 200 ml/h or 50 ml/h in a
patient with chronic
respiratory failure.
*Corey R, Hla KM.Am J Med Sci 1987; 294:301–309.
**de Gracia J, de la Rosa D, Catal!an E, Alvarez A, Bravo C, Morell F. Respir Med 2003; 97: 790–795
#Garzon AA, Cerruti MM, Golding ME: Exsanguinating hemoptysis. J Thorac Cardiovasc Surg 1982; 84: 829–833.

Approach
• Localization and treatment of hemoptysis
demands a multifaceted evaluation involving
medical, radiologic, and surgical disciplines.

Predictors of Mortality
 71% in patients who lost =>600 ml
of blood in 4 h
 22% in patients with =>600 ml
within 4–16 h
 5% in those with 600 ml of within
16–48 h
Life-threatening massive : 5 to 15%.
• *Crocco JA, Rooney JJ, Fankushen DS, et al:Massive hemoptysis. Arch Intern Med
1968;121: 495–498.

Initial Evaluation
• Assess Severity & Urgency
– Duration of bleeding
– Extent of bleeding
– Reliability
• Assess the Cardio-Respiratory reserve
• Prior Episodes of bleeding
• Clues to the cause
• In particular, the recognition of “sentinel bleeding” heralding
imminent major hemorrhage is of critical importance but is
often difficult on the basis of clinical findings alone.

Approach to a patient with
haemoptysis
• History & Physical Examination
• Diagnostics
– Laboratory studies
– Radiologic studies
– Endoscopic studies
• Management

Clues from the Hx
Risk Factors for
Bronchogenic CA
Smoking, Asbestosis
Risk Factors for
Lung Abscess
Alcohol, Coma
Poor dental hygiene
Risk Factors for
HIV Infection
Drug Abuse, Sexual Practices
Hx of blood transfusion
Renal disease GPS,WG

Clues from the Hx
History of previous or co-existing disease
SLE Lupus Pneumonitis
Malignancy Primary
Metastatic
AIDS Endobronchial KS
Previous bleeding Bleeding diathesis
Anticoagulant use
Thrombocytopenia
Blood streaking of
mucopurulent or purulent
sputum
Bronchitis

Clues from the Hx
Chronic sputum production +
Recent change in quantity or appearance
Acute Exacerbation
of COPD
Fever & chills + Blood streaking of
purulent sputum
Pneumonia
Putrid smell of purulent sputum Lung abscess
Sudden chest pain &/ SOB PE

Etiology
Make sure it is Hemoptysis
DDx:
• Hematemesis
• Epistaxis
• Other nasopharyngeal bleeding

20
Hemoptysis Hematemesis
1 Cough + -
2 Sputum Frothy
Bright red -pink
Liquid or clotted
Rarely frothy
Brown to black
Coffee ground
3 Respiratory
symptoms
+ -
4 Gastric or Hepatic
disease
- +
5 Vomiting &
Nausea
- +
6 Melena - +
7 Asphiyxia usual unusual
8 Laboratory
Parameters
Alkaline pH;Mixed with
macrophages and
neutrophils
Acidic pH;Mixed with food
particles

Diagnostics
Basics
Labs
Radiologic studies
Endoscopic studies
After comprehensive Hx & P/E
Goals:
• Identify the cause
• Localize the site of bleeding
• Assess the general
condition of the patient

LABS
CBC
PT, PTT & INR
Sputum Studies
Cultures
Urine Analysis
ABG’s

Radiologic Studies
• Radiographs
• CT
• Angiography
• Further investigations
– Nuclear Medicine
– MRI

ACR Appropriateness Criteria Hemoptysis

Conventional radiography
• Conventional radiography is a basic study and is readily
available even under emergency conditions.
• Due to its convenience and portability in the acutely ill
patient, chest radiography remains a basic and useful
diagnostic tool in the evaluation of hemoptysis.
• It may be helpful in diagnosing and localizing
pneumonia, acute or chronic pulmonary tuberculosis,
bronchogenic cancer, or lung abscess.
• Radiography can help lateralize the bleeding with a
high degree of certainty and can often help detect
underlying parenchymal and pleural abnormalities.

• The ability of chest radiography to accurately
localize the disease process is highly variable,
and can be normal in up to 30% of patients.
• Localization can be particularly difficult due to
either opacification of both lungs during
episodes of massive hemoptysis or in the
setting of bilateral disease.

• Although radiography is a useful initial examination, it
needs to be complemented with more detailed evaluation.
• In a retrospective evaluation of 208 patients with
hemoptysis, Hirshberg et al found that radiography was
considered to be diagnostic in only 50% of cases.
• In a study by Herth et al, almost one-quarter of patients
presenting with acute hemoptysis secondary to malignancy
had normal chest radiographic findings.
• Therefore it is recommended that additional follow-up
testing is done in patients presenting with hemoptysis in
whom the underlying cause was not detected at initial
radiography.

Role of CT
• Contrast material–enhanced multi– detector row CT
has the unparalleled advantage of allowing acquisition
of high-quality images of the entire thorax in a rapid,
safe, and noninvasive manner.
• Published studies on the efficacy of single– detector
row spiral CT have already demonstrated the capacity
of this imaging technique to help predict the site of
bleeding as accurately as bronchoscopy and to help
detect underlying disease with high sensitivity.
• Multi–detector row CT provides extended volume
coverage with higher image resolution and even
greater scanning speed

• The aims of multi– detector row CT in the evaluation of
hemoptysis are threefold:
– (a) to depict underlying disease with high sensitivity by means
of detailed images of the lung parenchyma and mediastinum,
and in particular to help detect early carcinoma;
– (b) to help assess the consequences of hemorrhage into the
alveoli and airways, which may cause immediate clinical
concerns as well as mask subtle underlying abnormalities; and
– (c) to provide a detailed “road map” of the thoracic vasculature
by means of two-dimensional (2D) maximum-intensity-projection
(MIP) reformatted images and three-dimensional
(3D) reconstructed images. Such road maps are of great use to
both the interventional radiologist anticipating arterial
embolization and the thoracic surgeon contemplating surgery.

Multi–Detector Row CT Technique
• An extended spiral CT study of the thorax can easily be
performed with a 16–detector row scanner during a single
breath hold (normally lasting less than 15 seconds) in most
patients.
• However, only a limited study with a four– detector row or
single– detector row scanner may be possible, depending
on the patient’s respiratory capacity.
• Image acquisition should be performed in a craniocaudal
direction from the base of the neck to the level of the
renal arteries to include the supraaortic great vessels and
the infradiaphragmatic arteries, which may be responsible
for an abnormal collateral contribution to the lungs.

• With current multi– detector row systems,
optimal enhancement of both the pulmonary and
systemic arteries is achieved with the injection of
approximately 120 mL of a relatively high-density
contrast material (350 mg/dL) at a rate of 4 mL/
sec via an 18-gauge cannula into an antecubital
vein or central venous catheter.
• The scan should be started during the phase of
peak systemic arterial enhancement (Table 2).

• Images should be acquired with thin
collimation and with the table movement
adjusted to allow extended volume coverage
during a single breath hold.
• By adjusting the exposure parameters and
kilovoltage according to the patient’s weight,
the radiation dose to be minimized without
compromising image quality.

• In certain cases, it may be useful or even necessary to
perform follow-up CT several months after the episode
of hemoptysis to study the evolution of underlying
parenchymal lung abnormalities or to exclude the
possibility that a small malignancy may have been
missed at initial CT.
• Repeat evaluation of the bronchial arteries is not
usually necessary unless there is continued
hemoptysis; consequently, follow-up imaging can be
performed without intravenously administered
contrast material and at low milliamperage to minimize
the radiation dose to the patient, which is of particular
importance in young patients.

