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Bronchial Arteries
Brandt C. Wible, MD; Mandeep S. Dagli, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Abbreviations

            • Bronchial artery embolization (BAE)
          • Definitions

            • Hemoptysis: Coughing up blood arising from lungs or airways
              • Typically caused by erosion/bleeding of overlying airway mucosa or rupture of hypertrophied bronchial arteries (BAs)
                • Often triggered by infection, mucosal inflammation, or malignancy
                • Most patients (90-95%) present with small-volume hemoptysis not requiring invasive therapy
              • Classically defined as massive, moderate, or mild
              • Death is result of asphyxiation as hemorrhage floods airways (not hemorrhagic shock)
                • Airway total volume: 150 mL in adults
            • Massive hemoptysis
              • Varied definitions
                • Most common: > 300 mL in 24 hours
                • Potentially life threatening
            • Moderate hemoptysis
              • > 100-300 mL/day; 3 episodes > 100 mL/week
            • Mild hemoptysis
              • < 100 mL/day; < 50 mL/episode
            • Etiologies of massive hemoptysis
              • Common causes of bronchial/systemic artery source
                • Chronic infections: Tuberculosis (most common worldwide), fungal, chronic pneumonia, abscess
                • Chronic inflammatory states: Cystic fibrosis, sarcoidosis, Wegener granulomatosis
                • Acquired/congenital pulmonary stenosis/occlusion
                • Malignancy
            • Potential sources: Generally arterial source due to systemic vascular pressure
              • BA (90%)
                • Localized BA proliferation and hypertrophy in response to chronic pulmonary artery vasoconstriction (from hypoxia), obstruction, or stimulation from chronic inflammation (rubor)
              • Isolated nonbronchial systemic artery (5%)
                • Common vessels include intercostal arteries, branches of brachiocephalic/subclavian arteries, inferior phrenic arteries
                • Communication between bronchial and nonbronchial systemic artery present on BA evaluation in 40-62% cases
                • Chronic inflammation/hyperemia can lead to collateral recruitment from systemic arteries, particularly when disease involves pleura/chest wall
              • Pulmonary artery (5%)
                • Low pressure of pulmonary artery makes it less common cause of massive hemoptysis
                • Consider with history of trauma/intervention or cavitary lesion
                • CTA often shows suggestive findings, such as pulmonary artery aneurysm/pseudoaneurysm or branch along inner wall of cavity
              • Common causes of pulmonary artery source
                • Rasmussen aneurysms, septic emboli, necrotizing pneumonia
                • Iatrogenic/traumatic pseudoaneurysm
                • Cavitary malignancy
                • Pulmonary arteriovenous malformation
            • BA anatomy: Many known anatomic variations in arterial number, origin, course
              • By definition, BAs, even when ectopic in origin, parallel central airways and enter lungs at hilum
              • Typically < 1.5 mm in diameter at origin ↓ to 0.5 mm when entering bronchopulmonary segment
              • Branch with airways and peripherally supply submucosal plexus in close proximity to airway lumen with anastomotic connections to pulmonary arteries (bronchopulmonary anastomosis)
                • Provide nutrient supply to multiple structures
                  • Bronchi
                  • Diaphragmatic/mediastinal visceral pleura
                  • Subcarinal lymph nodes
                  • Middle 1/3 of esophagus
                  • Dorsal/ventral nerve roots (radicular arteries)
                  • Vasa vasorum of aorta, pulmonary arteries/veins
                  • Spinal cord (medullary arteries): "Hairpin" with supply to anterior spinal artery (ASA); often arises from right intercostobronchial trunk (RICBT)
            • Normal/orthotopic origin of BAs (64% of patients on CTA)
              • Origin from descending thoracic aorta between T5-T6 within 1 cm of where left bronchus crosses aorta
                • RICBT usually arises from medial to posteromedial aorta similar in origin to intercostal artery
                • Right BA often arises from medial to anteromedial aorta, whereas left BA generally arises anteriorly
              • Cauldwell patterns of orthotopic BA branching (based on anatomic studies of 150 cadavers)
                • Type 1: RICBT/2 left BAs (41%)
                • Type 2: RICBT/1 left BA (21%)
                • Type 3: RICBT/1 right BA/2 left BAs (21%)
                • Type 4: RICBT/1 right BA/1 left BA (10%)
                • Types 5-9: Varying configurations and number of right and left BAs (8%)
            • Ectopic/aberrant origin of BAs (36% of patients on CTA)
              • BA origin not at T5-T6 level; however, entry into lung is still along major bronchi
                • Undersurface of aortic arch (74%)
                • Branches of brachiocephalic/subclavian artery (10.5%): Internal mammary artery, thyrocervical trunk, subclavian artery, costocervical trunk
                • Descending aorta or its branches (8.5%)

