Dealing with technical challenges in embolization of a rare aberrant left inferior bronchial artery arising from the left gastric artery in a patient with massive hemoptysis

Abstract

Bronchial artery embolization is an established intervention for management of recurrent massive hemoptysis in a majority of patients. The source of bleeding in a majority of cases is systemic arteries - orthotopic bronchial arteries, anomalous bronchial arteries, or nonbronchial systemic collaterals. We report a case of an aberrant left inferior bronchial artery arising from the left gastric artery (LGA) in a patient with massive hemoptysis. Such origin from infradiaphragmatic vessels and specially left gastric arteries is very rare and needs to be considered by interventional radiologists and pulmonologists in case with hemoptysis disproportionate to supply by orthotopic arteries. Technical challenges were present in the present case in the form of an aneurysm in the aberrant artery and nontarget hepatic and gastric branches arising from LGA. Appropriate selection of hardware and embolic agents was done to deal with the clinical situation.

Keywords: Aberrant bronchial artery; bronchial artery embolization; left gastric artery; massive hemoptysis; nonbronchial systemic collaterals.

Figure 1 (A-C)

(A) Selective angiogram of right intercostobronchial trunk reveals intercostal arteries (solid arrows – right second and third intercostal spaces) and a large common bronchial trunk (broken arrow). (B) Postembolization superselective angiogram of the common bronchial trunk revealed significant stasis of contrast material in the proximal lumen of bilateral bronchial arteries with no residual hypervascularity in bilateral lower zones. (C) Delayed phase in thoracic aortogram revealed a suspicious tortuous aberrant left inferior bronchial branch (square arrow) extending from infradiaphragmatic location (curved arrow) into mediastinum and then left lower zone

Figure 2 (A-C)

(A) Selective celiac angiogram revealed tortuous left gastric artery with accessory left hepatic artery (black arrow), small gastric artery (white arrow), and proximal hypertrophied mediastinal branch (dashed arrow). (B) Superselective angiogram of the aberrant hypertrophied superior branch of left gastric artery revealed tortuous course with a focal fusiform aneurysm (square arrow) from its lumen and aberrant hypervascular bronchial supply (curved arrow) to left lower zone with systemic-pulmonary shunting (dashed arrow). (C) Superselective angiogram of the aberrant left inferior bronchial artery in lateral projection confirming the posterior mediastinal course of the vessel likely para-esophageal

Figure 3 (A-D)

(A) Postembolization superselective angiogram of the aberrant left bronchial artery revealed significant reduction in hypervascularity and shunting and mild stasis in the vessel lumen. Note is made of diagnostic 5-Fr Sim1 catheter (straight arrow) deep in the left gastric artery lumen with well-positioned microcatheter tip (dashed arrow) beyond the nontarget hepatic and gastric branches. (B) Superselective 10% glue injection into the aberrant artery. (C) Selective left gastric angiogram revealed stasis with lumen of the aberrant hypertrophied artery with normal opacification of accessory left hepatic (square arrow) and gastric (curved arrow) branches. Note is made of glue cast within the distal aberrant left bronchial artery. (D) Coronal reformatted maximal intensity projection image revealed radio-opaque glue cast within the distal lumen of aberrant bronchial artery, the aneurysm arising from it, and the distal intrapulmonary branches