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Indications & Contraindications
Patient selection, etiologies, absolute contraindications
Indications
- Massive hemoptysis — >300 mL/24h or any volume causing life-threatening respiratory compromise / asphyxiation risk
- Recurrent hemoptysis — multiple episodes despite conservative management
- Hemoptysis refractory to conservative therapy — failed medical management, bronchoscopic intervention
- BAE is now considered the treatment of choice for massive hemoptysis (surgical mortality 37–43%)
Contraindications
- Absolute: Anterior spinal artery arising from bronchial artery — must identify before embolization; embolization of this vessel causes spinal cord infarction
- Relative: Uncorrectable coagulopathy
- Relative: Contrast allergy (premedicate)
- Relative: Renal insufficiency (minimize contrast)
Common Etiologies
| Category | Etiologies |
|---|---|
| Infectious | Tuberculosis, aspergilloma (mycetoma), lung abscess, necrotizing pneumonia |
| Structural | Bronchiectasis, cystic fibrosis |
| Neoplastic | Lung cancer (primary or metastatic) |
| Other | Cryptogenic (up to 25%), pulmonary arteriovenous malformations, trauma |
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Pre-Procedure Planning
Imaging, airway stabilization, labs, emergent notification
Imaging & Labs
- CTA chest — identify bleeding source, bronchial artery anatomy, enlarged/hypertrophied bronchial arteries, look for spinal artery feeders
- CTA accuracy for localizing bronchial artery bleeding approaches 100%; non-bronchial sources ~62%
- Identify variant anatomy: bronchial arteries from subclavian, IMA, thyrocervical trunk
- Labs: CBC, PT/INR, PTT, type & screen
- Review anticoagulation: BAE is SIR Category 2 (moderate risk). Warfarin: hold 5 days (INR <1.5). LMWH: hold 24h. DOACs: hold 24–48h. Aspirin: continue. Clopidogrel: risk-based — often does not need to be held; hold 5 days if bleeding risk exceeds thrombotic risk
Airway Stabilization
- Intubation if massive hemoptysis — protect airway from aspiration/asphyxiation
- Single-lung ventilation (double-lumen ETT or bronchial blocker) to isolate bleeding lung
- Position bleeding side down — prevents blood from flooding unaffected lung
- Bronchoscopy to lateralize bleeding source if CTA not available or indeterminate
- Fluid resuscitation and blood product transfusion as needed
CTA chest reviewed. Bleeding source identified, bronchial artery anatomy mapped, spinal artery feeders noted, non-bronchial systemic supply evaluated.
Airway secured. Intubation if massive hemoptysis; bleeding side positioned down; single-lung ventilation if available.
Labs obtained. CBC, coagulation studies, type & screen. Coagulopathy corrected.
IR nurse/technologist notified emergently. BAE is an emergency procedure — IR team activated via on-call pager/phone. Simultaneous notification of attending IR physician required.
Consent obtained. Key risks: spinal cord ischemia/paralysis, recurrence (10–30%), non-target embolization, chest pain, dysphagia.
Blood products available. PRBCs crossmatched; massive transfusion protocol on standby if needed.
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Relevant Anatomy
Bronchial artery origins, ICBT, spinal artery, variants
Bronchial Artery Origins
- ~70% arise from the descending thoracic aorta at T5–T6 level
- Right intercostobronchial trunk (ICBT) — most common configuration; supplies the right bronchial artery + right intercostal artery; typically arises from the right side of the aorta
- Left bronchial arteries — 1–2 arteries, arise from anterior/left aspect of the aorta
- 16–30% of bronchial arteries arise outside T5–T6 (ectopic origins)
Variant Origins
- Subclavian artery
- Internal mammary artery (IMA)
- Thyrocervical trunk
- Costocervical trunk
- Brachiocephalic artery
- Inferior phrenic artery
- Abdominal aorta / aortic arch
CRITICAL — Anterior Spinal Artery
- The anterior spinal artery can arise from a bronchial artery or intercostal artery — embolization causes spinal cord infarction and paralysis
- Look for the characteristic “hairpin” loop on selective angiography — a small branch coursing medially toward the spinal canal with a sharp turn
- If spinal artery is visualized: ABORT embolization of that vessel. Use microcatheter to achieve more distal purchase beyond the spinal artery origin, or abandon that artery entirely.
