1. Bronchial artery embolization (BAE) effectively treated patients with hemoptysis with minimal recurrent bleeding and complications, except in those with sarcoidosis, who displayed a significantly higher risk of recurrent bleeding and death as compared to patients with other chronic lung diseases.
2. Comparisons of rates of change in measurements of pulmonary function prior to and following intervention indicated that BAE did not accelerate deterioration in lung function.
Evidence Rating Level: 3 (Fair)
Study Rundown: BAE is a well-established, non-surgical procedure in the management of hemoptysis, or the coughing up of blood. Hemoptysis occurs in the setting of chronic inflammatory conditions of both infectious and noninfectious etiologies; alterations in blood flow and distribution result in expectoration of blood that originates from the systemic arterial supply to the pulmonary airway. While mild hemoptysis may be conservatively managed medically, major hemoptysis may lead to asphyxiation and exsanguination and should therefore be promptly assessed and treated with BAE as a first-line intervention. Although BAE as initial treatment of hemoptysis is a safe and useful therapy, recurrent hemoptysis in patients following successful BAE with chronic lung disease may occur due to the continued presence of inflammation, recanalization of a previously embolized bronchial artery, or bleeding from another nonembolized vessel. Recurrent bleeding following BAE leading to additional interventions is a significant concern and the effect of these interventions on recurrence, mortality and long-term pulmonary function is poorly understood. The present study retrospectively examined a cohort of patients who underwent BAE for a heterogenous array of lung conditions and tabulated the effect of BAE on hemoptysis recurrence, pulmonary function, and other procedure-related complications. The intervention was effective in treatment of hemoptysis, although patients whose hemoptysis resulted due to underlying sarcoidosis had a greater likelihood of recurrent bleeding and subsequent mortality. Additionally, measurements of pulmonary function across patient groups showed that BAE did not significantly contribute to deterioration in lung function. Strengths of the study included the variety of underlying etiologies of hemoptysis included, but the study was limited by its retrospective design and small included cohort from a single medical center, thereby restricting generalizability.
In-Depth [retrospective cohort]: A database search retrospectively identified 69 suitable candidates who underwent 97 total BAE procedures (n = 1–7 per patient) over an 11 year interval at a tertiary medical center in Philadelphia, PA. Patients were followed post-intervention and their outcomes in terms of pulmonary function changes, mortality, and recurrent bleeding over time were tabulated using a Kaplan–Meier curve. Comparison of the results of BAE for different underlying disease processes was performed to determine the technical and clinical success of BAE for various etiologies of hemoptysis. The baseline causes of hemoptysis in these patients included sarcoidosis (19%), cystic fibrosis (17%), pneumonia (16%), lung cancer (11%), COPD (9%), and bronchiectasis, tuberculosis, pulmonary hypertension, and various chronic inflammatory disease (each 1-4%.) 87 out of the 97 BAE procedures attempted delivered the embolic agent successfully, yielding a 90% technical success rate. Among technically successful procedures, clinical success rates were higher at 24 hours (82%) than at 30 days (68%); with a median time to recurrent bleeding of 29 days among patients with sarcoidosis and median time to rebleeding for those without sarcoidosis of 293 days (p = 0.0013). 75% of procedures resulted in complete recovery of symptoms at 24 hours, which dropped to 48% at 30 days. 70% patients (48) did not experience recurrent bleeding throughout the duration of the study, while 7% (5) patients required another bronchoscopy or additional embolization (23%). Evaluation of deaths in patients with sarcoidosis compared with those without the disease gave a hazard ratio of 4 (CI95: 2.6–14.6). Rates of change on pulmonary function parameters were significantly different: forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) changed between the pre- and post-embolization state (FEV1 p = 0.0048; FVC p < 0.0001), with an improvement following the intervention (FEV1 0.8%/year; FVC 1%/year) as compared to a baseline decline prior to treatment (FEV1 −1.6%/year; FVC −1.4%/year). Recurrent hemoptysis requiring repeat BAE or bronchoscopy at 1, 2, and 5 years following initial intervention were performed in 39%, 47%, and 51% of subjects, respectively.
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