Indications

• Massive hemoptysis

  • • Common definition: >300 mL in 24h, >50 mL in 1h

    • Patients die from asphyxia not acute anemia

    • Bronchial hemorrhage etiologies: CF, TB, Sarcoid, Wegener’s, recurrent pneumonia or abscess

Contraindications

• Absolute: Non-bronchial artery source

  • • PA hemorrhage etiologies: Rasmussen aneurysms, septic emboli, necrotizing PNA, traumatic pseudoaneurysm

    • Systemic collateral arterial source: hypertrophied extrapleural vessels

• Relative:

  • • Uncorrectable bleeding diathesis

    • Contrast allergy (premedicate, as time allows)

    • Renal impairment

Imaging Review

• CTA (systemic arterial rather than PA timing): Not required in an emergent situation if the hx is convincing, but it’s becoming more the standard of care to improve planning, reduce failure rate, reduce surgical interventions.

  • • Hypertrophied bronchial artery is a clear indication for angio in the setting of massive hemoptysis

    • Evaluate for nonstandard anatomy, ectopic origins of bronchials

• Bronchoscopy

  • • Useful in identifying bleeding side & confirming hemoptysis is not secondary to epistaxis, which it can be in some cases

    • Locoregional therapy becoming more common: laser coag, temporary bronchial plug

Tips for Workup

• Underlying etiology? Is bronchial bleed or PA bleed more common?

• Massive hemoptysis? Or can the pt be managed conservatively?

• Consent: Risk of non-target embolization (including paralysis from embolizing spinal artery or stroke if bronchial to PV shunt unrecognized), hemoptysis recurrence (up to 27% in 1^st month), chest pain, bronchial ischemia/necrosis (delayed), contrast nephropathy, access site complications