Introduction

​Hemoptysis is rare in children, the most common cause being cystic fibrosis with an incidence of 1% per year. Hemoptysis tends to be mild and self-limiting. Other causes include bronchitis, aspergillosis, tumor, pulmonary embolism, and coagulopathy.

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Indications

• Medical management has failed (vitamin K, antibiotics, tranexamic acid)
• Massive/moderate hemoptysis
• Consider in chronic/recurrent:
  1. Have had mild hemoptysis leading to massive hemoptysis before
  2. Have hemoptysis within 14 days after completing optimal medical management
  3. Hemoptysis persists despite a trial of optimal medical management
  4. Embolization is performed as a bridge to transplantation

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Contraindication 

• Uncorrected coagulopathy
• Clinical instability

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Pre-Procedure

• Attempt to localize the bleed. Bronchoscopy can be useful, but difficult in massive hemoptysis
• CT angiogram of the chest can be useful to delineate bronchial artery anatomy, identify dilated vessels and areas of parenchymal hemorrhage.
• Discontinue penicillin and NSAIDs.
• Give a dose of vitamin K and tranexamic acid, if available.

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Labs

• CBC and coagulation tests.
• Type and screen.

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Technique

Supplies

• 4-5 Fr vascular sheaths 
• Flush thoracic aortogram (can defer if likely source of bleeding identified on cross sectional imaging)
• Use angled (C1/C2) or reverse curve catheters (Sos, Simmons, etc.) to access most likely source of bleeding.
• Look for enlarged, tortuous bronchial artery with parenchymal hypervascularity and staining. Active extravasation is rarely seen.
• Perform DSA with breath-hold to accurately visualize bronchial artery and potential anterior spinal artery.
• Embolize as close to the site of hemorrhage as possible, Use microcatheters if needed, but larger lumen (0.021" or 0.026" e.g.  Renegade Hi-Flo), to avoid clumping of PVA,
• Catheterize all vessel indicated, including:

1. Bilateral subclavian arteries and branches, particularly internal mammary arteries.
2. Right intercostal bronchial trunk
3. Inferior phrenic arteries

Embolic Agents

• PVA particles. At least 300 um in caliber. Smaller particles can results in bronchial and esophageal necrosis and increase the risk of spinal infarction.
• Gelfoam - pledgets or slurry.
• Coils - only if large shunts. Avoid coiling of arteries proximally​

Common bronchial artery trunk

Selective catheterization of right bronchial artery

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Complications

• Spinal cord infarction: minimize risk by high quality imaging, distal embolization and avoiding small particles.
• Bronchial / esophageal necrosis.
• Chest pain and dysphagia.
• Arterial dissection.

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Post-Procedure

• Supportive care
• Monitor for post embolization syndrome

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Follow-up

​References

• Many patients will rebleed despite the greater than 90% success of this procedure
• Consider repeating procedure if no resolution of hemoptysis​​

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1. Kalva SP. Bronchial artery embolization. Tech Vasc Interv Radiol. 2009;12(2):130-138. doi:10.1053/j.tvir.2009.08.006
2. ​Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307-317. doi:10.5152/dir.2017.16454