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Year : 1999  |  Volume : 9  |  Issue : 4  |  Page : 165-168
Management of severe hemoptysis due to pulmonary tuberculosis by bronchial artery embolisation


Department of Radiodiagnosis, JLN Hospital & R.C. Bhilai, India

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   Abstract 

Objective : To assess the efficacy of bronchial artery embolization in the control of massive hemoptysis due to the sequelae of pulmonary tuberculosis. Material and Methods : Fifty patients, 28 men and 12 women between the ages of 14 to 58 years with a mean age of 40.5 years, were included in this study. All patients had severe hemoptysis (more than 300ml of blood in 24 hours) at the time of intervention. Pre-procedure bronchoscopy was not done. Bronchial artery embolization was performed on the side with the greater abnormality on the chest radiograph. Gel foam pieces (less than 3mm) were used as embolizing agents. These were introduced through a 4F visceral hook catheter. Pre and post-procedure angiographic films were obtained. Inflammatory hypervascularity, which regressed after embolisation, was seen in all patients. Results : Successful embolization was achieved in 47 patients. Two patients had recurrence and were re-embolised. In one patient the required artery could not be catheterized. Two patients had transient dysphagia. Mild chest pain lasting for 15 minutes was seen in 18 patients. Conclusion : Bronchial artery embolization is an effective procedure for the treatment of massive hemoptysis occurring due to the sequelae of pulmonary tuberculosis.

Keywords: Embolisation, Bronchial Arteries, Tuberculosis

How to cite this article:
Dwivedi M K, Pal R K, Borkar P B. Management of severe hemoptysis due to pulmonary tuberculosis by bronchial artery embolisation. Indian J Radiol Imaging 1999;9:165-8

How to cite this URL:
Dwivedi M K, Pal R K, Borkar P B. Management of severe hemoptysis due to pulmonary tuberculosis by bronchial artery embolisation. Indian J Radiol Imaging [serial online] 1999 [cited 2019 Sep 19];9:165-8. Available from: http://www.ijri.org/text.asp?1999/9/4/165/28348
Massive hemoptysis is a medical emergency associated with a 30- 50% mortality rate. Due to the prevalence of tuberculosis in the Indian population, hemoptysis due to pulmonary tuberculosis occurs as a complication of many sequelae such as cavities and bronchiectasis. Most of these patients have associated residual fibrosis, post-tubercular bronchiectasis and open, healed cavities with Aspergillus within the cavities [1]. These patients are also associated with poor pulmonary reserve that precludes them from surgical resection. The present study was undertaken to evaluate the efficacy of percutaneous bronchial artery embolization and its role as a life saving procedure.


   Materials and Methods Top


Fifty patients between the ages of 14 and 58 years, with a mean age of 40.5 years formed the group. There were 28 men and 22 women. All the patients had massive hemoptysis and were been treated for tuberculosis in the past. The criteria for massive hemoptysis were:

  1. More than 300 ml of blood in 24 hours.
  2. More than 100 ml per day for more than 2 days.


The treatment record is given in [Table - 1] No patient, at the time of the study was undergoing chemotherapy and none had active disease based on three samples of direct sputum examination. The rate of bleeding is shown in [Table - 2].

Angiographic intervention was performed on the basis of chest radiographs, which helped to localize the site and extent of lesion. Bronchoscopy was not performed in any case. Patients with abnormal radiographs were considered; unilateral lesions were found in 22 and bilateral lesions in 28 patients. Cavitary and non-cavitary lesions were seen in 12 and 28 patients respectively. A cavity with fungal ball was seen in two patients.

We used a 4F visceral hook catheter. Gelfoam (Abgel) was used as the embolic material. A catheter was properly hooked in the bronchial arteries through the transfemoral route and a preliminary angiogram was obtained. Subsequently the lesion was embolised by small gel foam pieces (less than 3mm) suspended in non-ionic contrast media. Patients were followed up for two days as in-patients and thereafter for six months as outpatients.


   Results Top


Therapeutic embolization was achieved in 47 patients. Embolization was abandoned in three patients. In one, the required artery could not be catheterized and in two, the patients did not co-operate. Dilated, tortuous bronchial arteries were seen at the site of lesion. Patients with bronchial to pulmonary artery shunting were also embolised [Figure - 1]. The average time taken for the procedure was forty-five minutes.