- Provocative testing with intra-arterial lidocaine or short-acting barbiturate can detect occult spinal artery supply
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Technique
Access, catheterization, angiography, embolization
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Vascular Access
Common femoral artery (CFA) access. Place 5F vascular sheath. Select a shaped catheter for the descending thoracic aorta: Cobra, SOS Omni, or Mikaelson catheter depending on anatomy and operator preference.
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Descending Thoracic Aortogram
Perform aortogram centered at T5–T6 level to identify bronchial artery origins. Look for hypertrophied, tortuous bronchial arteries. Identify ICBT on the right. Note any non-bronchial systemic collateral supply (intercostals, IMA branches).
▶ Hypertrophied bronchial artery — pre-embolization
Descending thoracic aortogram: hypertrophied, tortuous bronchial arteries arising near left mainstem bronchus — classic angiographic appearance in chronic hemoptysis.
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Selective Bronchial Artery Catheterization
Selectively catheterize each bronchial artery. Use microcatheter/microwire system (2.5–2.8F) for subselective access when needed. Perform selective DSA of each vessel.
▶ ⚠ Anterior spinal artery — must identify before embolizing
Anterior spinal artery (red arrow) arising from intercostal — identify and exclude before embolizing; failure to do so risks spinal cord infarction.
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Angiographic Assessment
Evaluate for signs of bleeding source: hypervascularity, arterial-venous shunting, active contrast extravasation, aneurysm formation. Carefully inspect for the hairpin loop of the anterior spinal artery on every selective injection.
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Embolization
Embolic agents: PVA particles 355–500 µm or Embosphere trisacryl microspheres 500–700 µm. Gelfoam pledgets also used as adjunct. NEVER use particles <300 µm — risk of passing through bronchopulmonary shunts and non-target embolization of the anterior spinal artery. NO coils as sole embolic — coils occlude proximal access needed for future re-embolization and have high recurrence rates. Glue (NBCA) limited to experienced operators.
▶ Post-embolization completion angiogram
Post-embolization angiogram confirming occlusion of bronchial artery supply with no residual opacification of previously hypertrophied vessel.
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Search for Non-Bronchial Systemic Supply
After embolizing all identified bronchial arteries, systematically evaluate for non-bronchial systemic collateral supply: intercostal arteries, internal mammary artery (IMA), subclavian branches, inferior phrenic arteries. These are the most common cause of recurrence if missed.
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Completion Angiography
Perform completion angiograms of all embolized vessels to confirm stasis of flow. Repeat aortogram to confirm no residual hypervascularity. Remove catheters, achieve hemostasis at CFA access site.
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Key Landmarks
T5–T6 level, ICBT identification, spinal artery hairpin sign
T5–T6 Aortic Level
- Primary origin of ~70% of bronchial arteries
- Center your aortogram here
- Corresponds roughly to the carina / left mainstem bronchus on fluoroscopy
- If no bronchial arteries found at this level, extend search above and below
ICBT Identification
- Right intercostobronchial trunk is the most common right-sided bronchial artery configuration
- Arises from the right posterolateral aorta
- Gives off the right bronchial artery + right intercostal artery
- The intercostal branch may supply the anterior spinal artery — always check
Spinal Artery Hairpin Sign
- Small branch coursing medially toward the spinal canal
- Makes a sharp “hairpin” turn as it joins the anterior spinal artery
- If seen: STOP — do NOT embolize that vessel from this position
- Advance microcatheter distal to spinal artery origin or abandon vessel
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Troubleshooting
Intraoperative problems and solutions
Cannot Find Bleeding Source
No Abnormal Bronchial Arteries Identified at T5–T6
Perform complete thoracic aortogram to identify ectopic bronchial arteries arising outside the T5–T6 level. Search for non-bronchial systemic collateral supply: intercostal arteries, internal mammary artery, subclavian branches, thyrocervical trunk, inferior phrenic arteries. Up to 30% of bronchial arteries have ectopic origins. If no arterial source found, consider pulmonary angiogram to evaluate for pulmonary artery bleeding source.
Critical — Spinal Artery Visualized
Anterior Spinal Artery Seen on Selective Angiogram
ABORT embolization of that artery from current catheter position. Options: advance microcatheter beyond spinal artery origin to achieve distal purchase and embolize from there (only if safe distance confirmed), or abandon that vessel entirely. Never embolize proximal to a visible spinal artery origin. Document finding. Consider provocative testing with intra-arterial lidocaine if occult spinal supply is suspected in other vessels.