Data Manipulation
and Image Interpretation
• Because of the very large number of images
acquired with a thin-collimation scan of the
extended thorax, studies are best interpreted at
the scanner console or remote workstation by
scrolling through the images.
• The lung parenchyma and gross soft-tissue
structures can be adequately evaluated with a
section thickness of 5 mm.
• Detailed analysis of the airways and lung
interstitium requires thinner sections.

• Thoracic CT angiography with a combination
of multiplanar reformatted images can help
identify the variable origins and courses of
arteries that may be responsible for bleeding
in cases of hemoptysis and can aid in planning
the embolization of these arteries.

• The origins of
orthotopic mediastinal
bronchial arteries are
best depicted on
overlapping axial thin-section
images (eg, 1-
mm-thick sections at
0.75-mm increments).
Axial 1-mm-thick CT scan obtained just below the aortic arch shows enlarged bronchial arteries
(arrow) manifesting as avidly enhancing nodules in the paratracheal and retrobronchial regions
of the mediastinum. These findings represent the typical appearance of enlarged bronchial
arteries on axial images.

• Two-dimensional MIP reformatted
images in the coronal oblique and sagittal
planes readily depict the tortuous
trajectories of the bronchial arteries from
their origins (descending thoracic aorta)
to the lungs along the main bronchi;
• reformatted images in straight coronal
planes are better suited for analysis of the
intercostal and internal mammary
arteries; and axial reconstructed images
are ideal for demonstrating the inferior
phrenic arteries and branches from the
celiac axis.
Coronal thin-section MIP image clearly demonstrates
an enlarged intercostobronchial artery (arrows)
coursing into the pulmonary parenchyma parallel to
the bronchial airways.
Coronal thin-section MIP image obtained in a different
patient provides a detailed analysis of the entire
intrapulmonary course of an intercostobronchial
artery (arrows). intracavitary mycetoma.

• The degree of obliquity of the reconstruction
planes and the section thickness of the
reformatted images normally have to be
adjusted on a case-by-case basis to provide
optimal depiction of the vessels in question.

• Three-dimensional volumetric and shaded surface- display
(SSD) reformatted images are useful not only to
interventional radiologists contemplating embolization
therapy, for whom they provide a better perspective on the
origin and course of the abnormal artery and aid in the
choice of catheter shape, but also to surgeons anticipating
arterial ligation, particularly when “minithoracotomy”
techniques are used.
• In addition to depicting the abnormal vessel itself and its
relationship to adjacent anatomic structures, volumetric
reformatted images can furnish the surgeon with a
“preview” of the osseocartilaginous and musculotendinous
structures that will be involved in any planned surgical
intervention.

• In summary, a comprehensive range of
reconstructed images that includes
– thick- and thin-section axial images obtained with
both mediastinal soft-tissue and parenchymal lung
window settings, as well as
– 2D MIP reformatted images in the coronal, sagittal,
and
– axial planes and selected 3D volumetric and SSD
reformatted images,
• are recommended for a thorough CT assessment
of hemoptysis (Table 3).

• There are studies suggesting that
multidetector CT may be more accurate than
arteriography at delineating the origin and
course of both the bronchial and nonbronchial
systemic arteries, especially when combined
with 3D reconstructions.
Hartmann IJ, Remy-Jardin M, Menchini L, Teisseire A, Khalil C, Remy J. Ectopic origin of
bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol
2007;17(8):1943–1953
Remy-JardinM, Bouaziz N, Dumont P, Brillet PY, Bruzzi J, Remy J. Bronchial and nonbronchial
systemic arteries at multidetector row CT angiography: comparison with conventional
angiography. Radiology 2004;233(3):741–749

• It has been stated that CT and FOB are not
competitive but complementary tools for
assessing patients with hemoptysis, and indeed,
the combined use of FOB and CT does yield the
best results in evaluating hemoptysis.
• However, many researchers are currently
suggesting that CT should be performed prior to
bronchoscopy in all patients with hemoptysis.

Assessment of CT
• Urgent evaluation with thoracic CT
angiography can help accurately identify the:
– source and
– predisposing causes of hemoptysis and
– effects of hemorrhage on the lungs.

Assessment of CT
• Assessment of the Lung Parenchyma
• Assessment of Pulmonary and Systemic
Vasculature
– Pulmonary arteries
– Bronchial arteries
– Non Bronchial Systemic arteries
– Bronchial-to-Systemic artery communication

Assessment of the Lung Parenchyma
• Possible underlying causes of hemoptysis that
are identifiable on axial CT scans obtained
with lung parenchymal window settings
include:
– bronchiectasis,
– lung carcinoma,
– acute and chronic lung infections (in particular,
tuberculosis and aspergillosis), and
– cardiogenic pulmonary edema.

• In patients with extensive bilateral
disease or equivalent findings, the
site of hemorrhage can usually be
localized on the basis of:
– the presence of liquified material in
segmental and lobar bronchi and
– hazy consolidation or
– ground-glass infiltrates in the lung
parenchyma, findings that represent
intraalveolar hemorrhage.
– show extravasation of contrast
medium into a bronchus
– Intrapulmonary shunting
• The accurate localization of the
site of bleeding is important both
for possible future lung resection
and prior to endovascular therapy,
for which identification of the
specific vessels that require
embolization is necessary.
Axial CT scan (1-mm-thick section) obtained with
parenchymal lung window settings
in a patient with hemorrhage following an episode of
hemoptysis demonstrates bronchial impaction from
blood clot (arrow) in a subsegmental branch of the
anterior segmental bronchus of the right upper lobe,
a finding that helps localize the site of bleeding.

45-year-old man with hemoptysis.
Axial MDCT reconstructions with 1-mm-thick slice
viewed at lung window settings show ground-glass
opacities on anterior segment of left upper lobe

Iodine extravasation into bronchi of 57-yearold
woman with hemoptysis.
A, Sagittal multiplanar reconstruction image on lung
window setting shows contrast medium (arrow) in
bronchi of left upper lobe with air bubbles
(arrowheads).
B, Sagittal multiplanar reconstruction image on
mediastinal window setting shows same density in
bronchi (arrows) and left pulmonary artery
(asterisk) as that shown in A.

45-year-old man with right upper lobe atelectasis
due to tubercular sequelae complicated by
aspergilloma was admitted for mild hemoptysis.
Coronal thin-slab maximum-intensity-projection
(MIP) image shows enhancement of pulmonary
arteries (arrows) with reflux into right main
pulmonary artery (arrowhead).

• The consequences of hemorrhage
into the airways and lung
parenchyma may also mask subtle
underlying disease.
• The filling of airway lumina or
intraparenchymal cavities with
blood may obscure small
endobronchial tumors and
intracavitary lesions such as
mycetomas.
• In addition, blood clots may
simulate more sinister disease
entities such as nodules and
masses.
• For these reasons, it is often
advisable to perform follow- up CT
several weeks after the episode of
hemoptysis for a more thorough
analysis of the underlying lung
parenchyma and for the detection
of early lung carcinoma.
Axial CT scan (1-mm-thick section) obtained at the
level of the right lower lobe in a patient with
lymphangioleiomyomatosis who presented with
recurrent hemoptysis depicts an air-fluid level in a
pulmonary cyst (arrow), a finding that represents
intracavitary blood.

Assessment of
Pulmonary and Systemic Vasculature
• Pulmonary arteries
• Bronchial arteries
• Non Bronchial Systemic arteries
• Bronchial-to-Systemic artery communication

Pulmonary Arteries
• The pulmonary arteries should
always be analyzed to exclude
the possibility of pulmonary
emboli, particularly in the
presence of subpleural areas
of enhancement that could
represent areas of lung
infarction and that may be
responsible for hemoptysis.
• Acute thromboembolic
disease is a frequent cause of
nonmassive hemoptysis that
requires urgent diagnosis and
treatment with
anticoagulation therapy.

