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Bronchial Artery Embolization
Mandeep S. Dagli, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Terminology

    • Procedure

      • Post Procedure

        • Outcomes

          TERMINOLOGY

          • Definitions

            • Hemoptysis: Coughing up of blood arising from lungs or airways
              • Typically caused by erosion/bleeding of overlying airway mucosa or rupture of hypertrophied bronchial arteries
                • Often triggered by infection, mucosal inflammation, or malignancy
                • Most patients (90-95%) present with small-volume hemoptysis not requiring invasive therapy
              • Classified as massive, moderate, or mild
            • Massive hemoptysis
              • Varied definitions
                • Most common: > 300 mL blood in 24 hours
                • Massive = potentially life-threatening
                • Patients with poor underlying ventilatory reserve may require less blood to inhibit adequate ventilation
              • Potential sources: Generally arterial source due to systemic vascular pressure
                • Bronchial artery (90%)
                  • Localized bronchial artery proliferation & hypertrophy in response to chronic pulmonary artery vasoconstriction (from hypoxia), obstruction, or stimulation from chronic inflammation (rubor)
                • Nonbronchial systemic artery (5%)
                  • Common vessels include intercostal arteries, branches of brachiocephalic/subclavian arteries, inferior phrenic arteries
                  • 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 PA aneurysm/pseudoaneurysm or branch along inner wall of cavity
              • Disease etiologies of massive hemoptysis
                • Common causes of bronchial/systemic artery source
                  • Chronic infections: Tuberculosis (most common world wide), fungal, chronic pneumonia, abscess
                  • Chronic inflammatory states: Cystic fibrosis, sarcoidosis, Wegener granulomatosis
                  • Acquired/congenital pulmonary stenosis/occlusion
                  • Malignancy
                • Common causes of pulmonary artery source
                  • Rasmussen aneurysms, septic emboli, necrotizing pneumonia
                  • Iatrogenic/traumatic pseudoaneurysm
                  • Cavitary malignancy
                  • Pulmonary arteriovenous malformation
            • Moderate hemoptysis
              • Blood loss > 100 mL/day over 3 days per week
            • Bronchial artery anatomy: Many known anatomic variations in arterial number, origin, course
              • By definition bronchial arteries, even when ectopic in origin, parallel central airways and enter lungs at hilum
              • Typically <1.5 mm in diameter at origin decreasing 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; often arises from right intercostobronchial trunk (RICBT)
            • Normal/orthotopic origin of bronchial arteries (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 bronchial artery often arises from medial to anteromedial aorta whereas left bronchial artery generally arises anteriorly
              • Cauldwell patterns of orthotopic bronchial artery branching (based on anatomic studies of 150 cadavers)
                • Type 1: RICBT/2 left bronchial arteries (41%)
                • Type 2: RICBT/1 left bronchial artery (21%)
                • Type 3: RICBT/1 right bronchial artery/2 left bronchial arteries (21%)
                • Type 4: RICBT/1 right bronchial artery/1 left bronchial artery (10%)
                • Types 5-9: Varying configurations and number of right and left bronchial arteries (8%)
            • Ectopic/aberrant origin of bronchial arteries (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

                      POST PROCEDURE

                      • Things to Do

                        OUTCOMES

                        • Problems

                          • Complications

                            • Expected Outcomes

                              Selected References

                              1. Walker CM et al: Bronchial arteries: anatomy, function, hypertrophy, and anomalies. Radiographics. 35(1):32-49, 2015
                              2. Ketai LH et al: ACR appropriateness criteria® hemoptysis. J Thorac Imaging. 29(3):W19-22, 2014
                              3. 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
                              4. 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
                              5. Khalil A et al: Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography. Chest. 133(1):212-9, 2008
                              6. Sidhu M et al: Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 25(3):310-8, 2008
                              7. Hartmann IJ et al: Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 17(8):1943-53, 2007
                              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. Kalva SP: Bronchial artery embolization. Tech Vasc Interv Radiol. 12(2):130-8, 2009
                              10. 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
                              11. Pelage JP: Bronchial artery embolization: anatomy and technique. Tech Vasc Interv Radiol. 10(4):274-5, 2007
                              12. 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

