Correct!
2. Bronchial artery embolization
It would not be entirely wrong to continue to observe but she was anxious to have a definitive procedure performed. Despite the presence of blood in the left lower lobe, the bleeding site is still not definitively identified since the blood may have pooled and formed a clot. Bronchial artery valves are used to deflate blebs and bullae but not bleeding. Balloon tamponade can be performed for massive bleeding but is overaggressive for a clot in the left lower lobe. For reasons mentioned previously left lower lobectomy is not appropriate.
Bronchial artery angiography revealed an abnormal appearance of the arterial supply to the left upper lobe from the throacoacromial artery originating from the left subclavian artery (Figure 7, Panel A). The abnormal flow was successfully embolized (Figure 7, Panel B).
Figure 7. Panel A: abnormal appearance of the arterial supply to the left upper lobe from the throacoacromial artery. Panel B: Same area after embolization.
The indications for angiography include persistent brisk hemoptysis despite correction of any coagulopathy and after bronchoscopy fails to identify a bleeding site (1-4). Usually the bleeding is slow and so observation of contrast extravasation into airway is very rare.
Bronchial artery embolization has about an 85% success rate in controlling bleeding (1-4). Rebleeding occurs in about 10-20% of patients from incomplete embolization, revascularization, or recanalization of the vessel. Complications are relatively rare and include bronchial wall necrosis, and most seriously, ischemic myelopathy. The anterior spinal artery arises from a bronchial artery in about 5% of the population. Embolization may block flow to anterior spinal cord, resulting in paraplegia. Fortunately, this complication occurs in <1% of embolizations.
Our patient continued to have some blood-tinged sputum but no frank hemoptysis and was discharged on empiric antibiotics, tapering doses of prednisone, and salmeterol/fluticasone for her asthma.
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