• The pulmonary arteries
may also be the source
of hemorrhage in cases
of direct invasion by
neoplastic disease or by
necrotizing
inflammatory disorders
such as tuberculosis.

• Rasmussen aneurysms, representing fragile pulmonary
arterial pseudoaneurysms arising within areas of tuberculous
inflammation, may be responsible for sentinel bleeding prior
to catastrophic hemorrhage and can be identified on contrast-enhanced
CT scans as avidly enhancing nodules located within
the walls of tuberculous cavities.

• Dieulafoy disease is a poorly understood condition characterized by
abnormally dilated submucosal vessels that are prone to
hemorrhage and has been described in the colon, the small
intestine, and, more recently, the bronchial airways.
• It usually coexists with chronic inflammatory disorders such as
chronic bronchitis and is thought to involve the pulmonary arterial
system rather than the bronchial arteries.
• At fiberoscopic endoscopy, the visualization of a tangle of dilated
submucosal blood vessels in the presence of mucosal inflammation
should raise suspicion for Dieulafoy disease and alert the
bronchoscopist to forego mucosal biopsy.
• There have been no published CT descriptions of this vascular
anomaly.

• Life-threatening hemoptysis may occur, albeit uncommonly,
following rupture of thin-walled pulmonary arteriovenous
malformations.

Bronchial Arteries
• In 95% of cases of hemoptysis, the systemic arterial system
is the origin of the bleeding .
• Although there is poor correlation between bronchial
arterial dilatation and the risk of hemorrhage , a diameter
of more than 2 mm is considered abnormal.
• The bronchial arteries have highly tortuous but predictable
trajectories that can easily be analyzed with a thorough
knowledge of bronchial arterial anatomy.
• Because they course predominantly perpendicular to the
scanning plane, on axial images they appear as a cluster of
avidly enhancing nodules in the posterior mediastinum,
usually just below the level of the aortic arch

• Although the bronchial arteries are the most
common source of bleeding in hemoptysis,
the actual hemorrhage usually occurs from
fragile thin-walled anastomoses between
distant bronchial arterial branches and
pulmonary arteries that are under high
systemic arterial pressure, located in the
airway submucosa and too small to be directly
visualized at CT.

• Active bleeding can
rarely be detected at CT
due to the presence of
contrast material in the
airway lumen.
• At conventional
angiography, active
hemorrhage can also
manifest as staining of
the lung parenchyma by
contrast material. Axial thoracic CT scans obtained on a 16–detector row
scanner with lung parenchymal window settings and
mediastinal soft-tissue window settings depict dense
material (arrow) within the apical segmental bronchus
of the right upper lobe.

• Active bleeding can
rarely be detected at CT
due to the presence of
contrast material in the
airway lumen.
• At conventional
angiography, active
hemorrhage can also
manifest as staining of
the lung parenchyma by
contrast material. Sequential arteriograms of the intercostobronchial
artery demonstrate immediate filling of the apical
segmental bronchus with contrast material (arrow), a
finding that indicates active bleeding from the
intercostobronchial trunk into the bronchial tree.

• Bronchial artery aneurysms are
rare entities that may arise either
within the mediastinum or from
the intrapulmonary portion of the
artery .
• Whereas intrapulmonary
bronchial artery aneurysms may
remain clinically silent,
mediastinal aneurysms can
manifest with symptoms related
to local compressive effects .
• Rupture of intrapulmonary
aneurysms gives rise to massive
and often catastrophic
hemoptysis; rupture of more
proximal mediastinal aneurysms
may manifest with acute tearing
chest pain simulating aortic
dissection.

• Bronchial artery aneurysms
can be detected with
contrast-enhanced CT.
• The success of coil
embolization therapy
depends on aneurysm
location; attempts at
embolization of aneurysms
arising close to the ostia of
the bronchial artery can be
limited by difficulty in coil
placement

• Bronchial arteries of anomalous origin are easily
overlooked during bronchial artery embolization, even
when complemented with arch aortography, but are well
depicted with extended thoracic CT angiography that
includes the base of the neck and the upper abdomen.

Nonbronchial Systemic Arteries
• Nonbronchial systemic arteries acting as a
source of hemoptysis can arise from:
– branches of the supraaortic great vessels
(brachiocephalic artery, subclavian arteries,
thyrocervical and costocervical trunks),
– the axillary arteries,
– the internal mammary arteries and
– infradiaphragmatic branches from the inferior
phrenic arteries, the gastric arteries, and the
celiac axis.

Classification of the nonbronchial
systemic arteries
Classification on CT according to the anatomic location:
– superolateral (branches of the subclavian and axillary
arteries at angiography and nonbronchial systemic arteries
at the apex of the chest above the level of the aortic arch
at CT),
– anteromedial (internal mammary artery and its branches
at angiography and nonbronchial systemic arteries along
the anterior and mediastinal pleura below the level of the
aortic arch), and
– posterior (intercostal arteries at angiography and
nonbronchial systemic arteries along the posterior pleura),
regardless of the exact name of the artery.
Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ
. Hemoptysis: bronchial and nonbronchial systemic arteries at 16-detector row CT.Radiology 2005;234(1):292–298

• At contrast-enhanced
CT, these vessels
manifest as abnormally
dilated arteries that
course into the lungs
along trajectories that
are not parallel to the
bronchi; they are
usually very tortuous
and are well depicted
on reformatted images. Posterior 3D SSD image from thoracic CT angiographic data
obtained with a 16–detector row scanner depicts an
enlarged right internal mammary artery supplying
hypertrophic mediastinal branches (arrows) to an area of
the right upper lobe.

• On axial images, their
presence can often be
predicted on the basis
of pleural thickening
greater than 3 mm with
enhancing arteries
within the extrapleural
fat .
Prediction of nonbronchial systemic arterial supply.
Contrast-enhanced CT scan demonstrates diffuse
pleural thickening at the upper thorax (solid
arrows) and tortuous, enhancing vascular structures
within a hypertrophic extrapleural layer of fat (open
arrows). Hypertrophic bronchial arteries are also
seen in the aortopulmonary window.

• Nonbronchial systemic arteries have
been reported to be important
contributing sources in 41%–88% of
cases of massive hemoptysis.
• Like dilated bronchial arteries, they
are often observed with other
radiologic signs of chronic pulmonary
inflammatory disease, usually with
evidence of pleural adhesions.
• Failure to recognize such systemic
arteries can lead to recurrent
hemoptysis following bronchial artery
embolization.
• The CT evaluation of hemoptysis
should always be extended, if
possible, to include the supraaortic
great vessels and the upper abdomen.

• Pseudosequestration, or purely vascular pulmonary sequestration, is a
rare entity that may be responsible for hemoptysis from nonbronchial
systemic arteries and that has traditionally been treated with surgical
resection but may also be suitable for embolotherapy.
• Unlike bronchopulmonary sequestration, pseudosequestration is
characterized by a purely vascular anomaly without involvement of the
bronchial tree or lung parenchyma.
• There is usually a single systemic artery arising from the descending
thoracic aorta that supplies a normal part of the lung, usually in the lung
bases, with venous drainage via the pulmonary veins.
• Although purely vascular sequestrations are mostly asymptomatic and are
usually discovered incidentally at chest radiography or thoracic CT, they
may be complicated by massive hemoptysis, which can be effectively
controlled with catheter embolization of the aberrant systemic artery.
• Other possible complications include thrombosis of the systemic artery,
causing acute pulmonary infarction and pain, and left-sided heart failure
due to left-to-left shunting.

