Bronchial Artery Embolization- By Dr.Tinku Joseph

PowerPoint presentation on Bronchial Artery Embolization (BAE) by Dr.Tinku Joseph

1. BRONCHIAL ARTERY EMBOLIZATION DR TINKU JOSEPH DM Resident Department of Pulmonary Medicine AIMS, Kochin Email-: [email protected]

2. contents Bronchial circulation Bronchial Artery Embolization (BAE) Indications Procedure Complications

3. Two Circulations in the Lung Bronchial Circulation Arises from the aorta. Part of systemic circulation. Receives about 2% of left ventricular output. Pulmonary Circulation Arises from Right Ventricle. Receives 100% of blood flow.

4. ANATOMICAL CONSIDERATION- Bronchial Artery Variable anatomy in terms of origin, branching pattern, and course. Bronchial arteries usually arise as a pair or as a common trunk, from the descending thoracic aorta below the origin of left subclavian artery. The standard or orthotopic origin is from the aorta between the levels of T5 and T6 (80%). ANOMALOUS – Outside the levels of T5 and T6 . ANOMALOUS - Aortic arch, Internal mammary artery, Thyrocervical trunk, Subclavian , Costocervical trunk, Pericardicophrenic artery, Inferior phrenic artery.

5. BRONCHIAL CIRCULATION Sometimes part of blood supply of anterior spinal artery come from bronchial vessels. When bronchial artery embolization is performed, consideration must be given to the arterial supply to the spinal cord. Most important is Anterior Spinal Artery. Anterior spinal artery receives contributions from the anterior radiculo medullary branches of the intercostals and lumbar arteries.

6. ARTERY OF ADAMKIEWICZ The largest anterior medullary branch. Has variable origin from T5 –L5 level, but most commonly from T8 – L1 level. In 5 % of population Rt. IBT contributes to artery of Adamkiewicz . The left bronchial arteries very rarely contribute the anterior spinal artery.

7. Topographical Facts: Normal Anatomy and Variations

8. Bronchial artery branching pattern Cauldwell et al - four patterns: Type I Type II Type III Type IV Cauldwell EW, Siekert RG, Lininger RE, Anson BJ.The bronchial arteries: an anatomic study of 105 human cadavers. Surg Gynecol Obstet 1948; 86:395– 412.

9. Type I Incidence: 40.6% Left: 2 Right:1 { intercostobronchial trunk (ICBT)}

10. Bronchial Artery- Course Leave the aorta at an upward angle, against the direction of blood flow. Send braches to oesophagus , mediastinum , lymph nodes and nerves. On reaching the main bronchi divide into visceral pleural branches to the mediastinal pleura and true bronchial arteries to the bronchial tree.

11. Bronchial Artery- Course Spiral course around bronchi, one on either side of each other but anastomosing frequently with each other The vessels form an arterial plexus in the adventitia from which branches pierce the muscle layer to enter the submucosa , where they break up into capillary plexus. Supplies bronchi, nerves, walls of pulmonary vessels and intra pulmonary lymph nodes.

12. Bronchial Artery- Course Arteriolar branches of the visceral pleural vessels pass along interlobular septa, reaching the interstitial tissue of the lung acinus . The true bronchial arteries reach as far down the airways as the terminal bronchiole. Much of the bronchial arterial blood, having gone through the submucosal capillaries, passes into the venous plexus in the adventitia. Veins from this plexus then join pulmonary venous system.

13. Bronchial Artery Embolization Minimally invasive alternative to surgery. selective bronchial artery catheterization and angiography, followed by embolization of any identified abnormal vessels to stop the bleeding. Considered to be the most effective nonsurgical treatment in the management of massive and recurrent hemoptysis .

14. Bronchial Artery Embolization First by Remy et al. in 1973.* Temporary or definitive Immediate control: 57–100% of patients** Embolization : bronchial and nonbronchial Long-term control: 70%-88% Remy J, Voisin C, Dupuis C, et al: Traitement des hémoptysies par embolisation de la circulation systémique. Ann Radiol (Paris) 1974; 17: 5–16. **Remy J, Arnaud A, Fardou H, et al: Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977; 122: 33–37.

