Bronchial artery embolization

2. Embolotherapy
In Patients With Massive
Hemoptysis
By
Mahmoud E. Abou El-Magd
Assistant lecturer of pulmonary and critical care medicine

3. Hemoptysis

4. • Hemoptysis is classified as massive or
nonmassive based on the rate of bleeding.
• The most commonly used definition of
massive hemoptysis is 600 mL in 24
hours .
(Ibrahim , 2008).

5. • Life-threatening (massive) hemoptysis was
defined as expectoration of at least 200 mL of
blood per hour in a patient with normal or nearly
normal lung function.
• Production of at least 50 mL of blood per hour in
a patient with a chronic respiratory failure, or
more than two episodes of moderate hemoptysis
within a 24 h period .
• Moderate hemoptysis was defined as more than
or equal to three episodes of 100 mL of bleeding
per day within 1 week.
(Agmy, 2013).

6. • The evaluation of hemoptysis involves a careful
history, physical examination, and a chest
radiograph. Initial studies also include a
complete blood count.
• In the vast majority (90%) of cases the source of
the bleeding is the bronchial circulation.
• Massive hemoptysis may be due to active TB,
prior TB, bronchiectasis, mycetoma, Tight mitral
stenosis, and lung cancer.
(Corder, 2003 )

7. Pathophysiology

8. Hemoptysis
Hypoxic pul . V.C
Direct erosion
Elevated local Bl . Pr
angiogenetic growth factors
(Yoon et al., 2002)

9. • Conservative management of massive
hemoptysis has a 50–100% mortality rate
.
• The diagnostic accuracy of FOB is 0%–
30% in patients with normal chest
radiograph and 10%–43% in all patients
with hemoptysis.
(Yoon et al., 2002)

10. • Two decades ago,surgery was regarded
as the treatment of choice for hemoptysis.
but mortality rates were up to 40%
following emergency surgery .
• The mortality rate in patients who are
incapable of tolerating surgical procedure
was 80%.
(Yoon et al., 2002)

11. Indications
for
Recurrent
hemoptys
-is
Pre-
operati-
ve
Bronchial angiography
Massive
hemoptysis
Undiagnosed
hemoptysis
(Sirajuddin and Lucien, 2008)

12. Pulmonary
vascular Anatomy

13. Bronchial Arteries
supply
trachea
Pulmonary airways
Visceral pleura
esophagus
Vasa vasorum of aorta,
Pul. A & V
(van den Berg, 2006)

14. classical bronchial
artery patterns
40 %
2 left & 1 right
20 %
1 left & 1 right
20 %
2 left & 2 right
10 %
1 left & 2 right
( JC. van den Berg, 2006)

18. Pathologic Features Of
The Bronchial Artery

29. Non-bronchial
Systemic
Artery
Anatomy
brachiocephalic arterythe aortic arch
internal mammary
artery
Pericardiacophrenic
subclavian artery
thyrocervical trunk
(Yoon et al., 2002)

33. Embolization
tools

34. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
( JC. van den Berg, 2006)

35. 1-Polyvinyl Alcohol Particles
• 50 and 2000 µm, the typical size ranges
used clinically are 300 to 500 µm or 500
to 700 µm.
• Irregular shape .
(J. Golzarian et al., 2006 )

36. Polyvinyl alcohol
Focal angio-
necrosis
Thrombus
formation
Plt
aggregation
Slow
flow
Adherence
Mechanism of action
(J. Golzarian et al., 2006 )

37. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
2- Spherical Embolic Agents
( JC. van den Berg, 2006)

38. 2-Spherical Embolic Agents
• Trisacryl Gelatin Microspheres
40–120, 100–300, 500–700, and 700–900 mm,
In its original form, these spheres are clear.
• Polyvinyl Alcohol microspheres (Contour
SE particles)
100–300,300-500, 500–700, 700–900, and 900–1,200
m m.
(Avritscher and Wallace, 2012 )

42. A - Particulate Agents
The potential to occlude a target vessel at a
desired point (proximal or distal) by selecting
a particle size that corresponds to that
diameter.
1- Polyvinyl Alcohol Particles
2- Spherical Embolic Agents
3- Gelfoam
( JC. van den Berg, 2006)

43. 3-Gelfoam
• Gelatin sponge (Gelfoam) is a white,
water-insoluble, prepared from purified
pig skin gelatin.
• Temporary.
• 4w to 4m
(Golzarian et al., 2006 )

45. B - Liquid Agents
1- Ethanol or Absolute Alcohol
not radiopaque and highly diffusible ,Severe
complications such as cardiac arrest and pulmonary
embolism have been reported.
2- Cyanoacrylate
(Burrows and Mason, 2004)

46. C- Coils and Metallic Embolization
• The metallic coils range in size from 0.018 in.
(microcoils) to the standard 0.035–0.038 in.
sizes. made from either stainless steel or
platinum , all coils are permanent Devices.
• Coils should not be used in combination with
particulate embolization for the treatment of
tumors .
• Gugliemi detachable coil (GDC) system
(Golzarian et al., 2006 )

52. D – Balloons
E – Microcatheters
come in a variety of sizes from the larger bore
(outer diameter 3 F) to standard size (2.7 F) to
very small bore (2 F).
(Golzarian et al., 2006 )

55. Chylothorax 55

56. Embolotherapy
Technique

57. PREPARATION
• consent .
• sedatives or narcotic analgesics .
• monitoring .
• contrast .
• Fasting 4h before examination, except diabetic
patient.
• Stop
(Aspocid, Clexane) 1 day before examination.
(Marivane) 3 days before examination.
• Control of hypertension.
(Bader et al., 2004 )

58. Contra-indications

59. • absolute contraindication
spinal artery !!
• relative contraindication
- Contrast allergy.
-Uncontrolled (Hypertension)
-Coagulopathy Problems.
-Renal dysfunction.
-Uncontrolled (arrhythmias).
-Pregnancy !
(Chun and Belli, 2009)

61. Complications

62. 1. (transient) chest pain, in 24% up to
91% of cases .
2. dysphagia, 0.7% to 18.2%.
3. spinal cord ischemia, 1.4%–6.5%
4. “post-embolization syndrome”.
5. Non-target embolization (colon,
coronary and cerebral circulation).
(McPherson, 2010 )

63. 6. Rare complications as Aortic and
bronchial necrosis .
7. Other complications related to
angiography in general as
-Bleeding, False aneurysm ,Reactions to the
dye and Kidney damage .
(Wong et al., 2002)

64. Recurrence

65. Recurrence of hemoptysis may
occur due to:
• Recanalization
• Incomplete embolization.
• Revascularization
• anomalous bronchial arteries .
• The underlying disease.
(Chun and Belli , 2009)

66. Results

67. • Active and old TB had the best results .
• Patients with malignancy were the most
difficult to manage … Why ?
• Poor outcomes have been observed in
patients with aspergilloma .
(Mauro et al ., 2006 )

68. • We recommend use of bronchial
arteriography as a routine investigatory
tool for patient with hemoptysis .
• Future researches regarding other uses of
radiological bronchial and pulmonary
arteries intevention .

81. Home takeaways

82. • Bronchial artery embolization is highly effective in the
treatment of acute hemoptysis. Short-term non
recurrence rates (with follow-up up to 1 month) range
from 77% to 99% .
• success rates of 100% can be achieved using repeat
embolization and control of underlying disease either
pharmacologically or surgically .
• The most effective nonsurgical treatment for massive
hemoptysis is bronchial artery embolization (BAE) .
(Chun and Belli , 2009)