Bronchial-to-Systemic Artery
Communications
• Important communications can also exist
between the bronchial and coronary arteries.
• In disease entities that cause diminished
pulmonary arterial blood flow such as
cyanotic congenital heart disease, chronic
thromboembolic disease, and vasculitides
such as Takayasu arteritis, shunting can occur
from coronary arteries to pulmonary arteries
via the bronchial arteries.

• Coronary-to-bronchial artery anastomoses are most often
identified in the region of the retrocardiac “bare areas” of the
heart, where the relatively wide pericardial reflections permit the
development of communications between the coronary and
extracoronary arteries.
• In situations of decreased pulmonary blood flow, anastomoses
between the bronchial arteries and the pulmonary arteries at the
level of the vasa vasorum are reinforced by collateral blood flow
from the high pressure coronary arterial system by way of coronary-to-
bronchial arterial shunting.
• Coronary-to-bronchial arterial anastomoses normally arise from the
atrial branches of both coronary arteries.
• Such shunting may be involved in the “pulmonary steal” syndrome
that manifests in some patients as classic angina-like symptoms in
the presence of angiographically normal coronary arteries.

• Conversely, in certain situations
atherosclerotic coronary artery disease can
promote the development of bronchial-to-coronary
arterial shunting.

• Coronary-bronchial arterial anastomoses can
be identified at thoracic CT angiography and
constitute an important finding prior to
anticipated bronchial artery embolization
therapy.

Coronary-bronchial arterial anastomoses in a 49-year-old man
with recurrent hemoptysis.
(a) Posteroanterior chest radiograph demonstrates severe
cystic bronchiectasis in the lingula.
(b) Axial 5-mm-thick CT scan obtained at the level of the
lingula with parenchymal lung window settings (window
center, 600 HU; window width, 1600 HU) demonstrates
severe cystic bronchiectasis.
(c) Axial 5-mm-thick CT scan obtained at the same level with
mediastinal softtissue window settings (window center, 50
HU; window width, 350 HU) depicts dilated systemic
arteries (arrow) in the region of the pericardial reflection of
the retrocardiac area.
(d) Axial 5-mm-thick MIP image obtained at a slightly lower
level demonstrates a dilated systemic artery (thin arrow)
coursing toward the left main coronary artery (thick
arrow). The systemic artery was identified as a dilated
bronchial artery.
(e) Axial 1-mm-thick image obtained at the level of the
thoracic inlet depicts dilated nonbronchial systemic
arteries (arrow) arising from the left subclavian artery.
(f) Axial 1-mm-thick image obtained at the level of the
aortopulmonary window shows dilated bronchial arteries
(arrow) in the mediastinum.
(g) Three-dimensional volume-rendered reformatted image
more clearly depicts the tortuous knot of dilated systemic
arteries (arrows) extending from the left subclavian artery
to the retrocardiac region.

Cryptogenic Hemoptysis
• Hemoptysis for which no cause has yet been identified
• Diagnosis of exclusion
• Reported prevalence of approximately 3%–42%.
• most often in patients who smoke.
• Its importance lies in the reported statistic that 6% of such patients
will present with unresectable lung carcinoma within the next 3
years.
• This risk rises to 10% among patients who are over 40 years old and
have a history of smoking.
• This emphasizes the importance of a detailed evaluation of the lung
parenchyma and bronchi to exclude early lung carcinoma in
patients who present with a first episode of hemoptysis.
• In patients who present with hemoptysis with no identifiable cause,
it is prudent to perform repeat CT several months later to ensure
that a small, occult neoplasm has not progressed in the interval.

Radiologic Studies
• Radiographs
• CT
• Angiography
• Further investigations
– Nuclear Medicine
• Pulmonary embolism
• malignancies
– MRI

Bronchoscopy
Flexible Bronchoscopy
• Better visualization
• Ability to navigate
smaller segments
• @ bedside in ICU
• Poor ability to suction
blood
• Less interventions
Rigid Bronchoscopy
• Better blood Suctioning
• More therapeutic
interventions
• Needs OR / GA
• Needs More Skills

Flexible Bronchoscope Rigid Bronchoscope

• In a recent article, Hsiao et al documented
that FOB prior to BAE is unnecessary in
patients with hemoptysis of known cause if
the site of bleeding can be determined on
conventional radiographs.

Management
Varies with
• the severity of bleeding
• The cause of bleeding
• General condition /Cardio-resp. Reserve

ALGORITHM FOR HEMOPTYSIS MANAGEMENT
Sirajuddin & Mohammed,Cleveland Clinic Journal of Medicine, Vol 75( 8),August 2008

Management of Non-Massive Hemoptysis
• Blood-streaking of
sputum or production
of small amounts of
pure blood
• Gas exchange is usually
preserved
Priority
Establishing a diagnosis
Specific therapy
Antibiotics
Immunosupression
Chemotherapy
Radiotherapy
FB removal
……etc

Management of Massive Hemoptysis
MEDICAL
EMERGENCY
ICU ALWAYS
Urgent need for treatment is
dictated by:
•Rapidity of bleeding
•Respiratory function
Priorities
Airway protection
ETT / MVS
Patient Stabilization
Find the site /cause of
bleeding
Attempt to stop bleeding
Prevent recurrence of
bleeding
Specific therapy

Air
way
Breathing
circulation
Provide suction.
Provide O2
crystalloid solutions

Management of Massive Hemoptysis
Needs ICU management
Keep NPO
Positioning of the patient
Strong cough suppressant
Large IV access + Fluid resuscitation
Correction of any coagulopathy

Conservative management
• Suppressing cough (codeine based)
• Antibiotics
• Antifibrinolytics like tranexemic acid.
• Sedation (Avoid over sedation)
• Coagulation disorders should be rapidly reversed.

Interventions
• Bronchospic interventions
• Radiologic interventions (BAE etc.)
• Surgery ( Lobectomy / Pneumonectomy)

Airway and Bronchoscopic
management
98

Protection of nonbleeding lung
 If bleeding side is known
Keep patient at:
-Rest
-Lateral decubitus
-Bleeding side down
-Head tilted down.
Rt.Main bronchus
Left main brochus flooded with blood

Selective Intubation
SINGLE LUMEN ETT
 Selectively intubate
the non bleeding lung.
Selective intubation of Lft Main bronchus
in Rt sided massive hemoptysis
100

Selective Intubation
DOUBLE LUMEN ETT
 Specially designed for
selective intubation of
the right or left main
bronchi
 Last option in an
asphyxiating pt.

Bronchoscopic measures
• Iced Saline Lavage
• Topical vasopressors
• Selective intubation / ventilation
• Endobronchial tamponade
– Fogarthy balloon
– Silicone Spigot
– Topical Hemostatic Tamponade(THT)
– Biocompatible Glue
• Laser photocoagulation
• Argon Plasma Coagulation
• Endobronchial Electrocautery
102

103
Cold-Saline Lavage
o Reported in 1980.* by Conlan et al.
• Lavage: Normal saline at 4 ° C in 50-ml aliquots
• Stopped the bleeding with massive hemoptysis(
600 ml/24 h), obviating the need for emergency
thoracotomy.*
 Rigid scope is better over FOB
*Conlan AA, Hurwitz SS, Krige L, Nicolaou N, Pool R: Massive hemoptysis: review of 123 cases. J Thorac Cardiovasc Surg 1983; 85: 120–
124.

Topical Vasoconstrictive Agents
• Local instillation
• Topical epinephrine
(1: 20,000)
 Effective :
mild to moderate.
Not useful:
massive bleeding*
• Endobronchial
epinephrine-side effects
-Tachyarrythmias
- HTN
• Newer agents: ADH
derivative
- ornipressin
* Cahill BC, Ingbar DH: Massive hemoptysis. Assessment and management.
Clin Chest Med 1994; 15: 147–167.
104

Tranexamic Acid(TA)
• Antifibrinolytic drug
• Route : PO ,IV & Topical (recently)
• Endobronchial :*
DOSE: 500–1,000 mg
• Response time: stops bleeding within seconds
* Solomonov A, Fruchter O, Zuckerman T,Brenner B, Yigla M: Pulmonary hemorrhage: a novel mode of therapy. RespirMed 2009; 103:
1196–1200.

