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A potential pitfall in bronchial artery embolization
Clinical Radiology (1995) 50, 105-107
A Potential Pitfall in Bronchial Artery Embolization M. G. COWLING and A.-M. BELLI
Department of Diagnostic Radiology, St James' Wing, St George's Hospital, London Two cases of patients with massive haemoptysis undergoing bronchial arteriography are described. Both had collateral vessels which filled the right subclavian artery from the right intercosto-bronchial trunk. Such vessels form a potential route for the passage of embolic material into the subclavian artery and its branches during therapeutic bronchial artery embolization. To avoid this potential complication, super selective catheterization with the positioning of the catheter tip well into the bronchial artery beyond the origin of the intercostal artery and any large collateral vessels is recommended. Cowling, M.G. & Belli, A.-M. (1995). Clinical Radiology 50, 105-107. A Potential Pitfall in Bronchial Artery Embolization
Accepted for Publication 22 August 1994
Percutaneous embolization of the bronchial arteries is an accepted technique for the control of massive haemoptysis. The bronchial arteries are the source of the bleeding in about 90% of cases [1,2], and the pulmonary arteries in about 5%. In addition to the bronchial arteries, other systemic vessels may contribute to the blood supply of lesions causing haemoptysis. Such nonbronchial collaterals are well recognized and may arise from phrenic, intercostal, internal mammary, thyrocervical and other branches of the axillary and subclavian arteries [3-5]. It is important to search for non-bronchial collaterals which may themselves require embolization to achieve control of haemoptysis. Two cases in whom filling of the subclavian artery occurred on injection of contrast into the intercosto-bronchial trunk are reported. CASE REPORTS Case 1. This 40-year-old male patient was previously fit and well, and smoked 15 cigarettes per day. For the fortnight prior to admission he had been complaining of a cough productive of green sputum. On the night prior to admission he had experienced a large haemoptysis, followed by a further episode the following morning with an estimated blood loss of 250 ml. A chest X-ray was normal. Bronchoscopy showed evidence of bleeding from the left upper lobe bronchus, but no specific lesion could be identified. It was therefore decided to carry out bronchial arteriography, which showed an enlarged left bronchial artery with peribronchial hypervascularity. This was embolized successfully with polyvinyl alcohol particles. During the procedure a right bronchial arteriogram was performed and two collateral vessels were identified connecting the right intercosto-bronchial trunk, to the right costocervical trunk and thence to the right subclavian artery (Fig. 1), but embolization was deemed unnecessary on this side. The patient made a good recovery with no further haemoptysis. Case 2. A 26-year-old male patient had been treated with warfarin for a proven DVT and large pulmonary embolus 3 years previously. He also gave a history of large haemoptysis on at least two previous occasions at another hospital over the previous year. Investigations at that time demonstrated no underlying haematological abnormality. On this admission he complained of massive haemoptysis with an estimated blood loss of 400 ml. Routine blood tests, chest X-ray and bronchoscopy were unrevealing. A V : Q scan was performed and showed no change compared with those obtained previously. In view of the past
Correspondence to: Dr M. G. Cowling, Department of Diagnostic Radiology, St James' Wing, St George's Hospital, Blackshaw Road, London SWl7 0QT.
history of pulmonary embolism, pulmonary arteriography was performed to assess the pulmonary arterial supply tothe lung and showed no filling of the lower lobe pulmonary arteries on either side, a finding which was unchanged when compared with the pulmonary arteriogram performed at the time of the previous pulmonary embolus. Bronchial arteriography was performed with the intention of carrying out embolization. Large bronchial arteries supplying both sides were demonstrated, and these were thought to be the source of haemorrhage. It was noted, as in Case 1, that there were two vessels connecting the right intercosto-bronchial trunk with the right subclavian artery via the costocervical trunk (Fig. 2). Ultimately it was decided not to proceed with embolization in view of the risk of causing pulmonary infarction by obstructing the bronchial arterial supply in a patient with an already compromised pulmonary arterial supply (J. Remy, personal communication), and the patient was referred for surgery.
DISCUSSION Bronchial embolization is a valuable treatment in controlling massive and recurrent haemoptysis not responding to medical therapy, and in situations where respiratory function is compromised [6,7]. Communication with the left costocervical trunk has previously been described on injection of contrast into the left bronchial artery [2]. To our knowledge filling of the subclavian artery from such an injection has not been described, although such filling may be expected from a knowledge of the anatomy. The superior intercostal artery, which is a branch of the subclavian artery, anastomoses with the first aortic intercostal artery. Hence, injection of contrast into the intercostobronchial trunk may fill the subclavian artery. The two cases presented here illustrate a potential pitfall that may be encountered during bronchial artery embolization. The vessels illustrated are reasonably large in size, and as such form a potential route for particulate embolic material such as polyvinyl alcohol particles to pass from the bronchial circulation to the subclavian artery or its branches, i.e. thyrocervical, vertebral and spinal arteries. These cases emphasize the importance of placing the catheter tip in a super-selective position, beyond the origin of the intercostal artery so that embolic material is directed only into the bronchial circulation. This may be achieved using a 3F coaxial catheter if necessary.
