César Abelleira. Hospital Ramón y Cajal. Madrid

INTERVENTIONAL TREATMENT OF HEMOPTYSIS IN THE CYANOTIC PATIENT César Abelleira. Hospital Ramón y Cajal. Madrid

Hemoptysis Blood expectoration from lungs. Infrequent Very traumatic for patient Life-threatening when massive (>300 ml/day) 50-100% mortality rate if not treated Rupture of abnormal vessels into the airways. Abnomaly enlarged bronchial arteries Abnormal nonbronchial systemic arteries (Neovascularization) More frequent in pulmonary and connective diseases

Hemoptysis Congenital heart diseases Etiology Pulmonary hypoperfusion, absent pulsatilty. Chronic hipoxia. Lack of hepatic venous effluent Previous thoracotomies and fístulae, Left to right shunt and competitive pulmonary flow in Fontan phisiology

Hemoptysis Aortic arch obstruction

Hemoptysis Progression over time If the underlying cause not treated Same patient, 2 years in between

Bronchial arteries- Anatomy and Physiology 1% of all pulmonary arterial supply. Trachea, pulmonary airways, visceral pleura, esophagus, spinal cord Vasa vasorum of the aorta, pulmonary arteries and veins. Variable anatomy Thoracic descending aorta (T5-T6 level). Ectopic 15-30% Normal diameter < 2 mm. Course parallel to that of the major bronchi Four most common bronchial branching patterns Complex anastomoses with pulmonary arteries

Non bronchial systemic arteries Normally obliterated embriologyc vessels. Abnormaly proliferated and enlarged. Non parallel to the major bronchi Very Complex anatomy. (Spiders web of interconnected vessels). Origin: Subclavian artery origin Internal mammary artery Tyro cervical trunk Parietal branches of axillary artery Diaphragmatic vessel

Bronchial and non bronchial systemic arteries Some examples of the same patient

Hemoptysis - Diagnostic image Bronchoscopy. Difficult to localize bleeding site in massive hemoptysis. Possible airway compromise due to sedation, delay of deffinitive treatment,.. CT Scan Localize site of bleeding 63-100%. Multidetector CT angiography 3D road mapping of the thoracic vessels More accurate than conventional angiography

Bronchial artery embolization (BAE) Most effective for management of massive an recurrent hemoptysis Primary therapy Prior to elective surgery. Experienced interventional radiologists familiar with this techniques or at least in close collaboration with them to: Increase de success rate Avoid potential serious complications Transverse myelitis due to spinal cord ischemia Pulmonary infarct or systemic embolization

Bronchial artery embolization (BAE) Study Protocol Preliminary descending thoracic aortogram Majority of abnormal, hypertrophied bronchial arteries are visualised. Inadequate for identification of non bronchial systemic arteries (More frequent in congenital heart diseases)

Bronchial artery embolization (BAE) Study Protocol Selective injections Left Int mammary Right subclavian junction Right diaphragmatic art. Left parietal branch Tyro cervical trunk Bronchial

Bronchial artery embolization (BAE) Embolization angiographyc criteria Extravasation of contrast medium (< 10%) Hypertrophic and tortuous bronchial arteries (>2 mm) Hypervascularity and neovascularity (Parenchimogram) Shunting of blood into pulmonary artery or vein

Bronchial artery embolization - technical comments Some important considerations Cut the tree from the root? Not a good option Embolize as distal as possible. Close to the brochopulmonary anastomoses in order to prevent their recurrence, Metal coils, closure devices should be avoided (Preclude further embolization if bleeding recours) Avoid embolic material that can pass through abnormal bronchopulmonary anastomoses Up to 325 μm have been demonstrated

Bronchial artery embolization - technical comments Catheters Hydrophilic. Cobra, Simmons, vertebral, int. Mamary,.. Microcatheters Embolic material. Absorvable gelatin sponge Tris-acryl microspheres Polyvinyl alcohol particulate (Our experience. most used 350-710 μm) In 20 cc SYRINGE: Contrast medium 17 cc, Saline 2 cc, Particulate 1 cc

Bronchial artery embolization - technical comments Selective target vessel catheterization Inject slowly until parenchimogram disappears Important catheter stability Careful with the back flow Thyrocervical trunk

Bronchial artery embolization Our series 1998 to date 16 catheterizations in 9 patients (all cyanotic) on emergency basis. 31 vessels treated Patient data Age 13 y (0,5 to 31). Weigh 31 Kg (7,1 to 51) Previous diagnoses PA and VSD 5 Univentricular heart + palliative Glenn. 3 Fontan palliation 1 Close collaboration with interventional radiologists

Transcatheter interventions- What have we learned? RESULTS 1 procedure in 5 patients (free of symptoms for more than 5 years). Recurrence in 4 patients 2 procedures in 2 patients 3 and 4 procedures in single patients. 1 patient died after 4 embolizations and 1 BT shunt. No significant complications 33 years of Fontan: evolution of a concept. Madrid. December 15/16 2011

Bronchial artery embolization Some examples Fallot + RPA hypoplasia 6 m After corrective surgery

Bronchial artery embolization Some examples 1998 to date

HEMOPTYSIS SUMMARY Hemoptysis: infrequent but serious complication and potentially lethal Cyanotic congenital heart diseases. Univentricular palliation. Non bronchial systemic arteries are frequently involved in CHD. Active search (Multidetector CT angiography, selective injections,..) Study protocol shortens time. Bronchial embolization techniques: effective and with minimal complications Collaboration with interventional radiologists (at least during the learning curve)

BRONCHIAL ARTERY EMBOLIZATION SUMMARY Microspheres or particles > 350 μm are the best choice. The disease process is in the smaller arteries and arterioles. Blocking proximal arteries may prevent access on subsequent occasion. Other possibilities (Coils, occlusion devices, covered stents) As distally as possible. Large distal connections (risk of particles embolism)

BRONCHIAL ARTERY EMBOLIZATION SUMMARY Many patients will require multiple procedures

BRONCHIAL ARTERY EMBOLIZATION SUMMARY Palliative procedure If the underlying cause not treated