Hemoptysis Recurrence Post-BAE
Recurrent Bleeding Days to Months After Initial Embolization
Recurrence rate is 10–30% at 1 year. Most commonly due to missed non-bronchial systemic collateral supply at initial procedure. Repeat CTA and re-angiogram. Systematically interrogate ALL potential systemic supply: intercostals, IMA, subclavian branches, inferior phrenic. Also evaluate for recanalization of previously embolized vessels. Pulmonary artery source should be excluded if no systemic source identified.
Difficult Catheterization
Unable to Select Bronchial Artery Ostia
Bronchial artery anatomy is highly variable. Try multiple catheter shapes: Cobra C2, SOS Omni, Mikaelson, Simmons. Consider reverse-curve catheter (Simmons) for acute angulation origins. Use a microcatheter/microwire coaxial system for subselective access. If ostium cannot be engaged, perform aortogram to redefine anatomy and attempt from different projection angle.
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Complications
Expected side effects vs serious adverse events
Common / Expected
- Chest pain / pleuritic pain — most common; typically transient 2–7 days post-embolization; treated with analgesics; may require IV corticosteroids
- Dysphagia — esophageal branch embolization; usually transient; self-resolves in days
- Low-grade fever — post-embolization syndrome; supportive care
- Groin hematoma — femoral access site complication; standard management
Serious Complications
- Spinal cord ischemia / paralysis (<5%) — most feared complication; due to anterior spinal artery embolization; can be devastating and irreversible; bilateral lower extremity weakness post-procedure = emergency imaging and neurology
- Recurrence (10–30% at 1 year) — missed non-bronchial systemic supply, recanalization, disease progression
- Bronchial necrosis (rare) — non-target embolization of bronchial wall supply
- Pulmonary infarction (rare) — in setting of compromised pulmonary arterial supply
- Aortic dissection (rare) — catheter-related injury
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Pearls & Pitfalls
Critical safety points and clinical tips
!
NEVER use particles <300 µm. Small particles can traverse bronchopulmonary anastomoses and embolize the anterior spinal artery, causing spinal cord infarction and paralysis.
!
Always look for the hairpin sign. On every selective bronchial artery injection, meticulously search for the anterior spinal artery before embolizing. If seen, abort embolization from that catheter position.
✦
Recurrence usually means missed non-bronchial systemic supply. The most common cause of BAE failure is incomplete embolization of all arterial sources. Intercostal arteries, IMA, and subclavian branches must all be interrogated.
✦
Position the patient with the bleeding side down. This prevents blood from flooding the unaffected lung, which is the primary cause of death from asphyxiation rather than exsanguination in hemoptysis.
✦
Search ALL potential systemic supply — not just bronchials. Non-bronchial systemic arteries (intercostals, IMA, subclavian, inferior phrenic) can be the sole or contributing source of hemoptysis, especially in patients with chronic inflammatory disease or pleural thickening.
✦
Avoid coils as sole embolic agent. Coils occlude the proximal vessel and prevent future catheter access for repeat embolization. BAE recurrence is common, and re-access is essential.
✦
Immediate bleeding control with BAE is 73–99%. Long-term success is lower (45–90%), particularly in patients with significant pleural thickening and underlying disease progression.
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References & Resources
Primary sources and key literature
Primary References
- Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics. 2002;22(6):1395–1409.
- Swanson KL, Johnson CM, Prakash UB, McKusick MA, Andrews JC, Stanson AW. Bronchial artery embolization: experience with 54 patients. Chest. 2002;121(3):789–795.
- O’Dell MC, Gill AE, Hawkins CM. Bronchial artery embolization for the treatment of acute hemoptysis. Tech Vasc Interventional Rad. 2017;20:263–265.
- Chun JY, Morgan R, Belli AM. Radiological management of hemoptysis: a comprehensive review of diagnostic imaging and bronchial arterial embolization. Cardiovasc Interv Radiol. 2010;33:240–250.
- Lopez JK, Lee HY. Bronchial artery embolization for treatment of life-threatening hemoptysis. Semin Interv Radiol. 2006;23:223–229.