In three patients, spinal arteries were found to originate from a major bronchial artery. In these cases, the catheters were negotiated beyond the origin of the spinal arteries [Figure - 2],[Figure - 3]. The criterion for successful embolization was expectoration of less than 100 ml of blood in the 24 hours following the procedure. Occasional blood stained sputum was seen up to one week following the procedure and cessation of this was considered success. Hemoptysis of more than 100ml in twenty-four hours was considered as treatment failure. The results of embolization are given in [Table - 3]. The angiograms were analyzed for anatomical classification. The types of arteries embolised and their number are given in [Table - 4]. Re-embolization was performed in two patients


   Discussion Top


Most of the patients with massive hemoptysis are poor surgical candidates as they lack respiratory reserve [2]. Bronchial artery embolization provides effective management in patients, when massive hemoptysis results from the sequelae of tuberculosis rather than complications of the disease [3],[4]. The bronchial arteries are the most common source of massive hemoptysis in these patients. This is usually due to chronic bronchial inflammation leading to bronchial artery hypertrophy and an aneurysmal dilatation of these vessels [5],[6].

On angiography, the major source of hemorrhage is the bronchial vessel and hypervascularity is the single most common pathological abnormality on the affected side [7],[8]. Generally, cavities are the source of hemoptysis and the arteries supplying these cavities were always embolised [9]. The presence of the anterior spinal artery as a branch of the costocervical trunk was not considered to be a contraindication for the procedure [10].

Complications of the procedure include transient dysphagia, which occurred in two of our patients and chest pain lasting for 15 minutes, which was seen in 18 patients. The chest pain is usually due to ischemic changes related to embolisation. None of our patients had inadvertent embolisation.

To conclude, bronchial artery embolization is a safe and simple procedure not associated with any significant complication.

 
   References Top

1.Conlan AA, Hurwitz SS, Krige L. Johannesburg N, Nicolaoun, Pool R. Massive hemoptysis. J.Thorac cardiovas. Surg. 1983; 85: 120 _ 124.   Back to cited text no. 1    
2.Eckstein MR, Wallman AC, Athanasulig CA. The management of massive hemoptysis, control by angiographic methods. In: Current Controversies in Thoracic Surgery. Philadelphia: WB Saunders, 1986; 255-260.   Back to cited text no. 2    
3.Uflacker R. Kaemmerer A, Neves C, Picon PD. Management of massive hemoptysis by bronchial artery embolisation. Radiology 1983; 146:627-637.   Back to cited text no. 3    
4.Cudkowicz L. The blood supply of the lung in pulmonary tuberculosis. Thorax 1952; 7: 270- 276.   Back to cited text no. 4  [PUBMED]  
5.Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33 _ 37.   Back to cited text no. 5  [PUBMED]  
6.Ramakantan R, Bardekar VG, Gandhi MS, Aulakh BG, Deshmukh HL. Massive hemoptysis due to pulmonary tuberculosis: control with Bronchial artery embolisation. Radiology 1996; 200: 691-694.   Back to cited text no. 6    
7.Utlacker R, Kaemmerer A, Picor PD. et al . Bronchial artery embolization in the management of hemoptysis: technical aspects and long term results. Radiology 1985; 157: 637-644.   Back to cited text no. 7    
8.Wholey MH, Chamorro HA, Rao G, Ford WB, Miller WH. Bronchial artery embolization for massive hemoptysis JAMA 1976; 236: 2501-2504.   Back to cited text no. 8    
9.Rabkin JE, Astatiev V.L, Gothman LN, Grigorjev YG. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987; 163: 361-365.   Back to cited text no. 9    
10.Hayakawa K, Tanaka F, Terizuka T et al . Bronchial artery embolization for hemoptysis: immediate and long term results. Cardiovascular Interventional Radiology 1992; 15: 154-159.  Back to cited text no. 10    

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Correspondence Address:
M K Dwivedi
Dwivedi, 2F, W.H.A.H.S.Bhilai
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

    Tables

[Table - 1], [Table - 2], [Table - 3], [Table - 4]

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