Fibrinogen/Thrombin
• Local application
• Immediate arrest of bleeding.
• Initial strategy before BAE.*
• Alternative treatment when endovascular
procedures cannot be performed.
* Wong LT, Lillquist YP, Culham G, DeJong BP, Davidson AG: Treatment of recurrent hemoptysis in a child with cystic fibrosis by repeated
bronchial artery embolizations and long-term tranexamic acid. Pediatr Pulmonol 1996; 22: 275–279

Balloon Tamponade
• Described: 1974*
• Life threatening
hemoptysis.
 4 Fr 100 cm Fogarthy
balloon catheter by
FOB.
• Inflated for 24-48 hrs
* Hiebert C: Balloon catheter control of lifethreatening hem1o0p7tysis.
Chest 1974; 66: 308– 309.

Fogarthy balloon catheter of various sizes
108
Inflated fogarthy catheter bronchoscopically

Advantages:
• Air way protection
• Allows gas exchange
• Supports patient before
embolization or surgery
Disadvantages:
• Ischemic mucosal injury
• Post obstructive pneumonia.
109

Endobronchial Airway Blockade
(Silicone Spigot)
• Dutau et al.* reported first case.
Temporary management.
• Silicone spigot is placed endobronchially .
Stabilizes patient before endovascular
embolization .
• *Dutau H , Palot A, Haas A, Decamps I, Durieux O: Endobronchial embolization with a silicone spigot as a temporary treatment for
massive hemoptysis. Respiration 2006; 73: 830–832.

posterior segment
of the right upper lobe
A rigid bronchoscope initially allowed aspiration of
blood and removal of clots followed by cold saline and
topical vaso active agents ,clearing the vision to place
spigot
Silicon spigots of various sizes

6-mm silicone spigot in place
posterior segment
of the right upper lobe
Following this procedure, the patient
underwent BAE, and the spigot
was removed 2 h later.

Bronchoscopy-Guided Topical
Hemostatic Tamponade(THT)
• Oxidized regenerated cellulose mesh, a sterile
kitted fabric is used. *
 Saturates with blood- swells-brownish or black
gelatinous mass -clot.
• Successful in life threatening hemoptysis.
• Immediate arrest of bleed: 98%(56 of 57)
*Valipour A, Kreuzer A, Koller H, KoesslerW, Burghuber OC: Bronchoscopy-guided topical hemostatic tamponade therapy for the
Management of life-threatening hemoptysis. Chest 2005; 127: 2113–2118.

114
Endobronchial view of a bleeding
subsegmental bronchus before THT
During bronchoscopy guided THT

Disavantages:
• Not suitable for proximal sites, trachea.
 Patients who cannot tolerate occlusion.
Recurrence of hemoptysis

Endobronchial Sealing with Biocompatible
Glue
• Parthasarathi Bhattacharyya et al,* 2002
• Material: n-butyl cyanoacrylate (adhesive)
• Injected into the bleeding airway through a
catheter via a flexible FOB.
• Used in mild hemoptysis.
• * *From the EKO Bronchoscopy Centre, Calcutta, India(CHEST 2002; 121:2066–
2069)

Laser Photocoagulation
• First introduced by Dumon et al. *
• Nd-YAG laser: employed since 1982.
• Effective in: Bronchoscopically visible source.
MECHANISM:
• Photocoagulation of the bleeding mucosa with
resulting hemostasis.
 Achieves photoresection and vaporization
*Dumon JF, Reboud E, Garbe L, Aucomte F, Meric B: Treatment of tracheobronchial lesions by laser photoresection. Chest 1982; 81: 278–28141.8

Flooding of the
bron.intermed.
Suctioning
airway clearance
visualization
Coagulation and
devascularization
of tissues
Carbonization of
the bleeding site

Argon Plasma Coagulation (APC)
• TYPE : Thermal tissue
destruction
• Non contact
electrocoagulation tool*.
• Used:
In bronchoscopically
visible areas of sources of
bleed
APC machine
*Keller CA, Hinerman R, Singh A, Alvarez F: The use of
endoscopic argon plasma coagulation In airway
complications after solid organ transplantation. Chest 2001;
119: 1968–1975.

• Once desired dessication is done ,deeper
penetration of current is stopped and damage to
further tissue is stopped.*
• Used for superficial and spreading lesions.
Advantages of APC over YAG laser.:
• It provides easy access to lesions.
• Allows homogeneous tissue dessication.

Endobronchial Electrocautery
• TYPE: Thermal tissue
destruction
• Coagulation mode:
contact
• Readily available in most
of the OT with
gastroenterology
colleagues
• .
Electro cautery machine Contact probes
Probe through working channel

• Indications :
- Bleeding endobronchial
growth & benign tumors
• Less expensive alternative to
laser.
• Control of hemoptysis using
endobronchial
electrocautery was achieved
in 75%* of the cases
* Homasson JP: Endobronchial electrocautery. Semin Respir Crit Care 1997; 18: 535–
543

Radiologic interventions
• Bronchial artery embolisation
• Pulmonary AVM embolisation
• MAPCOS embolisation

BRONCHIAL ARTERY
EMBOLOTHERAPY FOR HEMOPTYSIS

Anatomic Considerations
• The bronchial and pulmonary arteries comprise a divided blood supply to
the lungs.
• The bronchial arteries course in conjunction with these structures to the
level of the respiratory bronchus, where their terminal branches achieve
significant overlap with the pulmonary arterial circulation.
• Although less significant clinically with regards to hemoptysis, the
pulmonary artery provides the vast majority of pulmonary perfusion at
99%, but there is significant overlap between the bronchial arteries and
the pulmonary arteries at multiple levels throughout the lung’s anatomic
structure.
• In addition, nonbronchial systemic arteries are common offenders in the
patient with hemoptysis.
• This obviously necessitates a thorough understanding of the various
anatomic permutations and their associated potential clinical significance
when considering bronchial artery embolization.

BRONCHIAL ARTERIES
• The bronchial arterial distribution
supplies the:
– bronchi and interstitium of the lung
– contributes to the
• visceral pleura,
• the aortic and pulmonary artery vasa vasorum,
• mediastinum, and
• middle one-third of the esophagus.

The bronchial arteries vary considerably in their site of
origin and subsequent branching pattern
The four most prevalent patterns of bronchial artery anatomy.
Type I: single right bronchial artery via intercostobronchial trunk (ICBT), paired left bronchial arteries.
Type II: single right bronchial artery via ICBT, single
left bronchial artery.
Type III: paired right bronchial arteries with one from ICBT, paired left bronchial arteries.
Type IV: paired right bronchial arteries with one from ICBT, solitary left bronchial artery.

Origin
• 70 % - from the descending thoracic aorta
between the upper T5 to the lower T6
vertebral bodies
• 10% - a first order branch of the thoracic aorta
or arch, but outside of the T5–T6 confines
• 20 % - from other thoracic or abdominal
branches

• Thoracic
– brachiocephalic,
– Subclavian
– internal mammary
– pericardiophrenic, or
– Thyrocervical
• Abdominal
– aorta,
– inferior phrenic,
– celiac

• Thoracic
– brachiocephalic,
– Subclavian
– internal mammary
– pericardiophrenic, or
– Thyrocervical
• Abdominal
– aorta,
– inferior phrenic,
– celiac
Subselective angiogram of the right phrenic
artery (black arrow) shows arterial flow
(white arrows) to the poorly aerated right
lung base

Venous return
• Most often via the pulmonary veins,
• smaller contributions from the superior vena cava, azygos, and hemiazygos
systems.
• This venous system is well visualized during bronchial angiography and the
interventionist must determine if direct arteriovenous shunting is present.

