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Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT.
Correspondence to: Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St, Room 5039 LMP, New Haven, CT 06520; e-mail: white@biomed.med.yale.edu
Life-threatening hemoptysis has a 30 to 40% operative mortality when treated surgically during the acute episode.1 ,2 The description by Remy et al3 of bronchial artery embolotherapy (BAE) in 1973 provided a new interventional radiologic approach for managing hemoptysis and stabilizing the patient's condition.3 Despite widespread use of the technique since the initial report, there are relatively few analyses of short-term (first 30 days) and long-term (1 to 2 years) outcomes of this therapy. In this issue of CHEST (see page 996), Mal et al attempted a difficult retrospective study of factors influencing outcome in 56 patients treated by BAE over 12 years. Some of their observations and prior work by others deserve further commentary.
Intent To Treat Hypothesis–Analysis
Mal et al report on 56 consecutive patients in whom they attempted BAE. They were unsuccessful in completing the procedure in 10 (18%). Thus, their ability to control acute hemoptysis by completing BAE was possible in only 46 patients and their overall success rate was 43 of 56 (77%). Other observers report higher rates for controlling acute hemoptysis that range from 85 to 95%.4 ,5 ,6 Unfortunately, in these series, we are not informed whether the patients who are described are consecutive and how many additional patients had the procedure attempted but not completed. In other words, all consecutive patients who had the procedure attempted should be included for calculating initial success rate. Of treated patients in the series of Mal et al, 43 of 46 patients (93%) with embolization stopped bleeding, which is an excellent result in the patients who completed BAE.
Reasons for Initial Failure, Complications, and How To Prevent Them
In the 10 patients in whom embolization was attempted but the procedure was abandoned, 6 procedures failed because of failure to achieve a stable catheter position in the central bronchial artery and 4 were stopped because a spinal cord branch was identified arising from the bronchial artery (thus precluding safe embolization using their technique). Most of the failures of attempted BAE are due to these two factors.7
Since 1988, microcatheter technology has become available and is utilized by neurointerventionalists to treat intracerebral aneurysms and malformations.8 These techniques have just recently been applied for treating hemoptysis due to bleeding in the bronchial circulation.6 The use of microcatheters circumvents the two primary issues, accounting for failure in the series of Mal et al, ie, stability of catheter position in the bronchial artery and also inability to achieve a distal and safe position in the bronchial circulation beyond the origin of spinal cord branches.
Placing a microcatheter deep within the bronchial circulation is termed "superselective" catheterization rather than "selective" in the origin of the bronchial artery. The selective technique was used by Mal and associates and was the standard of care in France and the rest of the world during the years of their study. When superselective catheterization of the bronchial artery is performed, the origin of the bronchial artery, arising from the thoracic aorta, is engaged with a standard 5F catheter. Then, a coaxial 3F microcatheter is passed through it. Even if the bronchial artery is tortuous or the position of the 5F bronchial artery catheter is unstable, the inner 3F, hydrophilic, soft, microcatheter can usually be advanced coaxially through the 5F catheter deep into the bronchial circulation. Thus, a stable and safe position "superselectively" is achieved. BAE is performed well beyond the origin of the bronchial artery and any associated spinal cord branches.
It has been recognized for some time that spinal cord complications can occur without initial visualization of a spinal artery branch, arising from the bronchial artery as in the current series reported by Mal et al in which two patients had transient spinal cord symptoms and one patient had permanent paraplegia despite lack of visualization of a spinal cord artery initially.9 Undoubtedly in their series as well as others, spinal cord branches are present, even when they are not detected during diagnostic angiography. After occluding the peripheral bronchial artery branches and increasing resistance both distally and centrally, reflux of particles occurs in spinal cord branches not detected initially.9 ,10 This has been our unreported experience too when performing BAE in the origin of the bronchial artery rather than with coaxial microcatheters passed superselectively into the bronchial circulation. More recently, a superselective series reported by Tanaka et al,6 using microcatheters and distal embolization, was successful without spinal cord complications.
Choice of Embolic Material
An improvement in the choice of embolic materials as well as catheter techniques has also occurred recently. A variety of embolic materials were used for embolotherapy over the 12 years in the study currently reported. Polyvinyl alcohol particles (Ivalon), 250 to 500 µm in diameter, are the most frequently used worldwide. Remy et al3 used absorbable gelatin sponge (Gelfoam) particles, which are reabsorbable after 14 days, and he delivered them through selective 5F catheters. Absorbable gelatin sponges (Gelfoam) are still used and quite successfully with microcatheter technique.6 Polyvinyl alcohol (Ivalon) particles are inert, last much longer than Gelfoam, and are easily injected through microcatheters.11 They are available worldwide except in Japan where they are not yet approved by our Food and Drug Administration equivalent. Use of smaller polyvinyl alcohol particles (< 250-µm diameter), alcohol, or medical grade superglue can lead to bronchial necrosis and in general are not used.9 Use of large-vessel occluding agents such as coils or detachable balloons leads to distal collateralization and rebleeding. A variety of materials were used in the article by the authors in this month's CHEST, reflecting the different preferences and materials available to the radiologists performing BAE. Now, it is generally believed that superselective embolotherapy with polyvinyl alcohol (Ivalon) particles should be the standard of care.
Outcome by Interventional Radiologist–`Angiographer'
We agree with Mal et al that their experience is typical of a university or large community hospital not only in France as they report but also in the United States. During the 12 years of their study, 18 different radiologists, with "fellowship" equivalent training in interventional radiology, performed these emergency embolizations. Even accounting for the recurrences, seven during the first 30 days and three later on who required retreatment, the average number of bronchial embolizations per interventional radiologist was less than four per individual.
