Page 1267 - Hall et al (2015) Principles of Critical Care-McGraw-Hill

874 PART 7: Hematologic and Oncologic Disorders

Thrombectomy is performed by clot fragmentation, aspiration (directly of the patient, the cause and localization of the site of bleed should be
performed by the tip of the catheter), or rheolytic therapy (Venturi effect established. Chest x-ray is an adequate initial tool for diagnosis due to
by speed jet injection of saline which also lyses the clot). Suitable can- its easy availability. Although the chest x-ray can help localize the bleed
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didates are patients in whom thrombolysis or surgery is contraindicated, and show other parenchymal abnormalities in 30% to 60% of cases,
and as a rescue therapy for those who do not respond to initial thrombo- approximately 20% to 30% of chest x-rays are negative in patients with
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lytic therapy. Local injection of thrombolytics via catheter insertion has hemoptysis. 30,32 In addition, the diagnostic yield of chest x-rays to localize
increased the efficacy of clot fragmentation with no significantly higher the anatomic source of bleeding also decreases in the setting of bilateral
risk of bleeding ; however, there are no studies demonstrating outcomes lung compromise due to aspiration. 32
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benefits. Accordingly, this strategy cannot be recommended as standard Contrast computed tomography (CT) is superior to chest x-ray, as it
therapy. In a recent meta-analysis, the rate of survival and success of treat- can localize the site of bleed in about 70% to 100% of cases. 30,32 Initial
ment was similar for systemic thrombolysis and catheter-related therapy; CT evaluation, especially multidetector CT, can give radiological clues
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major complications were <3%. Caution is important during catheter- if the bleed originates from bronchial, nonbronchial systemic arteries or
directed therapy as these catheters were initially developed for peripheral the PA. Extrapulmonary causes that will require emergent surgery,
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and coronary arteries and can cause vascular rupture, especially if targeting such as false aortic aneurysms and aortobronchial fistulas, can also be
peripheral vessels. Other complications, even though infrequent, include detected on initial CT scans. 31,33
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arrhythmias, embolization, and bleeding from the site of insertion. 19,20 In massive hemoptysis, bronchoscopy has a diagnostic yield of 61%
Surgical embolectomy with cardiopulmonary bypass is another treat- to 93%, but its role is still debated by some experts. 28,29,34 Use of rigid
ment option for massive PE. The procedure is indicated in patients bronchoscopy has been widely supported as it facilitates airway patency,
who have contraindications for thrombolysis, as a rescue therapy for ventilation, and allows better clot evacuation and visualization of the
1
thrombolytics, or when there is evidence of intraventricular clots. Early airways. Despite these advantages, only <6% of pulmonologists in the
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studies showed a mortality rate of 28% after surgical embolectomy; United States have adequate training in the use of rigid bronchoscopy.
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however, with current techniques in selected patients, the mortality Flexible bronchoscopy, because of its availability and possibility of bed-
has been reduced to 6% to 18% in specialized centers. 1,21,22 Gulba et al side use, makes it an attractive diagnostic tool. Flexible bronchoscopy
compared the efficacy of surgical embolectomy with medical treatment allows better access to all segments; however, if the bleeding is massive,
of PE. These investigators found a slightly better outcome with surgical visualization may not be possible. 27,28 Even though some believe that
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embolectomy than with medical management (33% vs 23% mortality). performing bronchoscopy only delays ultimate treatment, recent studies
However, the study lacked statistical power as it included only have shown successful stenting and ballooning of airways in patients
37 patients, and had no adequately matched control groups. For all with hemoptysis. 35,36 Use of bronchoscopic instillation of epinephrine,
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patients being considered for surgical embolectomy, the overall prognosis cold saline, vasoactive solutions, and fibrin has been described in litera-
and functional status should be adequate. ture but the efficacy of these strategies in massive hemoptysis is limited
The use of vena cava filters is reserved for patients who have contra- and unreliable. 24,33
