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Radial artery access to bronchial artery embolization for massive hemoptysis: a case report
Abstract
Background: Massive hemoptysis is a potentially fatal respiratory emergency. Bronchial artery embolization (BAE) is commonly applied to treat massive hemoptysis. However, in most cases, BAE was performed via the access of femoral artery. The treatment via the access of radial artery is rare and challenging.
Case description: Herein We we reported a case of massive hemoptysis (woman aged 63 years). We discussed the results and treatment of the patient, and reviewed the literature. The patient was treated successfully with BAE via the access of radial artery using polyvinyl alcohol particles. Right intercostal artery, right bronchial artery, right subclavian arterial branch, right internal thoracic artery and right thyrocervical trunk wasere embolized. Hemoptysis was controlled. The patient was followed up since surgery, and there was a recurrence of bleeding at 6 months following embolization. Up to now, no hemoptysis or other complications occurred.[f1]
Conclusion: Radial artery access to BAE is effective for the treatment of massive hemoptysis. Nevertheless, few cases have been reported. More clinical and experimental researches are needed to confirm the safety and effectiveness in the treatment of hemoptysis.[f2]
Keywords: radial artery; bronchial artery embolization; massive hemoptysis
Introduction
Hemoptysis[f3] is a general clinical manifestation characterized by considered as the expectoration of blood that derives from the lower respiratory tract [1]. There are mMany etiologies causes contribute to hemoptysis, leading to hemoptysis such as including tuberculosis, bronchiectasis and lung cancer [2, 3]. In most cases, the hemoptysis is moderate and resolved with conservative medical therapy. [f4]However, for massive hemoptysis patients that are defined as more than 300 mL of expectorated blood in a period of 24 hours is universally accepted as the definition of massive hemoptysis in most cases [4], Cconservative medical or surgical treatment for massive hemoptysis seemed to be are ineffectual, the mortality rate is in 50% to 100% [5]. While surgical treatment of massive hemoptysis is relateded with mortality rates of 7.1–18.2%, the mortality rate of massive hemoptysi[f5]s is up to 40% when surgery is performed urgently [6].. Massive hemoptysis is a life-threatening respiratory emergency that needs urgent treatment . A former study has reported the mortality rate was up to 80% mainly due to asphyxiation .[f6]
Nowadays, there is no global consensus about the optimal treatment of patients with massive hemoptysis, and there are no considerable patients studied [7]. Conservative medical or surgical treatment for massive hemoptysis are ineffectual, the mortality rate of massive hemoptysis is up to 40% when surgery is performed urgently [7]. Complementarily, bronchial artery embolization (BAE) is an optional method in the management of massive hemoptysis [8].
It is routine to perform BAE via the access of femoral artery [9-11]. Generally, bleeding vessels can be found and embolized successfully. While catheter could not be inserted into the lesion vessels via conventional approach successfully, we can try to change the direction of the catheter. Therefore, radial artery approach for BAE provides a new method to the treatment of intractable hemoptysis. However[7], the treatment via the access of radial artery is rare and challenging.few have been reported[8] catheter was introduced into the radial artery using the Seldinger technique for the management of hemoptysis. Here, we describe a case of massive hemoptysis caused by tuberculosis successfully treated with BAE via the access of radial artery.
Case report
A 63-year-old woman was admitted to the emergency department of our hospital due to intermittent hemoptysis for more than 6 months. Thewith massive hemoptysis symptom was not resolved by after no significant relief with medical treatment (anti-inflammatory as well as symptomatic and supportive care), but . Hemoptysis symptoms became progressively severe 3 days before the accession to the emergency department with theand the about 500 mLtotal amount of hemoptysis amount was about 500 mL. Moreover, she had complained of more than 6-month history of intermittent hemoptysis. She had a history of pulmonary tuberculosis prior.
