Bronchial Artery Embolization:

Transcription

1 Bronchial Artery Embolization: Case Based Discussion GEST 2016 Jeffrey S. Pollak, MD Scott O. Trerotola, MD

2 Jeffrey Pollak, M.D. Consultant: Cook Medical

3 Scott Trerotola, M.D. Royalty: Cook Medical, Teleflex Consultant/Advisory Board: Teleflex, Bard PV, Lutonix, B Braun, MedComp Research Grants: National PI, Lutonix, AV Trial

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5 Case Early 20s yo woman with cystic fibrosis (colonized with MSSA & Aspergillus) and several months of minor hemoptysis that became worse one day ago Coughed up ~1 cup, with clots according to Cystic Fibrosis Foundation Consensus Report on Pulmonary Complications massive hemoptysis: 240 ml/24 h moderate hemoptysis: ml/24 h scant hemoptysis: <5 ml/24 h

6 Bilateral bronchiectasis, with many impacted, and cysts (some with air-fluid levels)

7 Comparison of Modalities in Evaluating Severe Hemoptysis Khalil, BJR 2007 (n=80) Localize bleeding (lobe or lung) CXR FOB HRCT 33% 89% 80% Etiology 3% 60% p <0.05 In certain conditions, bronchoscopy of lesser value, e.g. cystic fibrosis

8 CTA: 1 R BA (ICBT) and 2 L BAs L1 Transverse R L2 L1 Coronal R

9 CTA for Hemoptysis Advantages guide for endovascular therapy identifies bronchial arteries in >80-90% origins, including ectopic bronchials enlarged if >1.5 mm number identifies >60% of nonbronch systemic collat s enlarged, coursing into abn lung, usu w pl thck can detect unsuspected PA supply Disadvantages time & contrast load uncertain benefits if plan thorough angiography

10 Cauldwell 1948: Four Most Common Bronchial Artery Variations (>92%) 1 R (ICBT) 2 L BAs 40.6% 1 R (ICBT) 1 L 21.3% 2 R (1 ICBT) 2 L 20.6% 2 R (1 ICBT) 1 L 9.7% R & L bronchial arteries may arise from a common trunk

11 Pre R ICBT L BA 1 L BA 2 Post FU: Immediate control. Recurrent mild bleeding in next few months, stopped with antibiotics. No further recurrence for >5 years.

12 Hemoptysis: Vascular Pathology Inflam (esp chr), neoplasia, occluded PAs enlarged systemic arteries (BAs >1.5-2 mm) tortuosity hypervascularity neovascularity hyperemia shunting (small vessel level) to pulm circulation rupt small, fragile syst art s or PAs under syst P diffuse oozing across inflam or neoplastic tissue Necrotizing inflammation, tumor, trauma syst or PA art erosion ps-an, blding (infreq) PA fistula & aneurysm (congenital & acquired)

13 Hemoptysis in Cystic Fibrosis Generally occurs in adults, age 24 ± 9 yo usually in setting of infectious exacerbation Massive in 9% (240 ml/day re CF Foundation) Increases 2 year mortality by 6-16% worse if massive Rx of massive (± moderate, ml/day) antibiotics, support measures, airway protection identify source: history, imaging bronchoscopy is of limited value embolization (surgery only if this unsuccessful)

14 Embolization for Hemoptysis in Cystic Fibrosis Initial control in 75-97% Recurrence in 23-46% mean time ~12 months incidence blding frm nonbronchial collat s especially in recurrent hemoptysis Side effects temporary: chest pain, dysphagia Complications rare paralysis bronchial injury (e.g., w bronchoesoph fistula)

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16 Case 74 yo man with episodes of bright red hemoptysis over past week, not massive but accompanied by oxygen desaturations & concern over asphyxia. PMH 5 y SP CABG & LV aneurysm resection with perforation of esophagus at time of surgery secondary to transesophageal echo, with R side empyema. Eventually, had R thoracoplasty & repair of esophageal fistula.