indications to anticoagulant therapy such as active bleeding or immedi- More than three decades ago, the initial management of massive
ately following major surgery or major trauma. 10 hemoptysis was observant and mortality was >90%. Surgical inter-
vention was later integrated as an important part of the management
■ MASSIVE HEMOPTYSIS of hemoptysis. Surgery is the definitive treatment for patients with
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massive hemoptysis due to aspergillomas, early malignancy, arterio-
Massive hemoptysis, defined as expectoration of 300 to 600 mL of blood venous malformations, and thoracic aneurysms. 25,26 Mortality of these
in 24 hours, accounts for less than 5% of hemoptysis cases and car- procedures is usually 7% to 18.2%; however, when the interventions
ries a mortality greater than 50%. Common causes of hemoptysis are are emergent, the mortality rate increases to 40%. 25,26 Because massive
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(1) infections (mainly aspergillomas and tuberculosis); (2) pulmonary hemoptysis requires emergent intervention, less invasive modalities of
(bronchiectasis, diffuse alveolar hemorrhage); (3) malignancy (primary treatment, such as embolization, have been developed.
and metastatic); (4) vascular (aneurysms and arteriovenous malforma- Bronchial artery embolization was first described in 1974. Arterial
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tions); (5) vasculitis (Granulomatosis with polyangiitis [formerly known as access is usually femoral, and an aortogram is performed for adequate
Wegener’s granulomatosis] and Goodpasture syndrome); and (6) trauma or mapping of all arteries. Angiographic signs suggestive of a source
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iatrogenic (bronchoscopy, biopsy, and catheter-induced pulmonary artery of bleeding include hypertrophied and enlarged arteries, aneurysms,
rupture). 25,26 Cancer patients account for 30% of massive hemoptysis cases, shunting from the bronchial artery to the pulmonary vein or artery,
and about 10% of patients with lung cancer develop hemoptysis during the and active extravasation. 30,32 While most of the bleeds originate from
course of their disease. In the past, the mortality of malignancy-related the bronchial arteries, it is important to have adequate knowledge
27
hemoptysis was up to 90% in case reports compared to other causes of the anatomy and review any possible collateral vessels as a possible
(28%-50%). 25,27 However, recent studies have shown that the efficacy of source of bleed. Recurrence of bleed after embolization ranges from
treatment for hemoptysis in the oncological population is comparable to all 2% to 25%. 27,29,34 Van den Heuvel et al described a higher mortality in
other patients and mortality has been reduced significantly. 27,28 patients with recurrence and identified several risk factors: (1) residual
Ninety percent of pulmonary hemorrhages originate from the bron- mild bleed after first week of embolization; (2) blood transfusion before
chial arteries. Bronchial arteries derive from the aorta at the level of the procedure; and (3) aspergilloma as the underlying etiology. Early
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29
T5 and T6, and the anatomy of these branches can vary from patient to recurrence, considered to be within the first 6 months after interven-
patient. Thus, anatomical classifications of the bronchial artery anatomy tion, is secondary to incomplete embolization, or incomplete search of
have been described to facilitate diagnosis and embolization by interven- other bleeding vessels. 24,29 Late rebleed is secondary to recanalization of
tional radiologists. 24,30 In 5% of cases, bleeding can come from nonbron- the previous bleeding vessel or progression of the underlying disease. 24,29
chial systemic arteries. 24,30 In these cases, the bleeding vessels identified Multiple studies have shown success rates of over 90% after emboliza-
are transpleural collateral vessels from the subclavian, axillary, and tion, with rebleeding occurring in only 10% to 20% cases. 29,38,39 One
internal mammary arteries, which form after chronic inflammation. of the main complications associated to bronchial artery embolization
30
Bleeding from the pulmonary artery (PA) occurs in less than 5% of is spinal cord infarction. The anterior spinal arteries can feed from
cases. The most common cause for PA bleed is Rasmussen aneurysm, a branches of the bronchial arteries in 5% of patients, placing these arter-
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pseudoaneurysm that forms secondary to chronic inflammation. 24 ies at high risk of unintentional embolization when treating bronchial
In the presence of massive hemoptysis, early protection of the airway, bleeds. Currently with superselective embolization, the risk has been
24
resuscitation, and reversal of coagulopathy are essential. After stabilization reported to be lower than 2%. 40

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