15. Indications Haemoptysis -: Failure of conservative or bronchoscopic treatment to control bleeding. ISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pages

16. Indications Managing ruptured pulmonary artery venous malformation. To Stabilize patients before surgical resection or medical treatment. As a definitive therapeutic approach in patients: -Who refuse surgery -Who are not candidates for surgery -Where surgery is contraindicated Bronchial artery embolization : Managing ruptured pulmonary artery venous malformation e A case report Dharitri Goswami a,*, Shantanu Das b,1, Ashok Parida c,2, Joy Sanyal c,3. Respiratory Medicine CME 4 (2011) 160e163 poor lung function, bilateral pulmonary disease, co morbidities .

17. WHY BAE ?? 1)Bronchial circulation (90% of cases) - Pulmonary circulation (5%) . - Aorta (5%)( eg , aorto bronchial fistula, ruptured aortic aneurysm). 2) Surgery - Mortality 18% when performed electively, rising to 40% when performed emergently. - conservative approach , mortality risk of at least 50%. 3) Minimally invasive - clinical success - 85% to 100%, - recurrence of hemorrhage – 10%.

18. BAE- TECHNIQUE Prior to the procedure, a brief neurological exam is performed to establish a baseline. Femoral route/Trans- Axillary route Monitor vitals/spo2 Sedation optional Clean groin with antiseptics. Adequate LA A preliminary descending thoracic aortogram (Ionic/non ionic contrast) can be performed as a roadmap to the bronchial arteries.

19. BAE - TECHNIQUE Both bronchial arteries and nonbronchial systemic arteries are opacified . The diagnostic angiographic injections are always selective into the bronchial, intercostals, subclavian , internal mammary, intercostobronchial , and inferior phrenic arteries. Under X-Ray machine guidance (Digital cardiac imaging with digital subtraction facility) Reverse curve catheter – mikaelsson , simmons 1, shepherd’s hook. Low arotic arch – forward looking catheters ( cobra or RC ) used.

20. Angiographic signs of haemoptysis ISRN Vascular Medicine Volume 2013, Article ID 263259, 7 pages

21. BAE - TECHNIQUE The left main stem bronchus serves as a convenient fluoroscopic landmark for the general location of the bronchial arteries The catheter is directed lateral or anterolateral for the right bronchial and more anterior for the left. Bronchial arteries – course of main stem bronchi towards hila . Intercostal arteries – initial cephalic course , then laterally along undersurface of rib

22. BAE - TECHNIQUE The embolization materials commonly used are non-absorbable particles of polyvinyl alcohol (PVA) ( Ivalon ; Nycomed SA; Paris, France), 355–500 𝜇m in size (some larger vessels required particles as large as 2 mm), and fibred platinum coils of 2 and 3mm in size ( MicroNester Embolization Coils; Cook, Bjaeverskov , Denmark).

23. Catheters : Reverse-curved catheters ( Mikaelson , Simmons I, SOS Omni) Forward-looking catheters (Cobra, HIH,RC) Sizes: 4, 5, or 5.5 Fr are routinely used. Mikaelson catheter

24. Cobra type: curved catheter Most commonly used Microcatheter Superselective catherization Less complications

25. Embolizing materials : Absorbable gelatin sponge Gelfoam Pledgets (1 to 2 mm) Thrombin Glue Recently approved - Embospheres , -Spherical Poly vinyl alcohol(PVA) particles Permanent occlusive agents Polyvinyl alcohol (PVA), Trisacryl gelatin microspheres (TGM), Gelfoam

26. Embolizing materials : PVA particles (350-500 mic ) Most common & Safe Liquid embolic agents -ischemic necrosis Stainless steel platinum coils -occlude more proximal vessels.

