Bronchial artery embolization in hemoptysis: a systematic review

Abstract

We systematically reviewed the role of bronchial artery embolization (BAE) in hemoptysis. Literature search was done for studies on BAE published between 1976 and 2016. Twenty-two studies published in English, with sample size of at least 50 patients, reporting indications, technique, efficacy, and follow-up were included in the final analysis. Common indications for BAE included tuberculosis (TB), post-tubercular sequelae, bronchiectasis, and aspergillomas. Most common embolizing agent used was polyvinyl alcohol (size, 300-600 μm) with increasing use of glue in recent years. Overall immediate clinical success rate of BAE, defined as complete cessation of hemoptysis, varied from 70%-99%. However, recurrence rate remains high, ranging from 10%-57%, due to incomplete initial embolization, recanalization of previously embolized arteries, and recruitment of new collaterals. Presence of nonbronchial systemic collaterals, bronchopulmonary shunting, aspergillomas, reactivation TB, and multidrug resistant TB were associated with significantly higher recurrence rates (P < 0.05). Rate of major complications remained negligible and stable over time with median incidence of 0.1% (0%-6.6%). Despite high hemoptysis recurrence rates, BAE continues to be the first-line, minimally invasive treatment of hemoptysis in emergency settings, surgically unfit patients, or in patients with diffuse or bilateral lung disease.

Figure 1

Search strategy. *Eligibility criteria included: 1) Studies on patients with hemoptysis undergoing bronchial artery embolization (BAE) for management; 2) Clinical outcomes, follow-up, and complications reported; 3) Full-text publications in English available; 4) Publication date between 1975 and 2016.

Figure 2. a–c

Orthotopic bronchial arteries. Preembolization digital subtraction angiography (DSA) image (a) shows selective catheterization of common bronchial artery giving rise to hypertrophied right bronchial artery (black arrow) and left bronchial artery (white arrow) with parenchymal blush (white block arrow). Postembolization DSA image (b) shows contrast stasis in right bronchial artery (black arrow), obliterated left bronchial artery and no residual parenchymal blush suggestive of successful embolization. DSA image in a different patient (c) shows selective run of hypertrophied right intercostobronchial trunk giving rise to right bronchial artery (white arrow) and intercostal artery (black arrow).

Figure 3. a–c

Ectopic bronchial arteries. Preembolization DSA image (a) shows selective catheterization of hypertrophied tortuous left bronchial artery, ectopically arising from descending thoracic aorta at D8 level (black arrow). Postembolization DSA image (b) shows contrast stasis and decreased vascularity in left bronchial artery (black arrow) suggestive of successful embolization. DSA image (c) shows ectopic right bronchial artery arising from right subclavian artery (black arrow) in a different patient.

Figure 4. a–f

Nonbronchial systemic collaterals. Preembolization DSA image (a) shows selective catheterization of hypertrophied left internal mammary artery (arrow) arising from left subclavian artery. Postembolization DSA image (b) shows successful selective embolization of left internal mammary artery branches with decreased vascularity and parenchymal blush (arrow). DSA image (c) of another patient shows selective catheterization of hypertrophied left lateral thoracic artery (arrow) arising from left subclavian artery. DSA image (d) shows hypertrophied right costocervical artery with normal cervical component (black arrow) and abnormal parenchymal blush from the costal component (white arrow) in another patient. DSA image (e) of a different patient shows selective catheterization of hypertrophied left posterior intercostal artery (arrow) with significant parenchymal blush. DSA image (f) of another patient shows hypertrophied right inferior phrenic artery (arrow).