NONBRONCHIAL SYSTEMIC ARTERIES
• This arterial supply may originate from thoracic or abdominal
vascular distributions.
• Must be differentiated from true aberrant bronchial arteries.
• The most reliable method to distinguish bronchial from systemic
collaterals is through careful observation of the congruence of the
vascular course with that of the associated bronchi.
• It is important to note that both ectopic and orthotopic bronchial
arteries assume a more vertical or horizontal course prior to joining
the bronchial tree.
• Systemic nonbronchial collateral arteries do not adhere to this
pattern, instead following a transpleural course or potentially
ascend via the inferior pulmonary ligament, never joining the
bronchial tree.

**imp**
• The anterior spinal
artery courses along
the ventral surface of
the spinal cord
receiving collaterals
from up to eight
anterior segmental
medullary arteries
throughout its course.

• Angiographically, these
assume the classic
‘‘hairpin’’
configuration.

• The most prominent of
these, the artery of
Adamkiewicz, arises in
the majority of cases
from an intercostal artery
at T8–L1 .
• Contribution to one or
more of these medullary
arteries in the thorax is
documented in 5– 10% of
cases involving the
intercostal branch of an
intercostobronchial trunk.

• Nontarget embolization of the medullary
artery has been associated with transverse
myelitis; therefore, meticulous technique with
coaxial microcatheter approach distal to the
origin of the artery should be undertaken.

(A) A 24-year-old man undergoing spinal angiography for hemorrhage, same patient as Fig. 2A. Injection of the left
T12 intercostal artery demonstrates a prominent normal anterior spinal artery (artery of Adamkiewicz) (arrows).
(B) A 24-year-old woman with cystic fibrosis and hemoptysis. Injection of the right supreme intercostal artery (black arrowhead)
demonstrates a large, abnormal bronchial artery (white arrow) designating this as an intercostobronchial trunk. Note supply to the anterior
spinal artery from the supreme intercostal arterial supply (black arrows). Embolization was performed in this patient beyond the origin
of the supreme intercostal artery with the microcatheter placed at the level of the white arrow (see Fig. 8). Care was taken not
to reflux particles into the supreme intercostal artery distribution (white arrowheads).

Embolotherapy Technique for
Hemoptysis
• Since its introduction in 1974, bronchial artery
embolization is now considered by many to be
first-line therapy.
• A recent survey of clinicians revealed 50%
prefer an interventional radiology approach
over observation or surgery when treating
massive hemoptysis.

Purposes of BAE
• Three purposes for the BAE treatment were
defined:
– to achieve immediate control of bleeding in all
patients;
– to obtain lasting control of bleeding in patients
without surgical conditions;
– to improve clinical conditions for a prospective
surgery.

ANGIOGRAPHY IN THE DIAGNOSIS OF
HEMOPTYSIS
• Digital subtraction arteriography prior to
undergoing bronchial artery embolization is
optimally undertaken utilizing radiographic units
capable of high frame-rate acquisition.
• This allows for excellent delineation of both
bronchial and non-bronchial systemic arteries.
• Angiography and intervention are performed
under either moderate sedation or general
anesthesia, as dictated by the clinical
presentation and status of the patient.

Value of preliminary thoracic
aortography.
• Descending thoracic
aortogram demonstrates:
– two hypertrophic bronchial
arteries (solid arrows) and
– one intervening intercostal
artery (open arrow)
• that supply a
hypervascular lesion in
the right upper lobe.

Technique
• Standard common femoral arterial access
predominates although brachial artery access may be
necessary to address extraordinarily difficult
nonbronchial systemic arterial contributions.
• All arteriography should be performed with either low-osmolar
or iso-osmolar nonionic contrast material, as
high-osmolar contrast has been implicated in
transverse myelitis.
• Many advocate initial thoracic aortography to delineate
the number, size, and position of the bronchial arteries.
This is particularly helpful in cases of aberrant or
ectopic bronchial arteries.

• Both normal and enlarged diameter bronchial
arteries discovered via thoracic aortography
should be investigated for signs of
abnormality in the terminal vascular bed.

• Active extravasation,
while extremely helpful
and specific, occurs in
up to only 10.7% of
examinations.
The identification of extravasated
dye --INFREQUENT

• Absent identifying a
bleeding site, findings
sensitive for localization
of hemoptysis are:
– vascular hypertrophy and
tortuosity,
– neovascularity,
– hypervascularity,
– aneurysm formation, and
– shunting (bronchial artery
to pulmonary vein or
bronchial artery to
pulmonary artery)
Vascular hypertrophy

of hemoptysis are:
tortuosity,
– neovascularity,
bronchial artery to
pulmonary artery)

of hemoptysis are:
tortuosity,
– neovascularity,
bronchial artery to
pulmonary artery)
Parenchymal hypervascularity

of hemoptysis are:
tortuosity,
– neovascularity,
bronchial artery to
pulmonary artery)
aneurysm

of hemoptysis are:
tortuosity,
– neovascularity,
bronchial artery to
pulmonary artery).

• Generally accepted guidelines for abnormal
bronchial artery diameter is >3 mm, with
normal vascular diameter typically 1.5 mm.

• Combining chest CT findings
with angiographic findings
may further increase the
sensitivity and specificity of
localization of hemoptysis at
angiography.
• Of particular importance is the
presence of pleural thickening
measuring 3 mm or greater
adjacent to a parenchymal
abnormality.
• Extrapleural fat hypertrophy
may also be present with
enlarged vessels visualized in
this expanded space.

• The use of microcatheters in a coaxial
technique is now widespread, and its utility is
well documented both for superselective
angiography as well as for the administration
of embolic agents.
• This can be of benefit when the 5F catheter is
unable to maintain secure access for
diagnostic angiography, and of course for the
delivery of embolic materials.

• When negotiating an intercostobronchial
trunk with the microcatheter, special attention
is paid to manipulation of the catheter beyond
the intercostal moiety that may give rise to
the aforementioned anterior spinal artery.

(A) A 24-year-old woman with cystic
fibrosis and hemoptysis, same patient
as Fig. 5B. Chest radiograph shows
bilateral opacities in this patient with
cystic fibrosis.
(B) Injection of the right supreme
intercostal artery shows the enlarged
bronchial artery (arrow).
(C) A microcatheter (arrowhead) was
placed beyond the intercostal branch,
which contributes arterial
supply to the anterior spinal artery (see
Fig. 5B), and embolization was
successfully performed using large
(1000–1180 mm) polyvinyl alcohol
particles. Larger particles were used to
prevent migration into spinal artery
supply should accidental reflux
transpire, although care was taken not
to reflux into the intercostal artery.
(D) Postembolization angiogram of the
right supreme intercostobronchial
trunk. Note the very slow flow in the
bronchial artery (arrow) and its distal
branches (black arrowheads).
Microcatheter tip is in the
intercostobronchial trunk (white
arrowhead). Note the excellent filling of
the distal supreme intercostal artery,
which supplied the anterior spinal
artery in the lower cervical/upper
thoracic region (Fig. 5B). Patient was
neurologically intact following the
procedure.

• The injection method and rate should be selected
based also on intraprocedural assessment of individual
bronchial artery diameter and rate of blood flow.
• Hand injection of contrast through microcatheters is
best executed with small-volume syringes capable of
generating adequate pressures to achieve the flow
rates necessary for satisfactory vascular opacification.
• Alternatively, power injection may be performed with
attention to the maximal pressure tolerable by the
individual microcatheter.

Subselective angiogram of the right phrenic
artery (black arrow) shows arterial flow
(white arrows) to the poorly aerated right
lung base
• Interrogation of the
subclavian artery and
its distribution or the
abdominal vasculature
should be made with
selective end-hole
catheters.