106
CLINICAL RADIOLOGY
(a)
(b)
Fig. 1 - Selective digital subtraction angiogram from Case 1. (a) The catheter tip is in the right intercosto-bronchial trunk. One o f the two collateral vessels connecting with the costocervical trunk is clearly seen (arrow). (b) A later image in the same sequence demonstrates a further collateral vessel, and tilling o f the subclavian artery.
107
BRONCHIAL ARTERIOGRAPHY AND EMBOLIZATION
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(a)
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Fig. 2 - The selective angiogram from Case 2 showing (a) both collateral vessels (arrows) and (b) in the later image filling of the right subclavian artery via the costocervical trunk. REFERENCES 1 Isihara T, Inoue H, Kobayashi K et al. Selective bronchial arteriography and hemoptysis in non-malignant lung disease. Chest 1974;66:633-638. 2 Remy J, Remy-Jardin M, Voisin C. Endovascular management of bronchial bleeding. In: Butler J, ed. The bronchial circulation. New York: Marcel Dekker, 1992:667-723. 3 Vugic I, Pyle R, Hungerford GD et al. Angiography and therapeutic blockade in the control of hemoptysis. Radiology 1982; 143:19-23.
4 Vugic I, Pyle R, Parker E et al. Control of massive hemoptysis by embolisation of intercostal arteries. Radiology 1980; 137:617-620. 5 Moore LB, McWey RE, Vugic I. Massive hemoptysis: control by embolisation of the thyrocervical trunk. Radiology 1986; 161:173174. 6 Prioleau WH, Vugic I, Parker EF et al. Control of hemoptysis by bronchial artery embolisation. Chest 1980; 78:878-880. 7 Ulfacker R, Kaemmerer A, Picon PD et al. Bronchial artery embolisation in the management of haemoptysis: technical aspects and Iongterm results. Radiology 1985; 157:637-644.
A Potential Pitfall in Bronchial Artery Embolization M. G. COWLING and A.-M. BELLI
Department of Diagnostic Radiology, St James' Wing, St George's Hospital, London Two cases of patients with massive haemoptysis undergoing bronchial arteriography are described. Both had collateral vessels which filled the right subclavian artery from the right intercosto-bronchial trunk. Such vessels form a potential route for the passage of embolic material into the subclavian artery and its branches during therapeutic bronchial artery embolization. To avoid this potential complication, super selective catheterization with the positioning of the catheter tip well into the bronchial artery beyond the origin of the intercostal artery and any large collateral vessels is recommended. Cowling, M.G. & Belli, A.-M. (1995). Clinical Radiology 50, 105-107. A Potential Pitfall in Bronchial Artery Embolization
Accepted for Publication 22 August 1994
Percutaneous embolization of the bronchial arteries is an accepted technique for the control of massive haemoptysis. The bronchial arteries are the source of the bleeding in about 90% of cases [1,2], and the pulmonary arteries in about 5%. In addition to the bronchial arteries, other systemic vessels may contribute to the blood supply of lesions causing haemoptysis. Such nonbronchial collaterals are well recognized and may arise from phrenic, intercostal, internal mammary, thyrocervical and other branches of the axillary and subclavian arteries [3-5]. It is important to search for non-bronchial collaterals which may themselves require embolization to achieve control of haemoptysis. Two cases in whom filling of the subclavian artery occurred on injection of contrast into the intercosto-bronchial trunk are reported. CASE REPORTS Case 1. This 40-year-old male patient was previously fit and well, and smoked 15 cigarettes per day. For the fortnight prior to admission he had been complaining of a cough productive of green sputum. On the night prior to admission he had experienced a large haemoptysis, followed by a further episode the following morning with an estimated blood loss of 250 ml. A chest X-ray was normal. Bronchoscopy showed evidence of bleeding from the left upper lobe bronchus, but no specific lesion could be identified. It was therefore decided to carry out bronchial arteriography, which showed an enlarged left bronchial artery with peribronchial hypervascularity. This was embolized successfully with polyvinyl alcohol particles. During the procedure a right bronchial arteriogram was performed and two collateral vessels were identified connecting the right intercosto-bronchial trunk, to the right costocervical trunk and thence to the right subclavian artery (Fig. 1), but embolization was deemed unnecessary on this side. The patient made a good recovery with no further haemoptysis. Case 2. A 26-year-old male patient had been treated with warfarin for a proven DVT and large pulmonary embolus 3 years previously. He also gave a history of large haemoptysis on at least two previous occasions at another hospital over the previous year. Investigations at that time demonstrated no underlying haematological abnormality. On this admission he complained of massive haemoptysis with an estimated blood loss of 400 ml. Routine blood tests, chest X-ray and bronchoscopy were unrevealing. A V : Q scan was performed and showed no change compared with those obtained previously. In view of the past
Correspondence to: Dr M. G. Cowling, Department of Diagnostic Radiology, St James' Wing, St George's Hospital, Blackshaw Road, London SWl7 0QT.
