Transcatheter Bronchial Artery Embolization in the Multimodality Management of Massive Hemoptysis (2)
On arrival, chest roentgenogram revealed complete atelectasis of the right lung (Fig 1, left), and blood gas analysis demonstrated a P02 of 30 mm Hg. He was intubated, sedated, and ventilated with resultant improvement in Po2 to 60 mm Hg. Bronchoscopy was repeated and the bronchial balloon was deflated under direct vision, with no evidence of ongoing bleeding. The balloon was left in place (deflated), and the patient was kept sedated and ventilated for two days with no further bleeding. Chest roentgenogram after balloon deflation was unrevealing (Fig 1, right).
On the third hospital day, bronchoscopy was repeated. This time a large submucosal blood vessel with a central blood clot was noted in the right main-stem bronchus, opposite the orifice of the right upper lobe bronchus (Fig 2). The remainder of the tracheobronchial tree was remarkable only for a shelf of abnormal tissue present at the carina. Since the submucosal vessel was the likely source of hemorrhage and because previous high-dose radiation therapy precluded surgical extirpation, TBAE was elected to obliterate it. In the angiography suite, selective catheterization of the bronchial artery in the region of the right main-stem bronchus was achieved via the right femoral artery (Fig 3, left). ventolin inhaler
Multiple pellets of microencapsulated absorbable gelatin sponge (Gelfoam) were injected with resultant occlusion of the suspect artery (Fig 3, right). The patient tolerated the procedure without ill effects. The following day, he underwent biopsy and YAG laser excision of the abnormal carinal tissue. Pathologic study revealed the tissue to be bronchial epithelium with squamous metaplasia consistent with granulation tissue. He was discharged on the 13th hospital day in good condition. Follow-up at 24 months has shown no recurrence of hemoptysis and no change in chest roentgenogram appearance.
Figure 1. Left, chest x-ray film with bronchial blocking balloon inflated; right, after balloon deflation.
Figure 2. Artists representation of endoscopic appearance of bronchial lesion. Central clot was apparent over bulging submucosal blood vessel.
Figure 3. Left, angiographic appearance of right bronchial artery before embolization; right, during embolization.