BRONCHIAL ARTERY EMBOLIZATION

DR TINKU JOSEPH
DM Resident
Department of Pulmonary Medicine
AIMS, Kochin
Email-: tinkujoseph2010@gmail.com
 contents
 Bronchial circulation
 Bronchial Artery Embolization (BAE)
 Indications
 Procedure
 Complications
 Two Circulations in the Lung

• Bronchial Circulation
– Arises from the aorta.
– Part of systemic circulation.
– Receives about 2% of left
ventricular output.
• Pulmonary Circulation
– Arises from Right Ventricle.
– Receives 100% of blood flow.
 ANATOMICAL CONSIDERATION-
Bronchial Artery
 Variable anatomy in terms of origin, branching
pattern, and course.
 Bronchial arteries usually arise as a pair or as a
common trunk, from the descending thoracic aorta
below the origin of left subclavian artery.
 The standard or orthotopic origin is from the aorta
between the levels of T5 and T6 (80%).
 ANOMALOUS – Outside the levels of T5 and T6 .
 ANOMALOUS - Aortic arch, Internal mammary artery,
Thyrocervical trunk, Subclavian, Costocervical trunk,
Pericardicophrenic artery, Inferior phrenic artery.
 BRONCHIAL CIRCULATION

 Sometimes part of blood supply of anterior spinal

artery come from bronchial vessels.
 When bronchial artery embolization is
performed, consideration must be given to the
arterial supply to the spinal cord.
 Most important is Anterior Spinal Artery.
 Anterior spinal artery receives contributions from
the anterior radiculo medullary branches of the
intercostals and lumbar arteries.
 ARTERY OF ADAMKIEWICZ

 The largest anterior medullary

branch.

 Has variable origin from T5 –L5

level, but most commonly from
T8 – L1 level.

 In 5 % of population Rt. IBT

contributes to artery of
Adamkiewicz.

 The left bronchial arteries very

rarely contribute the anterior
spinal artery.
 Topographical Facts:
Normal Anatomy and Variations
Bronchial artery branching pattern
Cauldwell et al - four patterns:

 Type I
 Type II
 Type III
 Type IV

Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an
anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395–
412.
Type I

• Incidence: 40.6%
• Left:2
• Right:1
{intercostobronchial
trunk (ICBT)}
 Bronchial Artery- Course

 Leave the aorta at an upward

angle, against the direction of
blood flow.
 Send braches to oesophagus,
mediastinum, lymph nodes and
nerves.
 On reaching the main bronchi
divide into visceral pleural
branches to the mediastinal
pleura and true bronchial
arteries to the bronchial tree.
 Bronchial Artery- Course

 Spiral course around bronchi, one on either side of

each other but anastomosing frequently with each
other
 The vessels form an arterial plexus in the adventitia
from which branches pierce the muscle layer to enter
the submucosa, where they break up into capillary
plexus.
 Supplies bronchi, nerves, walls of pulmonary vessels
and intra pulmonary lymph nodes.
 Bronchial Artery- Course
 Arteriolar branches of the
visceral pleural vessels pass
along interlobular septa,
reaching the interstitial tissue of
the lung acinus.
 The true bronchial arteries
reach as far down the airways as
the terminal bronchiole.
 Much of the bronchial arterial
blood, having gone through the
submucosal capillaries, passes
into the venous plexus in the
adventitia.
 Veins from this plexus then join
pulmonary venous system.
Bronchial Artery
Embolization
 Minimally invasive alternative to
surgery.
 selective bronchial artery
catheterization and angiography,
followed by embolization of any
identified abnormal vessels to
stop the bleeding.
 Considered to be the most
effective nonsurgical treatment
in the management of massive
and recurrent hemoptysis.
 Bronchial Artery Embolization

 First by Remy et al. in 1973.*

 Temporary or definitive

 Immediate control: 57–100% of patients**

 Embolization : bronchial and nonbronchial

Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann
Radiol (Paris) 1974; 17: 5–16.
 Long-term control: 70%-88%
**Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries.
Radiology 1977; 122: 33–37.
 Indications

• Haemoptysis-:Failure
of conservative or
bronchoscopic
treatment to control
bleeding.

