Chest
Volume 97, Issue 6, June 1990, Pages 1322-1326
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Bronchial Artery Embolization for Severe Hemoptysis in Cystic Fibrosis

https://doi.org/10.1378/chest.97.6.1322Get rights and content

We studied the long-term outcome after BAE for life-threatening hemoptysis in patients with CF. Data from pulmonary function tests were available for 18 of the 25 patients followed. A case-control comparison revealed that these 18 patients died sooner than hemoptysis-free patients with CF matched for age, sex, and pulmonary function (p<0.02), with the excess mortality occurring within the first three months after BAE. Of all 25 patients followed, six died of cardiorespiratory failure within three months of BAE; in two of them, hemoptysis was a contributing cause of death. The 19 patients who lived more than three months after BAE had a mean survival after embolization of 3.5 years (five were still alive at the end of the study). Most patients experienced long intervals (>1 year) free of major hemoptysis. Extended follow-up (mean, 35 months) revealed a higher incidence of recurrent severe bleeding than previously reported for 13 of these patients followed a mean of 11 months. Repeat BAE for severe recurrence was performed successfully in eight of nine patients, without complication.

Section snippets

MATERIALS AND METHODS

Ten female and 15 male patients, aged 7 to 35 years (mean, 21 years) underwent BAE for severe hemoptysis. The indications for BAE and the technique used have been described.1 We no longer routinely submit patients to bronchoscopy before BAE to localize the source of bleeding. Attempts are made to occlude any abnormal, enlarged bronchial artery identifiable at angiography. Only patients with severe hemoptysis were considered; the 25 patients either had acute hemorrhage (immediately

Immediate Outcome

Twenty-one (84 percent) of 25 patients completely stopped bleeding immediately upon BAE (Fig 1). The other four (16 percent) continued to bleed, although less briskly than prior to BAE. Hemoptysis stopped after repeat BAE ten days later in one patient (case 7), two had ongoing, intermittent, spontaneously resolving minor (case 8) to moderate (case 19) hemoptysis, and the fourth (case 22) had moderate to severe hemoptysis which led to surgical removal of the bleeding right upper lobe.

Survival

Six

Technique

Gelatin (Gelfoam) has been our embolic agent of choice primarily because it is easily injected. We believe that it is necessary to inject a large number of small particles (usually 15 to 80 per artery) in order to occlude the bronchial vessels peripherally and completely. It is known that gelatin is not a permanent occluder and that resorption and recanalization take place over several weeks or months;7 however, the alternative material, polyvinyl alcohol (Ivalon), a more permanent occluder, is

ACKNOWLEDGEMENT

We thank Michael Feldstein, Ph.D., for instruction concerning the statistical test for censored data; Harvey Colten, M.D., for constructive suggestions; and Mary Ellen B. Wohl, M.D., for critical review of the manuscript.

REFERENCES (13)

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    Thus the 25% mortality of our cohort is consistent with these studies and adds to this information as we tracked the physiologic changes of respiratory failure (Fig 3). The attributable mortality of massive hemoptysis in CF is reported as 5% to 16%12,14; therefore we and others15 believe that in patients with severely reduced baseline respiratory function, BAE therapy may be more dangerous than the disease. For patients with limited lung function, we recommend expediting the transplant evaluation at the onset of hemoptysis.

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    A bronchial artery embolism (BAE) applies mainly for local bleeding when an abnormal vessel is documented in medical centers with a stand-by angiographic service. The last resort for significant bleeding is a surgical procedure.5–7,16,17 The management of bleeding from an unidentifiable source, on the other hand, is more complicated.

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    Lung resection is an effective treatment for haemoptysis due to localized disease,18 but it is rarely appropriate in children with diffuse diseases such as CF.17 The usual indication for BAE in children is an immediate threat to life when other treatments have failed.5 Various authors have proposed thresholds for intervention based on the volume of expectorated blood.

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Manuscript received August 7; revision accepted November 9.

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