The bleeding windpipe

Kalaimuhilan1, Aslesha Sheth1, Anantha Subramanian2, Santhakumar4

1Department of Emergency Medicine, Kauvery Hospital, Chennai, India

2Pulmonologist, Kauvery Hospital, Chennai, India

3Radiologist, Kauvery Hospital, Chennai, India

*Correspondence: [email protected]

Abstract

We describe a case of massive hemoptysis due to hypertrophied non-bronchial/bronchial arteries. They needed embolization and the paper discusses the management principles in achieving effective embolization.

Major haemoptysis defined as one of the following: bleeding of more than or equal to 200 ml per 24 h; bleeding resulting in hemodynamic instability; or respiratory compromise or blood loss resulting in a reduction in hematocrit to less than 30%.

Case report

A 60-year-old woman, with past history of tuberculosis involving the left lung, had developed a left main broncho- oesophageal fistula 15 years ago. The diagnosis had been made on a clinical history of recurrent cough, and supported by results of other relevant laboratory investigations. She then underwent left main bronchus stenting. During the subsequent follow-up clinical admissions, she developed multiple episodes of pseudomonal infections involving the left upper lobe and eventually underwent a left upper lobectomy in 2017.

She had a history of multiple episodes of mild hemoptysis, which were transient, and recovered without major hospital admissions. Before the index admission she had a massive hemotpysis of more than 200 ml in 12 h and was admitted to the ER of our hospital. After initial resuscitation by the ER team, clinical examination and blood investigations revealed no definite hemodynamic compromise; she had normal hemoglobin and coagulation parameters.

A CT angiogram of the thorax showed the presence of hypertrophied bronchial and non-bronchial systemic arteries with a flow-related saccular aneurysm from the left subclavian artery. Given multiple hypertrophied vessels, massive hemoptysis and higher mortality associated with massive hemoptysis, the patient was immediately taken up for an embolization procedure.

Embolization was done extensively involving the left internal mammary artery, the lateral thoracic branch of the left axillary artery, 2 left bronchial arteries, and 2 intercostal arteries. Embolization was achieved using polyvinyl alcohol particles of about 300-500 microns.

Post the embolization procedure, the patient experienced mild chest pain for 2 days which subsequently diminished. Hemoptysis stopped and there was no further recurrence during the hospital stay. She had a few low-grade fever spikes which were managed with antipyretics and antibiotics.

Discussion

The usual sources of massive hemoptysis are the bronchial arteries (in more than 90%), 5% through the aorta or systemic arterial branches and the remaining 5% due to the pulmonary circulation. In the setting of acute or chronic lung diseases, pulmonary arterioles remain occluded due to hypoxic vasoconstriction, thrombosis, and vasculitis. So bronchial arteries tend to dilate and enlarge to replace pulmonary circulation. The enlarged bronchial arteries tend to get eroded by an infection or due to elevated blood pressure.

Investigations

A diagnosis can be made by conventional radiographs, flexible bronchoscopy (FOB) and/or computed tomography of the chest. Radiography helps in the diagnosis of pneumonia, tuberculous infection, cancer or lung abscess which are the usual suspects in massive hemoptysis. But the sensitivity is too low and Hirschberg et.al. found radiographs only to be diagnostic in 50% of cases.

FOB is diagnostic and therapeutic in cases of a central bronchial lesion. If chest radiographs are normal or non-localizing, then the localizing potential of FOB is also limited and ranges from 0 to 31%. Also, the excess blood in bronchi can limit visualization through FOB.

CT angiogram of the thorax is a proven diagnostic modality in arriving at a specific diagnosis, and localizing the site of bleeding. CT and FOB are complementary tools and the combined use produces the best results in the evaluation of hemoptysis. CT also helps in identifying the bronchial and non-bronchial systemic feeders, thus help in achieving targeted embolization. The imaging finding of pleural thickening of more than 3 mm is very suggestive of the presence of non-bronchial systemic feeders and these feeders should be specifically targeted for embolization.

Angiography is done in the catheterization laboratory after a femoral puncture. After the advent of advanced CT scanners, the role of angiography for diagnosis is obsolete and it is predominantly done for embolization. A descending thoracic aortogram is done using a 5F pigtail to identify the number of bronchial arteries, feeders and abnormal findings. Selective catheterization of the vessels involved will help in characterizing the abnormal findings. The abnormal findings in angiogram include a) hypertrophied and tortuous bronchial arteries, b) focal hypervascularity, c) contrast extravasation into lung parenchyma/cavity, d) shunting into the pulmonary artery or vein, and e) bronchial artery aneurysms. The angiograms should include subclavian, internal mammary, inferior phrenic and intercostal arteries (as these arteries tend to supply these areas through the pleura or chest wall). Lack of selective cannulation and embolization of these non-bronchial systemic feeders can result in an immediate recurrence after successful bronchial artery embolization.

Treatment

Embolization can be performed using various embolic agents which include gelfoams, polyvinyl alcohol particles, coils and glue (n-butyl cyanacrylate- NBCA). Gelfoam, being a relatively inexpensive temporary embolic agent, can result in recanalization of the embolized vessels and cause recurrence. PVA particles had good mid-term results with a reduced risk of recurrence.

Complications

The complications of bronchial artery embolization include recurrence and it is reported to be between 9.8% to as high as 57%. In an Indian study, the recurrence rate was reported at 18.2% over a 6-month follow-up period. The failure to embolize the hypertrophied non-bronchial systemic arteries is the common cause for recurrence. The common adverse effect is chest pain. Our patient experienced mild chest pain which subsided after 2 days. Post embolization syndrome (fever, leukocytosis, and pain) can be seen in a few patients and it will generally subside with antibiotics. Dysphagia can occur if esophageal vessels are embolized in addition to bronchial vessels. The most dreaded complication is spinal cord ischemia due to inadvertent embolization of radiculomedullary vessels which can arise from the bronchial or intercostal vessels. In a case series, this complication was reported in 0.6-4.4% of cases. The presence of radicular branches is not a contraindication for embolization, but the presence of artery of Adamkewich is an absolute contraindication for embolization. Other less common complications include transient ischemic attack, stroke and blindness due to embolizing material crossing the bronchopulmonary anastomosis.

Conclusion

Thus, bronchial artery embolization is a safe and effective minimally invasive strategy for massive hemoptysis. The search for non-bronchial systemic feeders like subclavian, axillary and intercostal, inferior phrenic vessels are imperative to control hemoptysis and prevent a recurrence. The pleural thickening of more than 3 mm in CT is an important predictor of the presence of hypertrophied non-bronchial systemic feeders.

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Dr.-Aslesha-Vijaay-Sheth

Dr. Aslesha Vijaay Sheth

Consultant & Clinical Lead

Dr.-Anantha-Subramanian

Dr. Anantha Subramanian

Pulmonologist

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