                                      • Definitions

                                        • Hemoptysis: Coughing up of blood arising from lungs or airways
                                          • Typically caused by erosion/bleeding of overlying airway mucosa or rupture of hypertrophied bronchial arteries
                                            • Often triggered by infection, mucosal inflammation, or malignancy
                                            • Most patients (90-95%) present with small-volume hemoptysis not requiring invasive therapy
                                          • Classified as massive, moderate, or mild
                                        • Massive hemoptysis
                                          • Varied definitions
                                            • Most common: > 300 mL blood in 24 hours
                                            • Massive = potentially life-threatening
                                            • Patients with poor underlying ventilatory reserve may require less blood to inhibit adequate ventilation
                                          • Potential sources: Generally arterial source due to systemic vascular pressure
                                            • Bronchial artery (90%)
                                              • Localized bronchial artery proliferation & hypertrophy in response to chronic pulmonary artery vasoconstriction (from hypoxia), obstruction, or stimulation from chronic inflammation (rubor)
                                            • Nonbronchial systemic artery (5%)
                                              • Common vessels include intercostal arteries, branches of brachiocephalic/subclavian arteries, inferior phrenic arteries
                                              • 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 PA aneurysm/pseudoaneurysm or branch along inner wall of cavity
                                          • Disease etiologies of massive hemoptysis
                                            • Common causes of bronchial/systemic artery source
                                              • Chronic infections: Tuberculosis (most common world wide), fungal, chronic pneumonia, abscess
                                              • Chronic inflammatory states: Cystic fibrosis, sarcoidosis, Wegener granulomatosis
                                              • Acquired/congenital pulmonary stenosis/occlusion
                                              • Malignancy
                                            • Common causes of pulmonary artery source
                                              • Rasmussen aneurysms, septic emboli, necrotizing pneumonia
                                              • Iatrogenic/traumatic pseudoaneurysm
                                              • Cavitary malignancy
                                              • Pulmonary arteriovenous malformation
                                        • Moderate hemoptysis
                                          • Blood loss > 100 mL/day over 3 days per week
                                        • Bronchial artery anatomy: Many known anatomic variations in arterial number, origin, course
                                          • By definition bronchial arteries, even when ectopic in origin, parallel central airways and enter lungs at hilum
                                          • Typically <1.5 mm in diameter at origin decreasing 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; often arises from right intercostobronchial trunk (RICBT)
                                        • Normal/orthotopic origin of bronchial arteries (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 bronchial artery often arises from medial to anteromedial aorta whereas left bronchial artery generally arises anteriorly
                                          • Cauldwell patterns of orthotopic bronchial artery branching (based on anatomic studies of 150 cadavers)
                                            • Type 1: RICBT/2 left bronchial arteries (41%)
                                            • Type 2: RICBT/1 left bronchial artery (21%)
                                            • Type 3: RICBT/1 right bronchial artery/2 left bronchial arteries (21%)
                                            • Type 4: RICBT/1 right bronchial artery/1 left bronchial artery (10%)
                                            • Types 5-9: Varying configurations and number of right and left bronchial arteries (8%)
                                        • Ectopic/aberrant origin of bronchial arteries (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

                                                  POST PROCEDURE

                                                  • Things to Do

                                                    OUTCOMES

                                                    • Problems

                                                      • Complications

                                                        • Expected Outcomes

                                                          Selected References

                                                          1. Walker CM et al: Bronchial arteries: anatomy, function, hypertrophy, and anomalies. Radiographics. 35(1):32-49, 2015
                                                          2. Ketai LH et al: ACR appropriateness criteria® hemoptysis. J Thorac Imaging. 29(3):W19-22, 2014
                                                          3. 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
                                                          4. 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
                                                          5. Khalil A et al: Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography. Chest. 133(1):212-9, 2008
                                                          6. Sidhu M et al: Bronchial artery embolization for hemoptysis. Semin Intervent Radiol. 25(3):310-8, 2008
                                                          7. Hartmann IJ et al: Ectopic origin of bronchial arteries: assessment with multidetector helical CT angiography. Eur Radiol. 17(8):1943-53, 2007
                                                          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. Kalva SP: Bronchial artery embolization. Tech Vasc Interv Radiol. 12(2):130-8, 2009
                                                          10. 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
                                                          11. Pelage JP: Bronchial artery embolization: anatomy and technique. Tech Vasc Interv Radiol. 10(4):274-5, 2007
                                                          12. Cauldwell EW et al: The bronchial arteries; an anatomic study of 150 human cadavers. Surg Gynecol Obstet. 86(4):395-412, 1948