Computed tomography angiography CTA (CTAcomputed tomography angiography) examination was refused by patient and their families, and the informed consent was signed after communication. After blood cell analysis, the biochemistry analysis, blood gas analysis and monitoring of vital signs, the patient was scheduled to undergosubjected to BAE for hemostasis after communication with family members.
A standardized BAE procedure was applied [9, 12]. A 5F cobra catheter (Glide, Terumo, Japan) was introduced into the right femoral artery using the Seldinger technique. A flush catheter was advanced into the upper portion of the descending thoracic aorta to identify the bleeding arteries. The embolization was performed with polyvinyl alcohol PVA (PVApolyvinyl alcohol) particles. Right intercostal artery (Figure 1 A), right bronchial artery (Figure 1 B), right subclavian arterial branch (Figure 21 AC), right internal thoracic artery (Figure 21 BD) and right thyrocervical trunk (Figure 31 AE) was were embolized. However, this approach was ineffective when BAE was performed via the access to femoral artery. [9]Angiography angiography displayed a lesion vessel along with arteriovenous fistula at the proximal end and the vertebral artery side of the right subclavian artery along with arteriovenous fistula ([10]Figure 31 BF). This approach was ineffective when BAE was performed via the access to femoral artery. After analysis, judge the direction ostium of blood vessels open up and was upward. Conventional direction of catheter upward was not performed via superselective catheterization into the lesion artery. Thus, we decided to change the direction of catheter for BAE.[11] We tried to insert the 5F cobra catheter into the right radial artery to perform BAE (Figure 41 AG). The shape of 5F cobra catheter was changed to match the lesion artery easily, following BAE performance (Figure 41 BH–CI). Angiography displayed that the lesion artery was completely embolized, indicating a good outcome (Figure 41 DJ).
The patient was sent to his ward after BAE. Following the embolization, his vital signs were stable, and hemoptysis symptoms were alleviated significantly. So the patient was discharged at the fifth day after surgery. Hemoptysis occurred again at a follow-up 6 months following the surgery, with the main clinical symptom was of less bloody sputum. The patient was treated with anti-inflammatory, hemostasis and symptomatic treatment at a local hospital. She was discharged after her condition was improved after 1 week. Up to now, no hemoptysis or other complications occurred.
Discussion[12]
Massive hemoptysis is a life-threatening respiratory emergency that needs urgent treatment. The mortality rate is very high when massive hemoptysis is treated by conservative and the emergent surgical treatment [5]. For these, BAE is a well-accepted and widely used intervention in the treatment of recurrent and massive hemoptysis [13]. It is well known that bronchial arteries makes up over 90% of cases of hemoptysis [14]. Pulmonary arteries are also possible sources of the bleeding. Moreover, nonbronchial arteries including branches of the thyrocervical trunk, internal mammary artery, axillary artery, subclavian artery and the inferior phrenic artery are responsible for bleeding in hemoptysis [15]. These vasculars should be embolized adequately to ensure effective management of hemoptysis [16]. In the current case, the right intercostal artery, right bronchial artery, right subclavian arterial branch, right internal thoracic artery and right thyrocervical trunk were embolized successfully. with
It is routine to perform BAE via the access of femoral artery [9-11]. Generally, bleeding vessels can be found and embolized successfully. While the radial artery access to BAE has many advantages over the femoral artery access. The hand has a dual blood supply, reducing the potential for limb-threatening ischemia. Because the radial artery is superficial, this access decreases the risk of nerve injury and local hematoma. The safety of radial artery access in percutaneous interventions and coronary angiography has been confirmed in several studies relative to transfemoral access [17, 18]. The most common complications of transradial access are radial artery spasm and thrombotic occlusion [19]. The current case showed that a transradial approach can be safe and effective in performing BAE when femoral access is undesirable.
With rapid visualization by CTA and the development of embolic materials, the efficacy of BAE has improved and the complications have decreased.
