Bronchial artery complications

In this chapter the pathophysiology and etiology of hemoptysis will be discussed, as well as the diagnostic work-up of patients suffering from severe bronchial bleeding. Anatomy of bronchial arterial supply will be described. The techniques, pitfalls, complications and results of bronchial artery embolization will be discussed. 

Communications between bronchial arteries and systemic vessels are ubiquitous, and can sometimes complicate an embolization procedure. The most commonly seen communication is that of a right intercostobronchial trunk with an anterior medullary artery that contributes to the vascular supply of the spinal cord through the anterior spinal artery. The anterior medullary arteries have a characteristic hairpin configuration, and follow a course... 

Finally, operator experience in bronchial artery embolization is of crucial importance in achieving high success and low complication rates. Given the low incidence of acute massive hemoptysis, the risk that each patient represents a new learning experience is not unimaginable [38], and therefore bronchial artery embolization should only be performed by skilled operators (at least five to ten cases a year). 

The most commonly occurring complication encountered after bronchial artery embolization is (transient) chest pain, being reported in 24% up to 91% of cases. This is probably related to ischemia of embolized branches, and can be severe when intercostal branches are inadvertently embolized. Pleural pain can be avoided by using superselec-tive embolization techniques, with or without the use of large particles. The second most common complication is dysphagia, caused by embolization of esophageal branches, with a reported occurrence from 0.7% to 18.2% [30]. Spontaneous resolution of symptoms usually occurs. 

The most devastating complication is spinal cord ischemia, that has been reported to occur in 1.4%-6.5% of patients treated with bronchial artery embolization [9,30,39]. The occurrence of this complication can be reduced by using a superselective embolization technique, performing regular control angiograms before and after administration of embolic agents as has been described above. 

Ivanick MJ, Thorwarth W, Donohue J, Mandell V, Delany D, Jaques PF (1983) Infarction of the left main-stem bronchus a complication of bronchial artery embolization. AJR Am J Roentgenol 141 535-537... 

Girard P, Baldeyrou P, Lemoine G, Grunewald D (1990) Left main-stem bronchial stenosis complicating bronchial artery embolization. Chest 97 1246-1248... 

Munk PL, Morris DC, Nelems B (1990) Left main bronchial-esophageal fistula a complication of bronchial artery embolization. Cardiovasc Intervent Radiol 13 95-97... 

Technical Considerations Catheterization of the bronchial arteries is best approached from the femoral artery. Since most patients with lung cancer are older and the aorta is tortuous and atherosclerotic, a 5-F catheter with good torque control in a shepherd s crook (reverse curve) or forward seeking configuration is recommended. A finely tapered tip catheter for access which would allow a 3-F microcatheter coaxial system is optimal to bypass the spinal artery. The use of nonionic contrast media should minimize pain and the risk of contrast media-induced complications. The digital subtraction technique is of value for the identification of the anterior spinal artery with small branches to the spinal cord. 

Complications Transverse myelitis, aortic rupture, and ulceration of the trachea and esophagus complicate bronchial artery infusion of chemotherapeutic agents. Fever, malaise, and chemical pneumonitis, in addition to skin necrosis, have also been reported. Hemoptysis has occurred in the absence of residual tumor, presumably related to the infusion itself. These complications have minimized the rewards of infusion. 

Although similar events complicate the utilization of bronchial artery embolization in patients with hemoptysis due to lung cancer and/or radiation changes, pulmonary hemorrhage is frequently an acute medical emergency which demands instant and effective treatment. 

Bronchial artery embolization in CF patients is very effective immediately and on short-term basis. Many patients will require repeated embolizations during the follow-up [31]. Despite the reported severe complications of bronchial artery embolization, the procedure has proved to be safe if performed by experienced angiographers. 

Rare complications as have been reported in literature are aortic and bronchial necrosis [58], bronchial stenosis [59], unilateral diaphragmatic paralysis [60], pulmonary infarction (especially in patients who have suffered pulmonary artery embolism), left main bronchial-esophageal fistula [61], and non-target embolization (colon, coronary and cerebral circulation) [62]. Especially the newer spherical embolic materials (tris-acryl gelatin) can traverse from the bronchial into the pulmonary circulation, and then through unoccluded pulmonary arteriovenous malformations into the systemic circulation [41]. 

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