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Findings: (A) Selective arteriogram of a common bronchial artery demonstrates supply to both the right and left lungs. There is no evidence of bleeding or significant hyperemia. (B) Selective arteriography of the left subclavian shows multiple hypertrophied chest wall vessels. The lateral thoracic, thoraco-acromial, and several unnamed branches are identified. A tubular structure, which is thought to represent the source of bleeding, is seen in the superior portion of the left lung, supplied by hypertrophied chest wall vessels rather than the bronchial artery. (C) Selective arteriogram (of a patient with cystic fibrosis and hypertrophied bronchial arteries) demonstrates the internal mammary artery feeding an area of intense hyperemia in the left upper lobe. An atypical appearing vessel in the chest wall and an area of extravasation fed by the bronchial artery are seen.

Diagnosis: Massive hemoptysis due to bleeding in the chest wall.

Discussion: Massive hemoptysis is defined as the clinically observed expectoration of 600 ml of blood or more in a 24-hour period. Its most common cause worldwide is active tuberculosis, however, in the United States, bronchogenic carcinoma and chronic inflammatory conditions of the lung (abscess, aspergilloma, chronic infection, pneumoconiosis, cystic fibrosis) are the typical etiologies. In the presence of these processes, the bronchial arteries and non-bronchial systemic collaterals supplying the inflamed tissue dilate, and when these vessels are subjected to systemic pressures, they rupture.

In 90% of cases, the site of bleeding can be localized to the bronchial artery. Another 5% of cases are attributed to bleeding from the pulmonary artery. Rarely, in apical lung disease, as seen in the above case, the thoracic branches of the axillary artery are involved. The intercostal, inferior phrenic, and internal mammary arteries, and branches of the left gastric artery and thyro-cervical and costo-cervical trunks are other vessels that can be the origin of bleeding.

Plain films and bronchoscopy are used to localize the cause and site of bleeding. In urgent cases, some authors advocate going directly to selective angiography, especially if the use of embolization therapy is likely. The affected vessels will look tortuous and hypertrophied, and hyperemia, and less frequently, extravasation of contrast are present at the active bleeding site. In addition to excluding the nasopharynx and the gastrointestinal tract as sources, non-bronchial collateral vessels should also be investigated if the patient has had previous embolization in the bronchial circulation. It is important to remember that identification of a bleeder is not required to embolize a bronchial bleeder. Identification of arterial hypertrophy and tissue staining is sufficient.

Massive hemoptysis is associated with 75% mortality rate if treated conservatively, and even with surgical intervention, mortality is approximately 35%. The procedure of choice for patients that are not good surgical candidates is bronchial artery embolization (BAE). It provides immediate control of bleeding in 75-90% cases. In the above case, where non-bronchial systemic vessels were involved, embolization can be used if the feeding vessels are sufficiently hypertrophied. Peripheral particulate embolization is used when preservation of the feeding vessel is a concern.

The most common complication of BAE is a post-embolization syndrome of pleuritic chest pain, fever, leukocytosis, and dysphagia. The most serious complication is spinal artery embolization leading to ischemic or chemotoxic transverse myelitis and paralysis. Pulmonary artery embolization and pulmonary infarction may also occur from BAE if an abnormal bronchopulmonary connection exists. Rarely, regression of material into the aorta may lead to distal non-target organ infarctions.

References:
Jean-Baptiste E. Clinical assessment and management of massive
hemoptysis. Crit Care Med 28(5):1642-7, 2000.

Kadir S. Atlas of Normal and Variant Angiographic Anatomy.
W. B. Saunders Co. Philadelphia; 1991-21-23, 44-49, 55-58, 63-74.

Marshall TJ and Jackson JE. Vascular intervention in the thorax:
bronchial artery embolization for haemoptysis. Eur Radiol 7:1221-1227, 1997.

Saluja S, Henderson KJ, and White RI,Jr. Embolotherapy in the bronchial
and pulmonary circulations. Radiol Clin North Am 38(2):425-48, 2000.

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