Achieving greater experience per angiographer or limiting procedures to no more than two staff interventional radiologists in a large institution is a much more difficult problem than standardizing use of microcatheters or embolic materials. In rare disorders, when operations or interventional procedures are elective, it is possible to channel them to individuals or centers with sufficient expertise so that better outcomes are possible. Unfortunately, acute life-threatening hemoptysis is a rare condition that occurs infrequently, no more than 6 to 10 times per year, even in large centers. Perhaps in those centers treating < 10 patients yearly, BAE should be limited to no more than two radiologists in order to allow for cross coverage but also for the development of sufficient expertise so that each patient does not represent a new "learning" experience.
Recurrence of Hemoptysis 30 DAYS OR LONGER AFTER BAE
The recurrence of hemoptysis after BAE is typically bimodal. In the series of Mal et al, 7 of the 43 patients treated successfully for acute hemoptysis had recurrences during the first 30 days. In general, these patients responded to a second procedure. One of 29 patients had a recurrence between 30 and 90 days and 3 of 25 patients followed up > 3 months had a recurrence. Again, these results are consistent with what has been reported previously and is not unexpected since the conditions treated were chronic and in some instances progressive. Patients with tuberculosis, idiopathic hemoptysis, bronchiectasis, and cystic fibrosis respond well to BAE.9 Some of the early recurrences (within the first 30 days) might have been prevented by a more thorough embolization of nonbronchial pleural collaterals as has been suggested.12 ,13 It has been demonstrated that even in patients with cavitary disease and aspergilloma, BAE is successful providing these collaterals are treated over several sessions.13 We agree, though, with the approach of Mal et al, for first-time acute hemoptysis. They began by performing BAE only on the side(s) that is believed to be responsible for the acute hemoptysis, using patient history, chest radiography, and bronchoscopy as guides for the initial embolization. We believe that this approach is preferable, than prolonging the initial procedure in an acutely ill patient, by embolizing all the potential sources of pleural collaterals, which could cause a recurrence.9
Recurrent hemoptysis after BAE was the subject of the last editorial on BAE in CHEST.14 In that editorial, Nath,14 commenting on the articles by Katah et al13 and Keller et al,12 described recurrences of acute hemoptysis due to recanalization of a previously embolized bronchial artery and/or perfusion by nonbronchial systemic arteries supplying the lung through pleural adhesions. In patients with recurrent hemoptysis or continued hemoptysis within the first 30 days, nonbronchial collaterals should be treated.
We agree with Katoh et al13 and Fernando et al15 who suggest that BAE is a palliative procedure and the potential for recurrent hemoptysis exists as long as the disease process is not cured by drug therapy or removed surgically. In this sense, BAE is a palliative procedure preparing the patient for elective surgery of localized disease or continued antimicrobial therapy.13 ,15 In patients deemed too ill to undergo elective surgery, BAE may be repeated successfully for recurrent hemoptysis.
In summary, the experience as reported by Mal et al in this month's journal reflects realistically what can be expected worldwide using BAE to control hemoptysis. We believe that some of the initial failures with selective BAE can be avoided and their results improved upon by application of superselective BAE with microcatheters and standardized use of polyvinyl alcohol (Ivalon) particles. Hopefully additional experience will be reported in consecutive patients as was done by Mal et al demonstrating improvement in managing acute hemoptysis with adoption of more standardized techniques.
References
This article has been cited by other articles:
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  G. Reisz Topical Hemostatic Tamponade: Another Tool in the Treatment of Massive Hemoptysis Chest, June 1, 2005; 127(6): 1888 - 1889. [Full Text] [PDF]
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 A. Ayed Pulmonary resection for massive hemoptysis of benign etiology Eur. J. Cardiothorac. Surg., November 1, 2003; 24(5): 689 - 693. [Abstract] [Full Text] [PDF]
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 W. Yoon, Y. H. Kim, J. K. Kim, Y. C. Kim, J. G. Park, and H. K. Kang Massive Hemoptysis: Prediction of Nonbronchial Systemic Arterial Supply with Chest CT Radiology, April 1, 2003; 227(1): 232 - 238. [Abstract] [Full Text] [PDF]
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P. A. Kvale, M. Simoff, and U. B. S. Prakash Palliative Care Chest, January 1, 2003; 123(1_suppl): 284S - 311S. [Abstract] [Full Text] [PDF]
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 W. Yoon, J. K. Kim, Y. H. Kim, T. W. Chung, and H. K. Kang Bronchial and Nonbronchial Systemic Artery Embolization for Life-threatening Hemoptysis: A Comprehensive Review RadioGraphics, November 1, 2002; 22(6): 1395 - 1409. [Abstract] [Full Text] [PDF]
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M. L. Wong, P. Szkup, and M. J. Hopley Percutaneous Embolotherapy for Life-Threatening Hemoptysis Chest, January 1, 2002; 121(1): 95 - 102. [Abstract] [Full Text] [PDF]
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 Y. P. Lim, D. Wong, and T. Agasthian Management of Life-Threatening Hemoptysis Asian Cardiovasc Thorac Ann, September 1, 2001; 9(3): 200 - 203. [Abstract] [Full Text] [PDF]
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 B. Ghaye and R.F. Dondelinger Imaging guided thoracic interventions Eur. Respir. J., March 1, 2001; 17(3): 507 - 528. [Abstract] [Full Text] [PDF]
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E. F. Haponik, A. Fein, and R. Chin Managing Life-Threatening Hemoptysis : Has Anything Really Changed? Chest, November 1, 2000; 118(5): 1431 - 1435. [Abstract] [Full Text] [PDF]
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