CME article

Topic : Control of tubercular hemoptysis by bronchial artery embolization

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.