Selective And Super-selective Bronchi Arteries Embolization (BAE) To Treat Massive Hemoptysis

Massive hemoptysis has been described as the expectoration of an amount of blood over 300–600 mL per day and it is one of the most dreaded of all respiratory emergencies. Conservative management of massive hemoptysis carries a mortality rate of 50%–100%. The cause of death is usually asphyxiation, not exsanguination . Although surgery is a effective choice in the treatment of massive hemoptysis , poor pulmonary reserve and other medical comorbid conditions, most patients with massive hemoptysis are not surgical candidates The reported mortality rates for surgery performed for massive hemoptysis range from 7.1% to 18.2% . However, the mortality rate increases significantly, up to about 35%, when the surgery is undertaken as an emergency procedure. Bronchial artery embolization (BAE) has become an established procedure in the management of massive and recurrent hemoptysis; its use was first reported in 1973 by Remy et al . The efficacy, safety, and utility of BAE in controlling massive hemoptysis have been well documented in many subsequent reports. It has the characters of simply, security, fewer injure and effective, etc. It is the ideal choice for operation and is the micro-cut technology which worthy popularizing. Bronchial artery embolization does not address the underlying disease but rather treats the symptom. In this sense, BAE is a palliative procedure that prepares the patient for elective surgery for localized disease or continued antimicrobial therapy. Our hospital successfully used BAE to treat 30 instances of massive hemoptysis and obtain good effect. Among the 30 patients, there were 13 female and 17 male with an average age of 40.5(a range of 18 to 60). Fourteen patients is undertaken BAE as an emergency procedure after conservative management which have little effect. BAE was able to relieve the symptom immediately if all the feeder vessels were embolized completely. The efficient rate in 24 hours/1 week is 96.6%/100% separately; after 6-month regular follow-up visit, the efficient rate is 86.6%. The most disastrous complication of BAE is spinal cord ischemia due to the inadvertent occlusion of spinal arteries and other rare complications that have been reported in the literature include aortic and bronchial necrosis, bronchoesophageal fistula, non–target organ embolization (eg, ischemic colitis).These complications were not happened in our patiens. Massive hemoptysis may result from various causes. Pulmonary tuberculosis, tuberculosis bronchiectasis, bronchogenic carcinoma, chronic inflammatory lung diseases due to bronchiectasis, cystic fibrosis, or aspergillosis are the more prevalent causes of hemoptysis. Other causes include lung abscess, pneumonia, chronic bronchitis, pulmonary interstitial fibrosis, pneumoconiosis, pulmonary artery aneurysm (Rasmussen aneurysm), congenital cardiac or pulmonary vascular anomalies, aortobronchial fistula, ruptured aortic aneurysm, and ruptured bronchial artery aneurysm. In 90% of cases, the source of massive hemoptysis is the bronchial circulation. In the presence of pleural thickening, nonbronchial systemic feeder vessels that originate from various arteries (eg, intercostal artery, branches of the subclavian and axillary arteries, internal mammary artery, inferior phrenic artery). The object of hemostasia can be gained if all the feeder vessels were embolized completely. The indications that BAE treats include: ①Patients with massive hemoptysis cannot be controlled by conservative treatment or have difficulty for surgery. ②Radiographic findings and CT for patients with hemoptysis arenormal or nonlocalizing. ③have poor pulmonary reserve and other medical comorbid conditions. ④It also can apply to those who are not willing to take surgical operation or not suitable to take. ⑤Patients suffer from life-threatening hemoptysis. The taboo is demonstrated to consist of : ①Patients with poor lung, liver and kidney that can not stand operation or patients who are hypersusceptible to contract medium. ②Anterior medullary arteries are observed and cannot be avoided after superselective catheterization. ③Catheter can not be fixed in a stabilization of position and bronchial angiography can observe countercurrent of the contract medium. The control of taboo illness should be depended on actual work together with patient's condition. All angiograms, including intercostal arteriograms, must be carefully scrutinized and analysed. There have two kinds of signs in the angiograms of patients with massive hemoptysis: direct bleeding symptom and indirect bleeding symptom. Direct bleeding symptom is extravasation of contrast medium from vessel. Although extravasation of contrast medium is considered a specific sign of bronchial bleeding, this finding is rarely seen. Direct bleeding symptom can be seen only when the bleeding speed is over 0.5-1. 0 ml/min. Indirect bleeding symptom is the abnormal bronchial artery in the track ,form,quantity. It mainly include hypertrophic and tortuous bronchial arteries, neovascularity, hypervascularity, shunting into the pulmonary artery or vein, ion of, and bronchial artery aneurysm. Anterior medullary arteries have a characteristic "hairpin" configuration at angiography. All angiograms, including intercostal arteriograms, must be carefully scrutinized for opacification of spinal arteries to avoid inadvertent embolization.