Indications

• Massive hemoptysis (> 400-500 ml) – single episode.
• >2-3 episodes of moderate hemoptysis (200 ml).
• Chronic mild hemoptysis- disturbing for patient.
• Pre-operative for vascular tumors.

Rationale

Many patients get lung infections or sometimes tumors which lead to bleeding in the sputum. Lungs have dual blood supply. 98% blood is supplied by the pulmonary arteries. 2% of the blood is supplied by tiny blood vessels called bronchial arteries. While they are not very important for the lung in normal people, infections or tumors lead to their hypertrophy and result in bleeding from them sometimes amounting to massive proportions. These are the patients in whom the bleeding needs to be dealt with urgently as a life saving measure.

Pre-requites

• CT angiography chest (hemoptysis protocol) to confirm the etiology and map hypertrophied bronchial vessels and also to rule out other causes of bleed like pulmonary artery.
• Blood tests to determine if the intervention can be safely performed:- CBC, PT/INR, Sr.Creatinine, Viral markers.
• Shaving of bilateral groin.
• 3-4 hours of fasting before procedure
• Pulmonological work up like sputum examination, bronchoscopy, Mantoux test.

Technique

Using the angiography route (most commonly via the right groin), a small sheath (plastic hollow tube) is placed in the thigh blood vessel. This is done after local anesthesia injection. After this, under fluoroscopic (live x-ray) guidance multiple catheters can be used from that sheath/access to move into the aorta (main blood vessel from heart supplying blood to all organs). The bronchial arteries are selectively cannulated and once angiography is done to confirm that those arteries are the cause of bleeding, they are embolized using particles (made up of poly-vinyl alcohol). They get permanently destroyed and very recanalize again.

Potential risks/complications

• Non-target embolization – very rarely, due to natural channels and communications of the bronchial arteries with arteries of other organs, the particles may get injected into other organs leading to complications. These range from small infarcts in organs like spleen and kidneys to severely morbid complications like stroke or paralysis.
• Failure/Recurrence - Depending on the reason of bleed, the bleeding might come back. This is most common if the infection is fungus or chronic TB. But even in such cases repeat embolization sessions help as main /ancillary treatments.
• Puncture site complications – Generally after the procedure, the patient is instructed to not move the right leg for 8 hours. If the patient doesn’t obey the instructions or has violent coughing, the right thigh/groin puncture site may open up and bleed.

Despite the rare potential complication risks, the benefits far outweigh the risks and the risk of not performing the procedure on time may become life threatening.