Diagnostic interventions are important and necessary for the planning and success [13]of the treatment, including detection of the cause and location of bleeding. CTA is one of the most common approaches used for the detection of hemoptysis causes [16]. The modern CTA scan decreases the time of scanning and makes the process of scanning feasible in critically ill patients. However，, the patient in this case refused to receive CTA examination, thus, it is very difficult to find all the lesion vessels to increase the chances of recurrence of hemoptysis. Recurrences were observed at 6 months following embolization. The cause is likely to be incomplete embolised embolized embolization incompletely to an undetected non-bronchial systemic arterial supply, recanalization of previously embolized vessels, pulmonary tuberculosis progression, or secondary trauma because of failure of BAE via the femoral artery access and secondary resulting from two embolizations embolization via theradial artery access. [14]
The choice of embolic materials is vital for BAE outcomes. PVA particles > 250 microns were applied in all the cases for BAE. Particles < 250 microns should be prohibited because the passage of agents through bronchopulmonary may result in ischemia and necrosis in the lung tissue . PVA and absorbable gelatin sponge particles are most widely used due to that they are relatively inexpensive, easy to handle, and can be controlled on the basis of embolic size [16, 20]. MoreoverHowever, PVA may leads to permanent occlusion relative to gelatin sponge particles [21]. BAE with n–butyl-2-cyanoacrylate (NBCA) provided higher hemoptysis-free survival rates relative to PVA particles [22]. Moreover, NBCA has gained more interest for control of bleeding because of rapid and complete occlusion of target vessels [23]. While, it brings about a high risk for complications, such as tissue necrosis and uncontrolled reflux [16, 24]. Thus, further clinical and experimental researches are required to observe the effectiveness and safety of these embolic materials.
Several complications related with BAE have been reported in the previous literatures. Chest pain is the most common complication of BAE, the occurrence rate is 24-91% [25]. There are some rare complications reported previously, including bronchoesopha-geal fistula [26], ischaemic colitis, pulmonary infarction, ischemia of the spinal cord and transient cortical blindness [16]. Among these, the most disastrous event is spinal cord ischemia caused by spinal arterial occlusion. More than 250 microns of particles are big enough to not occlude spinal arteries distally [27]. In the current study, the patient had no complications published and mentioned above in the period of follow-up. This result suggested that it is feasible to perform BAE via the access of radial artery. This also may be due to the limited patients in the study.
In conclusion, radial artery access might increase the effectiveness and success rate of BAE, benefitting patients with hemoptysis. Nevertheless, few cases have been reported. More clinical and experimental researches are needed to confirm the safety and effectiveness in the treatment of hemoptysis, and its clinical use should be elucidated.
Legends[15]
Figure 1 Angiographies of right intercostal artery, right bronchial artery, right subclavian arterial branch, right internal thoracic artery and right thyrocervical trunk in 63-year-old woman. Polyvinyl alcohol (PVA) particles embolized the right intercostal artery and right bronchialthese arteryarteries. A. The right intercostal artery was filled with polyvinyl alcohol particlesPVA. Angiography did not display disordered vessels in the distal end, indicating that the right intercostal artery was completely embolized. B. The right bronchial artery was filled with polyvinyl alcohol PVA particles. Angiography did not display disordered vessels in the distal end, suggesting complete embolization of the right bronchial artery.
Figure 2 Polyvinyl alcohol particles embolized the right subclavian arterial branch and right internal thoracic artery. A C. The right subclavian arterial branch was filled with polyvinyl alcoholPVA particles. Angiography did not display disordered vessels in the distal end, indicating that the right subclavian artery was completely embolized. BD. The right internal thoracic artery was filled with polyvinyl alcoholPVA particles. Angiography did not display disordered vessels in the distal end, suggesting complete embolization of the right internal thoracic artery.
Figure 3
AE. The right thyrocervical trunk was filled with polyvinyl alcoholPVA particles. Angiography did not display disordered vessels in the distal end, indicating that the right thyrocervical trunk was completely embolized. BF. Angiography displayed a lesion vessel at the vertebral artery side of the right subclavian artery.
Figure 4