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18 Right lower lobe basilar soft tissue mass CT guided biopsy: inflammatory lesion Continued episodes of moderate hemoptysis

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20 Thoracic aortogram no bronchial arteries Probed thoracic aorta still no bronchial arteries found selected posterior intercostal arteries no supply into lung

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22 R SCA tortuous vessel off a SCA branch coursing along mediastinum, probably trachea, then along R bronchus, into base of right lower lobe, with hyperemia Difficulty selecting SCA branch and subbranch from femoral approach

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24 Transbrachial artery approach Right costocervical trunk branch coursing along trachea and right bronchus, into right lower lobe hyperemia & shunting to PA branches

25 Pre-embolization SP CCT branch embolization. No further bleeding over next few years.

26 Ectopic Bronchial Arteries Incidence 10-30% anterior arch ~14% subclavian art s & branches lower descending T aorta inferior phrenic art s rare abdominal aorta rare Enter lung through hilum along bronchi distinguish from acquired Red: more common origins Black: less common origins systemic-to-pulmonary artery collateral flow enter lung pleural adhesions or pulm ligament

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28 Case Late 40s yo man with nearly 30 pack-year smoking history Several months cough &intermittent dyspnea with 40 lb weight loss Several days of hemoptysis, progressing to massive bright red bleeding requiring intubation Evaluate for source/location radiographic imaging and bronchoscopy

29 R bronchus

30 CTA Ectopic CBT from L SCA. Enlarged R branch into R hilar mass RLL saccular pseudoaneurysm

31 Coronal Coronal oblique

32 Vascular Source of Hemoptysis Frequency (%) Systemic bright red* >90% Bronchial ~90 Nonbronchial collaterals 7-58 Pulmonary dark red* 2-10 Combined syst & pulm <5-10% * color not a reliable indicator of source

33 Two potential sources of hemoptysis in this patient Decision here was to start with systemic source

34 Ectopic CBT with enlarged R branch L SCA SP embolization R bronchial branch with Embosphere

35 Embolization Agents for Hemoptysis Particulates preferred, distal occlusion nonspherical polyvinyl alcohol, > mcm gelatin sponge, sub-mm to several mm microspheres, probably at least 500 mcm Mechanical agents give relatively prox occl avoid for distal dis: collat s develop & resupply can use if at a macro-fistula or aneurysm Liquids ethanol avoid: risk bronchial & other injury polymerizing agents (glue, Onyx) perhaps if prox to small dist fistula or aneurysm

36 Decreased but continued slow bleeding Returned 2 days later

37 Stopped bleeding

38 Infarction risk from treating both circulations? did not occur in this patient

39 Massive Hemoptysis: More Basics 1-15% of all hemoptysis Life-threatening hemoptysis asphyxiation tracheobronchial tree ~150 ml significant inhibition of gas exchange with 400 ml blood retained in alveolar space exsanguination pneumonia depends on rate of bleeding amount of retained blood in lungs underlying pulmonary reserve

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41 Case 65 yo man with COPD and recurrent massive hemoptysis of several hundred ml per day after two prior embolizations done elsewhere left bronchial artery probably left lateral thoracic artery

42 Supine Prone Left apical aspergilloma. Also, smaller R one not depicted.

43 Third embolization Numerous small systemic collaterals, with shunting to left pulmonary artery and right apical pulmonary circulation

44 Embolized left thyrocervical trunk left internal thoracic artery right costocervical trunk

45 Acquired Nonbronchial Systemic Collaterals Arise in response to chr inflam, neoplasia, & occlusive PA dis Origins post & anterior ICAs SCA & axillary artery br s inf phrenic & other abd Ao br s Enter lung across pleura adhesions through inferior pulm ligament not along major bronchi as do BAs/ectopic BAs Not uncommon & often multiple TB w massive hemoptysis

46 Continued massive hemoptysis Pulmonary angiography negative Next option?

47 Catheter placed for intracavitary amphotericin instillation hemoptysis stopped. Resolution of fungus ball Recurrent hemoptysis later from right apical aspergilloma also stopped with intracavitary therapy.

