Efficacy and safety of transcatheter arterial embolization for hemodynamically unstable bleeding after percutaneous transthoracic needle biopsy

Abstract

Purpose: To evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in controlling hemodynamically unstable bleeding following a percutaneous transthoracic needle biopsy (PTNB).

Methods: A total of seven patients (four men and three women; mean age, 62 ± 12 years) who received TAE for post-PTNB bleeding between May 2007 and March 2022 were included. The observed types of bleeding were hemothorax (n = 3), hemoptysis (n = 2), and a combination of both (n = 2). In patients with active bleeding, the technical success of TAE was defined as superselective embolization of the target artery with no active bleeding visible on post-TAE angiography. Clinical success was defined as sustained cessation of bleeding without hemodynamic instability, requirement of repeat TAE, or the need for post-TAE hemostatic surgery during the initial admission. The metrics analyzed included technical and clinical success rates, complications, and 30-day mortality.

Results: All seven patients achieved technical success, with a clinical success rate of 86% (6/7). Six patients were discharged alive, while one patient died of respiratory failure accompanied by hemothorax 19 days post-biopsy. The angiographic findings associated with bleeding were contrast media extravasation or pseudoaneurysm (n = 3) and vascular hypertrophy with tortuosity (n = 2). The implicated bleeding arteries included the intercostal artery (n = 2), bronchial artery (n = 2), and internal thoracic artery (n = 1). In two cases, no clear bleeding foci were identified; nonetheless, prophylactic embolization was performed on the right intercostal artery (n = 1) and right intercostobronchial trunk (n = 1). The embolic agents utilized included microcoils (n = 1), gelatin sponge particles (n = 2), polyvinyl alcohol (PVA) with gelatin sponge particles (n = 1), PVA with microcoils (n = 1), microcoils with gelatin sponge particles (n = 1), and microcoils with n-butyl-2-cyanoacrylate and gelatin sponge particles (n = 1). The 30-day mortality rate was 14% (1/7). No ischemic complications related to TAE were observed.

Conclusion: The study suggests that TAE is safe and effective for controlling hemodynamically unstable bleeding following a PTNB.

Keywords: Transcatheter arterial embolization; angiography; hemoptysis; hemothorax; percutaneous transthoracic needle biopsy.

Figure 1

A 69-year-old man (no: 1) developed a hemothorax following a percutaneous thoracic needle biopsy (PTNB) of left pleural tissue. (a, b) Computed tomography images obtained immediately after a PTNB showed a hemorrhagic pleural effusion with extravasation of contrast medium at the left 10^th intercostal artery. (c) The left intercostal angiogram showed a definite pseudoaneurysm (arrow) and contrast extravasation (arrowhead) at the left 10^th intercostal artery. (d) The bleeding focus was embolized using two microcoils, and the completion angiogram showed no further bleeding.

Figure 2

A 74-year-old man (no: 2) with massive hemoptysis following a percutaneous thoracic needle biopsy (PTNB) for an adenocarcinoma in the left upper lobe. (a) Selective left bronchial angiogram showing tortuous branches (arrows) that supply a hypervascular area, and mass staining (arrowheads). Hypertrophied left bronchial artery was embolized with polyvinyl alcohol (355–500 um) and gelatin sponge particles. (b) Postembolization angiogram revealing occlusion of the left bronchial artery with no opacification of the hypervascular lesion (arrow).

Figure 3

A 64-year-old woman (no: 4) developed a massive hemorrhagic pleural effusion following a percutaneous thoracic needle biopsy (PTNB) for an adenocarcinoma in the right upper lobe. (a) A computed tomography image obtained nine days after a PTNB showing a pseudoaneurysm (arrow) with linear contrast extravasation (arrowhead) from the right internal thoracic artery. (b) The right internal thoracic arteriogram shows a pseudoaneurysm and contrast extravasation (arrow). (c) The right internal thoracic artery distal to the pseudoaneurysm was embolized with one microcoil (arrowhead), and the pseudoaneurysm was embolized with n-butyl-2-cyanoacrylate and gelatin sponge particles (arrow), with no further bleeding.