ISRN Vascular Medicine

Volume 2013, Article ID 263259, 7 pages
 Indications
 Managing ruptured pulmonary artery venous
malformation.
Bronchial artery embolization: Managing ruptured pulmonary artery venous
malformation e A case report Dharitri Goswami a,*, Shantanu Das b,1, Ashok
Parida c,2, Joy Sanyal c,3. Respiratory Medicine CME 4 (2011) 160e163

 To Stabilize patients before surgical resection or

medical treatment.
 As a definitive therapeutic approach in patients:
-Who refuse surgery
-Who are not candidates for surgery
-Where surgery is contraindicated
poor lung function, bilateral pulmonary disease, co morbidities.
 WHY BAE ??
1)Bronchial circulation (90% of cases)
- Pulmonary circulation (5%) .
- Aorta (5%)(eg, aorto bronchial fistula,
ruptured aortic aneurysm).
2) Surgery
- Mortality 18% when performed
electively, rising to 40% when performed
emergently.
- conservative approach , mortality risk of at
least 50%.
3) Minimally invasive
- clinical success - 85% to 100%,
- recurrence of hemorrhage – 10%.
 BAE- TECHNIQUE
 Prior to the procedure, a brief neurological exam is
performed to establish a baseline.
 Femoral route/Trans-Axillary route
 Monitor vitals/spo2
 Sedation optional
 Clean groin with antiseptics.
 Adequate LA
 A preliminary descending thoracic aortogram
(Ionic/non ionic contrast) can be performed as a
roadmap to the bronchial arteries.
 BAE - TECHNIQUE
 Both bronchial arteries and nonbronchial systemic
arteries are opacified.
 The diagnostic angiographic injections are always
selective into the bronchial, intercostals, subclavian,
internal mammary, intercostobronchial, and inferior
phrenic arteries.
 Under X-Ray machine guidance (Digital cardiac imaging
with digital subtraction facility)
 Reverse curve catheter – mikaelsson, simmons 1,
shepherd’s hook.
 Low arotic arch – forward looking catheters ( cobra or RC
) used.
 Angiographic signs of haemoptysis

ISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pages

BAE - TECHNIQUE
 The left main stem
bronchus serves as a
convenient fluoroscopic
landmark for the general
location of the bronchial
arteries
 The catheter is directed
lateral or anterolateral for
the right bronchial and
more anterior for the left.
 Bronchial arteries – course
of main stem bronchi
towards hila.
 Intercostal arteries – initial
cephalic course , then
laterally along undersurface
of rib
 BAE - TECHNIQUE
 The embolization materials commonly used
are non-absorbable particles of polyvinyl
alcohol (PVA) (Ivalon; Nycomed SA; Paris,
France), 355–500 𝜇m in size (some larger
vessels required particles as large as 2 mm),
and fibred platinum coils of 2 and 3mm in size
(MicroNester Embolization Coils; Cook,
Bjaeverskov, Denmark).
 Catheters:
 Reverse-curved catheters
(Mikaelson, Simmons I,
SOS Omni)

 Forward-looking
catheters (Cobra, HIH,RC)

 Sizes: 4, 5, or 5.5 Fr are

routinely used.
Mikaelson catheter
 Cobra type: curved catheter
 Most commonly used

 Microcatheter

 Superselective
catherization

 Less complications
 Embolizing materials:
• Absorbable gelatin • Glue
sponge
• Recently approved
• Gelfoam
-Embospheres,
• Pledgets (1 to 2 mm)
-Spherical Poly vinyl
• Thrombin alcohol(PVA) particles

Permanent occlusive agents

Polyvinyl alcohol (PVA), Trisacryl gelatin microspheres (TGM), Gelfoam
 Embolizing materials:
 PVA particles (350-500 mic)
 Most common & Safe

 Liquid embolic agents

 -ischemic necrosis

 Stainless steel platinum coils

 -occlude more proximal
vessels.
Embolization coils: Platinum Microcoils
Embolizing materials:

 Particles > 200 to 250 micr.m should be used

 No ischaemia and no neurologic damage

 Isobutyl-2 cyanoacrolate, Absolute alcohol

Used in pulmonary artery aneurysms
to avoid tissue ischemia and neurologic
damage
 Embolizing materials:

 Distal embolization : ideal

 Proximal occlusion: temporary relief
 particles < 200 micr.m :avoided

-Tissue infarction

 Liquid embolic agents should always be

avoided because these cause tissue
infarction
 Clues to bronchial artery as the source of
bleeding:

Vascular hypertrophy
Parenchymal hypervascularity aneurysm
34
 Neovascularisation