48 Aspergilloma and Hemoptysis Most frequent complication, in ~75% abundant bronchial & nonbronch system supply massive, resulting in death in 2-50% Treatment of hemoptysis medical: antifungal agents no definite effect surgical resection traditional & definitive recent series: morbidity 24-40%, mortality 1-6% many pts inoperable severe, diffuse disease systemic emboliz recurrence up to % massive collateral circulation rapid recruitment/recanalization of vessels

49 Percutaneous Intracavitary Amphotericin B for Aspergilloma Liquid solution or gel/paste prefer involved side down & traverse adhesions liquid administered through catheter in cavity instill ~50 mg in ml daily (± NAC later) gel/paste gelatin or glycerides (± iodized oil) warm mixture w 50 mg through G needle Rapid control of hemoptysis in ~all patients recurrent bleeding infrequent, at least early Complications:acute hemoptysis, pneumothorax, pneumonitis (chem, bact, asperg w gel/paste)

50 58 yo man with past atypical mycobacteria and subsequent bronchiolitis obliterans. Loculated R pn-thorax, L apical aspergilloma: hemoptysis and L pneumonia Amphotericin B gel Limited small immediate bleed. No hemoptysis next couple months. Resection at 5 mos.

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52 Case 58 yo woman with HHT and 3 days of back pain, now worse, with right chest pain and difficulty breathing SaO2 94% on 60% oxygen mask BP 90/50

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54 Current 2 y earlier

55 Large right hemothorax with different densities 2 moderate sz RLL PAVMs w rel large sacs anterior one subpleural lateral one exophytic component, within the hemothorax Other smaller PAVMs LLL, RUL, RML Right surgical chest tube drained 1800 ml bloody fluid

56 One segmental artery supplying feeding arteries to both anterior and lateral RLL PAVMs

57 Coil embolization: one 10 mm MReye as a scaffold and two 8 mm Nesters to provide dense matrix

58 Persistent large right hemothorax despite surgical chest tube

59 SP 12 F IR catheter into R pleural base & fibrinolytic therapy with t-pa 1 month later: small residual nonlayering R pleural density R side down decubitus

60 Another month later Persistent occlusion of RLL PAVMs. Embolized other, smaller, bilateral PAVMs

61 Hemoptysis 1-18% PAVM Hemorrhage Hemothorax up to 9% Massive blding ~8%, can be life threatening Pregnancy risk enlargmnt & complic s Shovlin 2008: pregnant women pulmonary hemorrhage 1% stroke 1.2% death 1% (general population 0.014%) Prefer elective treatment, after screening

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63 Case 32 yo woman with HHT and diffuse pulmonary arteriovenous malformation When 24 yo marked dyspnea, with PaO2 36 mm Hg

64 RLL & LLL proximal embolization to redistribute flow away from more involved diffuse regions Partial Further

65 ~8 years later, developed massive hemoptysis

66 Bilateral bronchial artery embolization with microspheres. Patient developed stroke and MI recovered.

67 Multiple episodes recurrent hemoptysis over next few years Recanalized R bronchial artery Inferior phrenic artery Further embolization with thick gelatin sponge

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82 Pt w DPAVM prior to any embo

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84 Massive agreed upon at 200/24h

85 Note 100 ml/24h daily x 3 days or more

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90 Case 1 40 year old lady Cystic fibrosis First embo 2007

91 2007

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93 Case 1 40 year old lady Cystic fibrosis Represented 2013 (don t forget alternative supply IMA)

94 2013

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97 Identify non bronchial artery supply

98 Bronchial artery origins Normal Orthotopic origin T5 / T6 Vertebral level (64%)

99 Bronchial artery origins Ectopic origin 36% (undersurface of the aortic arch most common)

100 Intercostal bronchial artery trunk (ICBAT)

101 Variations in bronchial artery configurations

102 TYPE: 1-40 % (1R 2L) TYPE : 2-20% (1R- 1L) TYPE: 3-20 % (2R-2L) FOUR CLASSIC BRONCHIAL ARTERY BRANCHING PATTERNS. TYPE 4-10 % (2R-1L)

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104 MDCT ANGIO 22 YR OLD MALE WITH HEMOPTYSIS

105 Case 2 40 year old lady Cystic fibrosis

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109 Dissection

110 Case 3 60 year old male Long history TB

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