• It is well known that bronchial arteries comprise the vast
majority of instances of hemoptysis.
• However, it has been reported that up to 5% of patients
presenting with hemoptysis have the pulmonary artery as
the offending vascular bed.
• In patients with disease known to result in direct
pulmonary arterial injury such as tuberculosis, lung
abscess, iatrogenic trauma, or malignancy, bronchial artery
embolization may not achieve adequate clinical resolution.
• It is not uncommon that patients with hemoptysis of
pulmonary arterial origin may require multiple
interventions in the angiographic suite prior to definitive
diagnosis and treatment.

• Aneurysmal disease and
pseudoaneurysm contribute
to pulmonary arterial
hemorrhage and hemoptysis.
• The classic situation is the
finding of enhancing nodules
along the periphery of cavitary
lesions of a patient with
known tuberculosis where
hemoptysis should suggest the
possibility of Rasmussen
aneurysm.
• Aneurysmal rupture is possible
and carries a high mortality
rate, but is fortunately rare in
developed countries due to
the rarity of tuberculosis.

49 Y/M DM II,Htn. C/o Rt Fungal Pneumonia (Aspergillosis) with
massive hemoptysis

• Rarely, in a patient with hereditary
hemorrhagic telangiectasia rupture of a
congenital pulmonary arteriovenous
malformation may result in hemoptysis.

MATERIALS AND TECHNIQUES OF THE
EMBOLIZATION OF HEMOPTYSIS
• The interventional radiologist has at his or her
disposal a variety of materials capable of
achieving vascular occlusion.
• Considerations when choosing an embolic
agent should include:
– ease of delivery,
– durability of occlusion,
– propensity for recanalization, and
– size.

• Size depends clinically upon the site of desired vessel occlusion
(proximal vs distal) as well as the catheter lumen used for delivery.
• Regarding the former, utilization of materials of diminutive size
results in very distal embolization occluding at the end-arteriolar
level, which conceivably may result in ischemic complications to the
bronchi, esophagus, or vascular structures.
• Alternatively, shunting of small embolic agents into the pulmonary
venous system in effect places the embolic agent into the left heart
with subsequent systemic arterial embolization.
• Alternatively, however, embolization with agents that occlude
proximally may produce a suboptimal result due to the propensity
to form collaterals around the occlusion site.
• As with all embolotherapy, the choice of agent is critical to the
success and safety of the procedure.

Gelatin sponge
• Advantages:
– Readily available
– Inexpensive
– Easy to handle
• Disadvantages:
– No radiopaque
– Absorbable – recanalisation of
the vessel
• Not the embolic agent of first
choice
• Efficient temporary embolic
agent

Polyvinyl alcohol (PVA) particles
• Readily available and
relatively inexpensive.
• Do not undergo absorption
- more durable vascular
occlusion.
• The most common particle
size for bronchial artery
embolization ranges from
250–500 mm.
• Size above a threshold of
325 mm theoretically
ensures that no significant
bronchopulmonary
shunting will occur.

Polyvinyl alcohol (PVA) particles
• Nonspherical PVA
particles are, however,
prone to clumping
resulting in a more
proximal occlusion than
anticipated based solely
on particle size.
• Currently agent of first
choice.
Light microscopic findings of PVA particles
with irregular shape,

Microspheres
• tris-acryl gelatin microspheres
• cross-linked gelatin
• utilized successfully in
embolization of uterine fibroids.
• Due to their smoothly spherical
shape and hydrophilic nature,
they are less prone to clumping
and are more uniform in size than
their PVA counterpart.
• In a recent study, bronchial artery
embolization with 500–700 mm
microspheres achieved short-term
clinical success comparable
to PVA particles.

Liquid Embolic Agents
• The use of liquid embolic agents such as n-butyl- 2-
cyanoacrylate (NBCA; e.g., TruFill1 n-BCA Liquid Embolic
System, Johnson & Johnson/DePuy, Raynham, MA) and
ethylene vinyl alcohol polymer (Onyx Liquid Embolic
System, eV3 Neurovascular, Irvine, CA) for bronchial artery
embolization have been infrequently reported.
• Utilization of NBCA requires expertise and knowledge in the
art of varying the concentration to alter the rate of
polymerization and the depth of vascular penetration.
• This, in conjunction with the risk of distal embolization with
tissue necrosis and propensity for nontarget embolization,
has relegated NBCA to a very peripheral role in bronchial
artery embolization to date.

In a recent study examining 25 patients who underwent bronchial artery embolization with
NBCA, technical and clinical success was similar to standard particulate embolic agents.
No major complications were noted, but 16% had prolonged chest pain or dysphagia perhaps
due to distal embolization.

Metallic coils
• To achieve a relatively proximal occlusion in the vascular bed. In this
patient population with a high rate of rebleeding, this position
within the vascular tree may jeopardize further embolic attempts.
• In addition, as with the gelatin sponge, proximal occlusion permits
collateral flow resulting in poor control of hemoptysis.
• Both pushable and detachable coils have been utilized. In a study
comparing mechanically detachable coils to conventional coils, a
lower rate of recurrence was noted with the detachable group.
• Data on the efficacy of coil embolization is scarce and dated,
probably signifying that most do not employ the use of these
agents for bronchial artery embolization today.

(A) A 12-year-old woman with
Lennox-Gastaut syndrome and
history of recurrent hemoptysis
with multiple previous
embolization procedures. As this
patient had undergone multiple
prior bronchial embolization
procedures, pulmonary
angiogram was performed to
exclude this arterial circulation as
a source. It is normal with no
evidence for a bleeding site.
(B) Angiogram via
a microcatheter (white
arrowhead) of an enlarged
collateral branch of the left
thyrocervical artery shows
collateral filling (black
arrows) around and through the
coils placed from a previous
embolization. Proximal
embolization such as with coils
can often lead to this situation.
(C) Embolization successfully
performed via the microcatheter
(white arrowhead) using 355–500
mm polyvinyl alcohol particles
resulting in slow flow in the main
trunk (black arrow) and no flow
distally (black arrowheads).

• Although not first-line therapy for hemoptysis
per se, the presence of pseudoaneurysm in
the bronchial arteries may represent an ideal
situation to be managed by application of
metallic coils.

Outcomes for Bronchial Artery
Embolization for Hemoptysis
• Multiple studies have established
transcatheter embolization as an effective
treatment for massive hemoptysis arising
from both the bronchial and nonbronchial
systemic circulation.

Technical success occurs in greater than 90% of interventions, with associated clinical success
immediately post-embolization attainable in 73–99% of patients.

Unfortunately, recurrence remains frequent ranging from 10–55% for follow-up as long as 46
months.

• Technical success rates have been increased
with:
– More meticulous technique
– Using superselective embolisation
– Performing control thoracic aortography

• Procedural failures are usually caused by:
– Inability to achieve stable catheter position
– Inability to achieve catheter position beyond spinal cord
branches
– technically inadequate occlusion
– incomplete characterization of all arteries responsible for
hemorrhage at initial arteriography
• Recurrence at long term follow up can be as high as
52%, however, success rates of 100% can be achieved
using repeat embolisation and control of underlying
disease either pharmacologically or surgically.

• However, attaining control of hemoptysis does NOT
alleviate the underlying cause of hemorrhage.
• Dependent upon the etiology, recurrence rates can be
highly variable, and in the setting of infectious (e.g.,
tuberculosis, aspergillus) or neoplastic (e.g.,
bronchogenic carcinoma) offenders, one can expect
nearly all patients to eventually rehemorrhage.
• Although the embolization technique may be entirely
adequate, clinical remission is not always achieved.
Generally accepted rates of cessation of hemoptysis
following bronchial artery embolization approach 90%.

