The systemic arterial circulation to the lung is the
primary source of bleeding in hemoptysis. In patients with tuberculosis, cavitatory
lesions colonized by aspergillus, broncho-pulmonary arterial shunts, and Rasmussen
aneurysm can cause massive hemoptysis.
Massive hemoptysis secondary to post-tubercular aetiology is a medical emergency, and when
untreated carries a mortality of over 50 %. As surgical management is not always possible
due to bilateral diffuse disease, anaemia and hypoproteinemia, BAE is a widely accepted
and preferred treatment for management of massive and severe hemoptysis.
Transfemoral Seldinger technique is the preferred route; angiographic images include
tortuous, enlarged bronchial vessels, pseudoaneurysm formation, and early draining veins.
Embolization should be withheld if anterior spinal artery is noted arising from a common
intercosto-bronchial trunk.
A number of agents including gelatin ponge (Gelfoam), polyvinyl alcohol foam particles
(Ivalon), bucrylate, ethanol, steel coils, and detachable balloons have been used for
embolization. Gelfoam particles are probably the easiest to handle and are very effective
for BAE as they go smoothly through the catheter, allowing adequate control of the power
of injection and avoiding backflow into the aorta, as well as allowing flexibility of
adjustment in size of the fragments according to individual arterial anatomy.
Embolization is considered complete when 95 % of peripheral vessels are occluded and
antegrade flow is stopped. Immediate control of hemoptysis is usually acheived in 70-90 %
of patients, and rebleeding may be seen in about 20 % of successfully treated patients
usually due to incomplete embolization, re-cannalization of a previously embolized vessel,
or hypertrophy of small collateral vessels which were not embolized initially. |