          PREPROCEDURE

          • Indications

            • Contraindications

              • Preprocedure Imaging

                • Getting Started

                  PROCEDURE

                  • Procedure Steps

                    • Findings and Reporting

                      • Alternative Procedures/Therapies

                        POST PROCEDURE

                        • Things to Do

                          OUTCOMES

                          • Problems

                            • Complications

                              • Expected Outcomes

                                Selected References

                                1. Charya AV et al: Management of life-threatening hemoptysis in the ICU. J Thorac Dis. 13(8):5139-58, 2021
                                2. Davidson K et al: Managing massive hemoptysis. Chest. 157(1):77-88, 2020
                                3. Ittrich H et al: The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 114(21):371-81, 2017
                                4. Panda A et al: Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 23(4):307-17, 2017
                                5. Walker CM et al: Bronchial arteries: anatomy, function, hypertrophy, and anomalies. Radiographics. 35(1):32-49, 2015
                                6. Ketai LH et al: ACR appropriateness criteria® hemoptysis. J Thorac Imaging. 29(3):W19-22, 2014
                                7. Woo S et al: Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles. Radiology. 269(2):594-602, 2013
                                8. Chun JY et al: Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol. 33(2):240-50, 2010
                                9. McCullagh A et al: The bronchial circulation--worth a closer look: a review of the relationship between the bronchial vasculature and airway inflammation. Pediatr Pulmonol. 45(1):1-13, 2010
                                10. Kalva SP: Bronchial artery embolization. Tech Vasc Interv Radiol. 12(2):130-8, 2009
                                11. Wang GR et al: Bronchial artery embolization for the management of hemoptysis in oncology patients: utility & prognostic factors. J Vasc Interv Radiol. 20(6):722-9, 2009
                                12. Khalil A et al: Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography. Chest. 133(1):212-9, 2008
                                13. Sidhu M et al: Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 25(3):310-8, 2008
                                14. Hartmann IJ et al: Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 17(8):1943-53, 2007
                                15. Pelage JP: Bronchial artery embolization: anatomy and technique. Tech Vasc Interv Radiol. 10(4):274-5, 2007
                                16. Cauldwell EW et al: The bronchial arteries; an anatomic study of 150 human cadavers. Surg Gynecol Obstet. 86(4):395-412, 1948
                                Related Anatomy
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                                Related Differential Diagnoses
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                                References
                                Tables

                                Tables

                                KEY FACTS

                                • Terminology

                                  • Procedure

                                    • Post Procedure

                                      • Outcomes

                                        TERMINOLOGY

                                        • Abbreviations

                                          • Bronchial artery embolization (BAE)
                                        • Definitions

                                          • Hemoptysis: Coughing up blood arising from lungs or airways
                                            • Typically caused by erosion/bleeding of overlying airway mucosa or rupture of hypertrophied bronchial arteries (BAs)
                                              • Often triggered by infection, mucosal inflammation, or malignancy
                                              • Most patients (90-95%) present with small-volume hemoptysis not requiring invasive therapy
                                            • Classically defined as massive, moderate, or mild
                                            • Death is result of asphyxiation as hemorrhage floods airways (not hemorrhagic shock)
                                              • Airway total volume: 150 mL in adults
                                          • Massive hemoptysis
                                            • Varied definitions
                                              • Most common: > 300 mL in 24 hours
                                              • Potentially life threatening
                                          • Moderate hemoptysis
                                            • > 100-300 mL/day; 3 episodes > 100 mL/week
                                          • Mild hemoptysis
                                            • < 100 mL/day; < 50 mL/episode
                                          • Etiologies of massive hemoptysis
                                            • Common causes of bronchial/systemic artery source
                                              • Chronic infections: Tuberculosis (most common worldwide), fungal, chronic pneumonia, abscess
                                              • Chronic inflammatory states: Cystic fibrosis, sarcoidosis, Wegener granulomatosis
                                              • Acquired/congenital pulmonary stenosis/occlusion
                                              • Malignancy
                                          • Potential sources: Generally arterial source due to systemic vascular pressure
                                            • BA (90%)
                                              • Localized BA proliferation and hypertrophy in response to chronic pulmonary artery vasoconstriction (from hypoxia), obstruction, or stimulation from chronic inflammation (rubor)
                                            • Isolated nonbronchial systemic artery (5%)
                                              • Common vessels include intercostal arteries, branches of brachiocephalic/subclavian arteries, inferior phrenic arteries
                                              • Communication between bronchial and nonbronchial systemic artery present on BA evaluation in 40-62% cases
                                              • Chronic inflammation/hyperemia can lead to collateral recruitment from systemic arteries, particularly when disease involves pleura/chest wall
                                            • Pulmonary artery (5%)
                                              • Low pressure of pulmonary artery makes it less common cause of massive hemoptysis
                                              • Consider with history of trauma/intervention or cavitary lesion
                                              • CTA often shows suggestive findings, such as pulmonary artery aneurysm/pseudoaneurysm or branch along inner wall of cavity
                                            • Common causes of pulmonary artery source
                                              • Rasmussen aneurysms, septic emboli, necrotizing pneumonia
                                              • Iatrogenic/traumatic pseudoaneurysm
                                              • Cavitary malignancy
                                              • Pulmonary arteriovenous malformation
                                          • BA anatomy: Many known anatomic variations in arterial number, origin, course
                                            • By definition, BAs, even when ectopic in origin, parallel central airways and enter lungs at hilum
                                            • Typically < 1.5 mm in diameter at origin ↓ to 0.5 mm when entering bronchopulmonary segment
                                            • Branch with airways and peripherally supply submucosal plexus in close proximity to airway lumen with anastomotic connections to pulmonary arteries (bronchopulmonary anastomosis)
                                              • Provide nutrient supply to multiple structures
                                                • Bronchi
                                                • Diaphragmatic/mediastinal visceral pleura
                                                • Subcarinal lymph nodes
                                                • Middle 1/3 of esophagus
                                                • Dorsal/ventral nerve roots (radicular arteries)
                                                • Vasa vasorum of aorta, pulmonary arteries/veins
                                                • Spinal cord (medullary arteries): "Hairpin" with supply to anterior spinal artery (ASA); often arises from right intercostobronchial trunk (RICBT)
                                          • Normal/orthotopic origin of BAs (64% of patients on CTA)
                                            • Origin from descending thoracic aorta between T5-T6 within 1 cm of where left bronchus crosses aorta
                                              • RICBT usually arises from medial to posteromedial aorta similar in origin to intercostal artery
                                              • Right BA often arises from medial to anteromedial aorta, whereas left BA generally arises anteriorly
                                            • Cauldwell patterns of orthotopic BA branching (based on anatomic studies of 150 cadavers)
                                              • Type 1: RICBT/2 left BAs (41%)
                                              • Type 2: RICBT/1 left BA (21%)
                                              • Type 3: RICBT/1 right BA/2 left BAs (21%)
                                              • Type 4: RICBT/1 right BA/1 left BA (10%)
                                              • Types 5-9: Varying configurations and number of right and left BAs (8%)
                                          • Ectopic/aberrant origin of BAs (36% of patients on CTA)
                                            • BA origin not at T5-T6 level; however, entry into lung is still along major bronchi
                                              • Undersurface of aortic arch (74%)
                                              • Branches of brachiocephalic/subclavian artery (10.5%): Internal mammary artery, thyrocervical trunk, subclavian artery, costocervical trunk
                                              • Descending aorta or its branches (8.5%)