• Recurrence of haemoptysis may occur due to:
– Recanalisation of embolised vessels
– Incomplete embolisation
– Revascularisation by new collateral formation
– Presence of anomalous bronchial arteries
• Tuberculosis and aspergillus have been identified as
independent risk factors for the recurrence of
hemoptysis.
• Patients with lung cancer carry a 10–30% risk of
developing hemoptysis, and are also at risk for
recurrence following embolization.

• Re-embolization is an accepted approach to
recurrent hemoptysis; however, surgery
remains as the definitive treatment of
hemoptysis recalcitrant to multiple
embolizations and maximum medical therapy.

Complications of Bronchial Artery
Embolization for Hemoptysis
• Aside from the typical complications
associated with angiography, adverse events
most frequently arise from unintentional,
non-target embolization.

• As previously discussed, the vascular distribution
of the bronchial arteries includes:
– mediastinal structures,
– pleura,
– bronchi,
– esophagus, and
– walls of the thoracic and pulmonary vasculature.
• Hence, the complications arise due to
unintentional embolisation of these strucures.

Common complications
• Transient chest pain
– Most common
– 24 – 91%
– Probably due to ischemia of embolised branches.
– Can be severe when intercostal branches are
inadvertently embolised.
– self-limiting in the vast majority of cases
• Pleural pain
– Can be avoided with
• Superselective embolisation techniques
• Use of larger particles

Common complications
• Transient dysphagia
– Esophageal nontarget embolization
– up to 18% of interventions
– usually self-limiting.
• Low grade fever
• Nausea / Vomiting

• Transverse myelitis due to spinal cord
ischemia
– most serious complication
– 1.4–6.5%
– Superselective microcatheter techniques with
special attention to position distal to the anterior
medullary arteries
– Performing regular check angiograms before and
after administration of embolic agents

• Although some believe spinal ischemia may in
fact be due to toxicity related to the contrast
media, low and iso-osmolar contrast agents
have for the most part eliminated this line of
thinking.

• Cortical blindness has been reported and
represents an extraordinarily rare neurologic
complication.
– The predominant proposed pathway is from
unintentional embolization of the occipital cortex in
the setting of fistula formation arising from the
bronchial artery to either the pulmonary veins or the
vertebral arterial distribution.
• Pain in the orbit or temporal region ipsilateral to
the side of embolization may occur, but is
thought to be referred pain rather than nontarget
embolization in these territories.

Incidental complications
• Subintimal dissection or perforation of the
bronchial artery
– Caution with the use of glide-wire type guidewires
• Dissection of aorta

• Other rare complications include:
– bronchial stenosis,
– bronchial necrosis, and
– bronchoesophageal fistula
• left main bronchus
• presumably due to bronchial wall ischemia as well as ischemic
necrosis of the aorta with or without associated dissection.
– Pulmonary infarction
• Especially in patients who have suffered pulmonary artery
embolism
– Non target embolisation
• Colon, coronary and cerebral circulation

Pulmonary AVMs
• Abberent connection
between pulmonary
artery and venous
circulation that
bypasses capillary
system
• 50-70% located in the
lower lobes

Complications from PAVM
• Haemorrhage:
– Haemoptysis or haemothorax
• Massive R to L shunting:
– Hypoxia, dyspnoea, clubbing, cyanosiss,
polycythemia
• Paradoxical Emboli:
– Cerebral abscess, embolic stroke, TIAs
– Serious neurological complications occur in upto
35% of patients with PAVM

Treatment
• Preferrred for :
– Symptomatic PAVMs
– Asymptomatic lesions more than 3mm
• Trans Catheter Embolotherapy (TCE) is the
treatment of choice.
– Avoids major surgery and general anaesthesia
– Loss of lung parenchyma

Trans Catheter Embolotherapy (TCE)
for PAVMs
• Coil Embolisation
• Amplatzer Vascular Plug

The Amplatzer® vascular plug
• self-expandable cylindrical
device that allow the device
to compress inside a
catheter, and then when
released from the catheter,
return to its intended shape
to occlude the target vessel.
• The device has platinum
markers on both ends.
• The AVP is available in
diameters ranging from 4
mm to 16 mm, in 2-mm
increments.

The Amplatzer® vascular plug
• It is preloaded in a loader and
delivered through currently
available guiding catheters in
sizes ranging from 5F to 8F.
• Once positioned by holding the
delivery shaft steady and pulling
the outer guiding catheter back, it
is released by rotating the
delivery cable counter clockwise.
• It is recommended to select a
device approximately 30%–50%
larger than the vessel diameter.
• Since the AVP is a flexible nitinol
wire mesh, it adjusts to the shape
of the vessel and thus, oversizing
prevents device migration after
deployment.

Major aortopulmonary collateral
arteries (MAPCAs)
• Major aortopulmonary
collateral arteries (MAPCAs)
are blood vessels that bring
systemic blood flow to the
pulmonary arteries.
• They develop in response to
decreased pulmonary blood
flow and cyanosis.
• Tetralogy of Fallot (TOF) with
pulmonary stenosis is
associated with the
development of MAPCAs in
less than 5% of cases,
although it is seen in about
two thirds of patients having
pulmonary atresia.

• MAPCAs are usually clinically silent,
presenting only in late cases with
haemoptysis.
• Their presence complicates the
operative management of TOF as
excessive return of blood floods the
operative field.
• Postoperatively also, the presence of
MAPCAs may make it difficult to
wean a patient off the ventilator
because of pulmonary congestion,
and may provoke congestive cardiac
failure by raising pulmonary arterial
pressures.
• Therefore, appropriate management
of MAPCAs is necessary for both
short and long term outcome.

• Occlusion of the MAPCAs before open heart
surgery is important.
• Coil embolization of large MAPCAs under
fluoroscopic control is a useful technique.
• Coiling of the MAPCAs may also be done after
surgery to allow better growth of native
pulmonary arteries.

SURGICAL MANAGEMENT
• BAE unavailable
• Uncontrolled bleed with
BAE.
• Localised lesions
• Mortality : 1% to 50%
• Mortality :7.1-18.2%
(massive hemoptysis)
• Mortality :upto 40%
(emergency procedure)

Indications of surgery
Procedure of choice in:
• Bronchial adenoma
• Aspergilloma
• Hydatid cyst
• Iatrogenic pulmonary
rupture
• Chest trauma

Contra indications for surgery
• Unresectable carcinoma
• Inability to lateralize the
bleeding site
• Diffuse disease
• Multiple AVM
• Cystic fibrosis
• Arterial hypoxia
• Co2 retention
• Marginal pulm. Reserve
• Dyspnea at rest
• Non-localizing
bronchiectasis

Life Threatening hemoptysis
Pulmonary isolation & identification of bleeding source
(Radiological/Bronchoscopic means:CT Thorax,Balloon bronchial blockers)
Rigid Bronchoscopy
Surgery BAE
(Delayed TREATMENT)
Follow up at OPD
SUCCESS
FAILURE

Conclusion
• Massive hemoptysis is a medical emergency that requires prompt
assessment.
• CT is a quick and noninvasive tool that is helpful in the diagnosis
and management of hemoptysis, and its use should be considered
in any patient who presents with this condition.
• The management of life-threatening hemoptysis demands a well-integrated,
multidisciplinary approach.
• Bronchial artery embolization serves as both first-line therapy for
massive hemoptysis, and as a bridge to more definitive therapies
targeted to the underlying etiology.
• Bronchial artery embolization possesses high rates of immediate
clinical success coupled with low complication rates.
• It can be performed repeatedly for hemorrhage recurrence and
associated angiography can elucidate alternative sources of
hemoptysis including nonbronchial systemic and pulmonary
arteries.

Imaging in haemoptysis

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