27. Embolization coils: Platinum Microcoils

28. Embolizing materials : Particles > 200 to 250 micr.m should be used No ischaemia and no neurologic damage Isobutyl-2 cyanoacrolate , Absolute alcohol Used in pulmonary artery aneurysms to avoid tissue ischemia and neurologic damage

29. Embolizing materials : Distal embolization : ideal Proximal occlusion: temporary relief particles < 200 micr.m :avoided -Tissue infarction Liquid embolic agents should always be avoided because these cause tissue infarction

30. Clues to bronchial artery as the source of bleeding: 34 Parenchymal hypervascularity Vascular hypertrophy aneurysm

31. 35 The identification of extravasated dye --INFREQUENT Bronchopulmonary shunting Neovascularisation

32. Left upper lobe bronchial artery After Embolization Decreased vascularity & hypertrophy Tortous and hypertrophied vessel Before Embolization

33. Right Left Abnormal circulation Pre- embolisation bronchial angiogram No abnormal circulation Post embolisation

34. Bronchial artery aneurysm Hypervascular lesion with aneurysm Pre embolisation Post embolisation PVA particles No hypervascular lesion & aneurysm

35. Super selective Embolization of intercostal artery Hypervascular areas and a small amount of pulmonary arterial shunting Decreased vasularity POST EMBOLIZATION PRE EMBOLIZATION Radicular arteries INTERCOSTAL ARTERY Micro catheter passed beyond radicular artery

36. Bronchial Artery Embolization Success rates : 64% to 100%. Recurrent non-massive bleeding : 16–46% Recurrence of haemoptysis may be due to: Incomplete embolization of the bronchial vessels Recannalization of the embolized arteries. Presence of non-bronchial systemic arteries. Development of collateral circulation in response to continuing pulmonary inflammation.

37. Bronchial Artery Embolization Technical failure: 13% Technical failure is caused by non-bronchial artery collaterals from systemic vessels such as the phrenic , intercostal , mammary,(PLEURA) or subclavian Arteries.

38. Complications of BAE Transversemyelitis The most feared complication due to non target occlusion of branches. When the anterior spinal artery is identified as originating from the bronchial artery, embolisation is often deferred owing to the risk of infaction and paraparesis .

39. The anterior spinal artery is the blood vessel that supplies the anterior portion of the spinal cord. It arises from branches of the vertebral arteries and is supplied by the anterior segmental medullary arteries, including the artery of Adamkiewicz , and courses along the anterior aspect of the spinal cord. Disruption of the anterior spinal cord leads to bilateral disruption of the corticospinal tract , causing motor deficits , and bilateral disruption of the spinothalamic tract, causing sensory deficits in the form of pain/temperature sense loss Complications of BAE

40. Complications of BAE

41. Complications of BAE Chest pain is the most common complication. Dysphagia due to embolization of esophageal branches may also be encountered. Rare complications Aortic and bronchial necrosis Bronchoesophageal fistula Non–target organ embolization ( eg , ischemic colitis) Pulmonary infarction.

42. References 1) Haponik E F, Fein A, Chin R. Managing life-threatening hemoptysis : has anything really changed? Chest. 2000;118(5):1431–1435. 2) Shigemura N, Wan I Y, Yu S C, et al. Multidisciplinary management of life-threatening massive hemoptysis : a 10-year experience. Ann Thorac Surg. 2009;87(3):849–853. 3)Marshall T J, Jackson J E. Vascular intervention in the thorax: bronchial artery embolization for haemoptysis. Eur Radiol . 1997;7(8):1221–1227.

43. 4)Yoon W, Kim J K, Kim Y H, Chung T W, Kang H K. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis : a comprehensive review. Radiographics . 2002;22(6):1395–1409. 5)Fernando H C, Stein M, Benfield J R, Link D P. Role of bronchial artery embolization in the management of hemoptysis . Arch Surg. 1998;133(8):862–866 6) Ramakantan R, Bandekar V G, Gandhi M S, Aulakh B G, Deshmukh H L. Massive hemoptysis due to pulmonary tuberculosis: control with bronchial artery embolization . Radiology. 1996;200(3):691–694. References

44. CONCLUSION The development of bronchial artery embolization techniques has revolutionized the approach to hemoptysis patients. Bronchial artery embolization possesses high rates of immediate clinical success coupled with low complication rates. When bronchial artery angiography and embolization is performed, consideration must be given to the arterial supply to the spine.

45. 4) Surgery should be considered only in case where embolisation is not possible due technical difficulty and in case of embolisation failure. Otherwise bronchial artery embolisation is considered as the mainstay treatment for hemoptysis . CONCLUSION