101 - Massive Hemoptysis due to Acquired Bronchial Artery - Pulmonary Artery Fistula - Endovascular management.
Purpose: Bronchial artery embolization (BAE) is an established treatment for moderate to severe hemoptysis. N-butyl cyanoacrylate (NBCA) is used to achieve distal embolization and avoid recurrence from collateralization. Non-target embolization is a concern during BAE and a bronchopulmonary shunt increases the risk of non target embolization. Here we describe a case of acquired Bronchial artery - Pulmonary artery (BA - PA) fistula treated with embolization
Material and Methods: Case report
Results: 71 year old male with treated tuberculosis and post treatment left upper lobe cavity (LUL). CT demonstrated multiple soft tissue nodules within the cavity suggesting Aspergilloma, confirmed on bronchoscopy. He presented with large volume hemoptysis within a week of initiation of anti-fungal therapy. Repeat CTA showed similar cavitation in the LUL with hypertrophied bronchial arteries along the superior aspect of the cavity. Prominent pulmonary artery branches were noted along the inferior aspect of the cavity, however no direct fistulous communication was seen. Interventional Radiology was consulted for Bronchial artery embolization.
Left supreme intercostal arteriogram (via a reverse Chung catheter) and left pulmonary arteriogram (via an angled catheter) was performed. Left supreme intercostal arteriogram demonstrated BA - PA fistula with reversed flow in the left upper lobe PA. The supreme intercostal artery was embolized using NBCA. Left upper lobe PA branches were embolized with coils. Final angiography showed cessation of flow around the left upper lobe cavity. Patient remained asymptomatic at 10 month follow up.
Conclusions: Acquired BA - PA fistulas are uncommon and literature is sparse. They typically occur in chronic inflammatory conditions such as Tuberculosis , Aspergilloma, Bronchiectasis etc. It is postulated that chronic regional hypoxemia results in angiogenesis and hypertrophy of bronchial arteries and in rare cases pulmonary arteries around the cavity. It is also postulated that BA-PA fistula is a natural course of pressure decompression. While performing embolization, one should have a high suspicion of systemic- pulmonary anastomosis and look for the same. Embolization of both systemic and pulmonary vasculature should be performed to achieve effective hemostatic control and to prevent further episodes of hemoptysis.