The identification of extravasated

Bronchopulmonary shunting
dye
35
--INFREQUENT
 Left upper lobe bronchial artery

Tortous and hypertrophied vessel Decreased vascularity & hypertrophy

Before Embolization After Embolization

Pre-embolisation bronchial angiogram Post embolisation

Left

Right

Abnormal circulation
No abnormal circulation
 Bronchial artery aneurysm

Pre embolisation PVA particles Post embolisation

Hypervascular lesion with aneurysm No hypervascular lesion & aneurysm

 Super selective Embolization of
intercostal artery
PRE EMBOLIZATION POST EMBOLIZATION
INTERCOSTAL ARTERY

Decreased vasularity
Radicular arteries Hypervascular areas and a small amount of Micro catheter passed
pulmonary arterial shunting beyond radicular artery
Bronchial Artery Embolization
 Success rates : 64% to 100%.

 Recurrent non-massive bleeding :16–46%

• Recurrence of haemoptysis may be due to:
 Incomplete embolization of the bronchial
vessels
 Recannalization of the embolized arteries.
 Presence of non-bronchial systemic arteries.
 Development of collateral circulation in
response to continuing pulmonary
inflammation.
 Bronchial Artery Embolization

 Technical failure: 13%

 Technical failure is caused by non-bronchial artery
collaterals from systemic vessels such as the phrenic,
intercostal, mammary,(PLEURA) or subclavian
Arteries.
 Complications of BAE
• Transversemyelitis
 The most feared complication
due to non target occlusion of
branches.
When the anterior spinal
artery is identified as
originating from the bronchial
artery, embolisation is often
deferred owing to the risk of
infaction and paraparesis.
 Complications of BAE
 The anterior spinal artery is the blood vessel that
supplies the anterior portion of the spinal cord.
 It arises from branches of the vertebral arteries and is
supplied by the anterior segmental medullary arteries,
including the artery of Adamkiewicz, and courses along
the anterior aspect of the spinal cord.

 Disruption of the anterior spinal cord leads to bilateral

disruption of the corticospinal tract, causing motor
deficits, and bilateral disruption of the spinothalamic
tract, causing sensory deficits in the form of
pain/temperature sense loss
Complications of BAE
 Complications of BAE
 Chest pain is the most common
complication.
 Dysphagia due to embolization of
esophageal branches may also be
encountered.
• Rare complications
 Aortic and bronchial necrosis
 Bronchoesophageal fistula
 Non–target organ embolization (eg,
ischemic colitis)
 Pulmonary infarction.
 References
 1) Haponik E F, Fein A, Chin R. Managing life-
threatening hemoptysis: has anything really
changed? Chest. 2000;118(5):1431–1435.
 2)Shigemura N, Wan I Y, Yu S C, et al.
Multidisciplinary management of life-
threatening massive hemoptysis: a 10-year
experience. Ann Thorac Surg. 2009;87(3):849–
853.
 3)Marshall T J, Jackson J E. Vascular
intervention in the thorax: bronchial artery
embolization for haemoptysis. Eur Radiol.
1997;7(8):1221–1227.
 References
 4)Yoon W, Kim J K, Kim Y H, Chung T W, Kang
H K. Bronchial and nonbronchial systemic
artery embolization for life-threatening
hemoptysis: a comprehensive review.
Radiographics. 2002;22(6):1395–1409.
 5)Fernando H C, Stein M, Benfield J R, Link D
P. Role of bronchial artery embolization in
the management of hemoptysis. Arch Surg.
1998;133(8):862–866
 6)Ramakantan R, Bandekar V G, Gandhi M S,
Aulakh B G, Deshmukh H L. Massive
hemoptysis due to pulmonary tuberculosis:
control with bronchial artery embolization.
Radiology. 1996;200(3):691–694.
 CONCLUSION

1) The development of bronchial

artery embolization techniques has
revolutionized the approach to
hemoptysis patients.
2) Bronchial artery embolization
possesses high rates of immediate
clinical success coupled with low
complication rates.
3) When bronchial artery
angiography and embolization is
performed, consideration must be
given to the arterial supply to the
spine.
 CONCLUSION

4) Surgery should be considered

only in case where embolisation
is not possible due technical
difficulty and in case of
embolisation failure. Otherwise
bronchial artery embolisation is
considered as the mainstay
treatment for hemoptysis.