history of pulmonary embolism, pulmonary arteriography was performed to assess the pulmonary arterial supply tothe lung and showed no filling of the lower lobe pulmonary arteries on either side, a finding which was unchanged when compared with the pulmonary arteriogram performed at the time of the previous pulmonary embolus. Bronchial arteriography was performed with the intention of carrying out embolization. Large bronchial arteries supplying both sides were demonstrated, and these were thought to be the source of haemorrhage. It was noted, as in Case 1, that there were two vessels connecting the right intercosto-bronchial trunk with the right subclavian artery via the costocervical trunk (Fig. 2). Ultimately it was decided not to proceed with embolization in view of the risk of causing pulmonary infarction by obstructing the bronchial arterial supply in a patient with an already compromised pulmonary arterial supply (J. Remy, personal communication), and the patient was referred for surgery.
DISCUSSION Bronchial embolization is a valuable treatment in controlling massive and recurrent haemoptysis not responding to medical therapy, and in situations where respiratory function is compromised [6,7]. Communication with the left costocervical trunk has previously been described on injection of contrast into the left bronchial artery [2]. To our knowledge filling of the subclavian artery from such an injection has not been described, although such filling may be expected from a knowledge of the anatomy. The superior intercostal artery, which is a branch of the subclavian artery, anastomoses with the first aortic intercostal artery. Hence, injection of contrast into the intercostobronchial trunk may fill the subclavian artery. The two cases presented here illustrate a potential pitfall that may be encountered during bronchial artery embolization. The vessels illustrated are reasonably large in size, and as such form a potential route for particulate embolic material such as polyvinyl alcohol particles to pass from the bronchial circulation to the subclavian artery or its branches, i.e. thyrocervical, vertebral and spinal arteries. These cases emphasize the importance of placing the catheter tip in a super-selective position, beyond the origin of the intercostal artery so that embolic material is directed only into the bronchial circulation. This may be achieved using a 3F coaxial catheter if necessary.
106
CLINICAL RADIOLOGY
(a)
(b)
Fig. 1 - Selective digital subtraction angiogram from Case 1. (a) The catheter tip is in the right intercosto-bronchial trunk. One o f the two collateral vessels connecting with the costocervical trunk is clearly seen (arrow). (b) A later image in the same sequence demonstrates a further collateral vessel, and tilling o f the subclavian artery.
107
BRONCHIAL ARTERIOGRAPHY AND EMBOLIZATION
F
:,
9
I
?
.....
r 4
(a)
(b)
Fig. 2 - The selective angiogram from Case 2 showing (a) both collateral vessels (arrows) and (b) in the later image filling of the right subclavian artery via the costocervical trunk. REFERENCES 1 Isihara T, Inoue H, Kobayashi K et al. Selective bronchial arteriography and hemoptysis in non-malignant lung disease. Chest 1974;66:633-638. 2 Remy J, Remy-Jardin M, Voisin C. Endovascular management of bronchial bleeding. In: Butler J, ed. The bronchial circulation. New York: Marcel Dekker, 1992:667-723. 3 Vugic I, Pyle R, Hungerford GD et al. Angiography and therapeutic blockade in the control of hemoptysis. Radiology 1982; 143:19-23.
4 Vugic I, Pyle R, Parker E et al. Control of massive hemoptysis by embolisation of intercostal arteries. Radiology 1980; 137:617-620. 5 Moore LB, McWey RE, Vugic I. Massive hemoptysis: control by embolisation of the thyrocervical trunk. Radiology 1986; 161:173174. 6 Prioleau WH, Vugic I, Parker EF et al. Control of hemoptysis by bronchial artery embolisation. Chest 1980; 78:878-880. 7 Ulfacker R, Kaemmerer A, Picon PD et al. Bronchial artery embolisation in the management of haemoptysis: technical aspects and Iongterm results. Radiology 1985; 157:637-644.