                                        PREPROCEDURE

                                        • Indications

                                          • Contraindications

                                            • Preprocedure Imaging

                                              • Getting Started

                                                PROCEDURE

                                                • Procedure Steps

                                                  • Findings and Reporting

                                                    • Alternative Procedures/Therapies

                                                      POST PROCEDURE

                                                      • Things to Do

                                                        OUTCOMES

                                                        • Problems

                                                          • Complications

                                                            • Expected Outcomes

                                                              Selected References

                                                              1. Charya AV et al: Management of life-threatening hemoptysis in the ICU. J Thorac Dis. 13(8):5139-58, 2021
                                                              2. Davidson K et al: Managing massive hemoptysis. Chest. 157(1):77-88, 2020
                                                              3. Ittrich H et al: The diagnosis and treatment of hemoptysis. Dtsch Arztebl Int. 114(21):371-81, 2017
                                                              4. Panda A et al: Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 23(4):307-17, 2017
                                                              5. Walker CM et al: Bronchial arteries: anatomy, function, hypertrophy, and anomalies. Radiographics. 35(1):32-49, 2015
                                                              6. Ketai LH et al: ACR appropriateness criteria® hemoptysis. J Thorac Imaging. 29(3):W19-22, 2014
                                                              7. Woo S et al: Bronchial artery embolization to control hemoptysis: comparison of N-butyl-2-cyanoacrylate and polyvinyl alcohol particles. Radiology. 269(2):594-602, 2013
                                                              8. Chun JY et al: Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Intervent Radiol. 33(2):240-50, 2010
                                                              9. McCullagh A et al: The bronchial circulation--worth a closer look: a review of the relationship between the bronchial vasculature and airway inflammation. Pediatr Pulmonol. 45(1):1-13, 2010
                                                              10. Kalva SP: Bronchial artery embolization. Tech Vasc Interv Radiol. 12(2):130-8, 2009
                                                              11. Wang GR et al: Bronchial artery embolization for the management of hemoptysis in oncology patients: utility & prognostic factors. J Vasc Interv Radiol. 20(6):722-9, 2009
                                                              12. Khalil A et al: Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography. Chest. 133(1):212-9, 2008
                                                              13. Sidhu M et al: Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 25(3):310-8, 2008
                                                              14. Hartmann IJ et al: Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 17(8):1943-53, 2007
                                                              15. Pelage JP: Bronchial artery embolization: anatomy and technique. Tech Vasc Interv Radiol. 10(4):274-5, 2007
                                                              16. Cauldwell EW et al: The bronchial arteries; an anatomic study of 150 human cadavers. Surg Gynecol Obstet. 86(4):395-412, 1948