Bronchial Artery Embolization

Massive hemoptysis = >240 mL/24hr (~1 cup) -> emergent BAE
Crescendo hemoptysis / Major hemorrhagic hemoptysis = >2 episodes with >100 mL in 24 hr or >100 mL/24 hr for multiple days -> urgent BAE
Moderate hemoptysis (debated) = 50-100 mL/24 hrs + FEV1 < 40% -> possible elective BAE
Often associated with bronchiectasis, aspergillosis, TB, or chronic PNA

No absolute contraindication though underlying coagulopathy should be corrected if present to try to achieve INR <1.7 and Plt >50K.

High mortality from conservative treatment due to asphyxiation
Recurrence after BAE 2-27% early likely due to incomplete embolization of non-bronchial feeding vessels and 10-52% long term via recanalization. It can be safely repeated though becomes more technically challenging with greater likelihood of non-bronchial arterial supply.

CTA chest to delineate anatomy and identify a target: bronchial artery >>> pulm artery
- Bronchial arteries often arise from the aorta at T3-T8, often T5/6. However, up to 20% have ectopic bronchial arteries from subclavian, internal mammary, etc. Often no active extravasation but can see tortuous, enlarged bronchial artery to target.
- Caldwell branching types: (1, 41%) common right intercostobrachial artery trunk and two left; (2, 21%) same as 1 but single left; (3, 21%) right intercostobronchial trunk plus second right and two left; (4, 10%) same as 3 but single left
- Think about rarer pulmonary arterial source if h/o Swan Ganz or TB with traumatic or Rasmussen PsA
*Bronchoscopy* found to not be helpful - identifies site of bleed in <50%, endobronchial therapies tend to be ineffective and delays BAE
- NOT RECOMMENDED per 2014 ACR Appropriateness Criteria and 2010 Cystic Fibrosis Foundation Expert panel
CBC, INR/Coags, Cr, ECG, Type & screen
NPO except medication 6 hrs prior if possible. Often good to have anesthesia support for respiratory monitoring.

Femoral or radial arterial access
Advance flush catheter into descending thoracic aorta and perform run if anatomy not already delineated on CTA
Select bronchial arteries/intercostobrachial trunk (often from descending thoracic Ao at T5-T6), often SOS, Simmons, or Mikaelsson, and perform run

If arising from undersurface of arch - Judkins left coronary (JL) catheter can be helpful
If arising from right side wall of arch - Rosch hepatic (RH) catheter can be helpful
If arising steeply from descending aorta with shared origin with contralateral bronchial - can cut a side hole near tip of microcatheter, extend into one bronchial, and advance wire out the side hole into the other

Advance microwire/microcatheter system to select abnormal vessel. Often only abnormal vascularity and parenchymal blush seen rather than extravasation.
- If normal, think about pulmonary artery supply of bleeding, particularly is history of TB or Swan-Ganz
- Watch out for anterior spine artery, which can arise from the bronchial artery but more commonly seem from right intercostal > left intercostal > right bronchointercostal > left bronchointercostal, left thyrocervical, right costocervical. Classically courses back towards midline with hairpin turn.
Embolize, most commonly with >325 um particles.

Most common = 350-500 um PVA but tends to clump
Embospheres can be used but may want larger size to avoid infarction. Must also rule out right to left shunting that can lead to stroke.
Liquid embolics can save time and potentially has less recurrence but requires experience to use. Many use a thicker 1:2 glue-lipiodol ratio.
Coils traditionally avoided but data from Japan suggests superselective coil embolization is equally effective with potentially less risk of spinal ischemia.

Transient chest pain/dysphagia is common and often self-limited

Spinal cord ischemia (old data suggested 1-6% but some data pre microcatheters)

*BAE does NOT accelerate deterioration in lung function*

Often return care to primary ICU team for continued close hemodynamic monitoring.