Recurrent hemoptysis in pediatric bronchial Dieulafoy’s disease with inferior phrenic artery supply:A case report

BACKGROUND Bronchial Dieulafoy’s disease(BDD)is characterized by the erosion of an anomalous artery in the submucosa of the bronchus.The etiology of pediatric BDD is mainly congenital dysplasia of bronchus and pulmonary arteries,which is different from chronic inflammatory injury of the airway in adult patients.The internal thoracic artery,subclavian artery,and intercostal artery are known to be involved in the blood supply to the BDD lesion in children.CASE SUMMARY We report a case of BDD in a 4-year-old boy with recurrent hemoptysis for one year.Selective angiography showed a dilated right bronchial artery,and anastomosis of its branches with the right lower pulmonary vascular network.Bronchoscopy showed nodular protrusion of the bronchial mucosa with a local scar.Selective embolization of the bronchial artery was performed to stop bleeding.One month after the first intervention,the symptoms of hemoptysis recurred.A computed tomography angiogram(CTA)showed another tortuous and dilated feeding artery in the right lower lung,which was an abnormal ascending branch of the inferior phrenic artery(IPA).The results of angiography were consistent with the CTA findings.The IPA was found to be another main supplying artery,which was not considered during the first intervention.Finally,the IPA was also treated by microsphere embolization combined with coil interventional closure.During the one-year follow-up,the patient never experienced hemoptysis.CONCLUSION The supplying arteries of the bleeding lesion in children with BDD may originate from multiple different aortopulmonary collateral arteries,and the IPA should be considered to reduce missed diagnosis.CTA is a noninvasive radiological examination for the screening of suspected vessels,which shows a high coincidence with angiography,and can serve as the first choice for the diagnosis of BDD.

Value of CT-Angiography in the Emergency Management of Severe Hemoptysis

Objective To depict imaging anatomy of bronchial artery(BA)using multidetector CT-angiography(MDCTA)and evaluate the value of MDCTA for management of hemoptysis patients requiring admission to emergency room.Methods We retrospectively studied the clinical and radiological data of patients with severe hemoptysis(≥100 ml of expectorated blood in a 24-hour period)requiring admission to emergency room from Jan 1,2013 to Dec 31,2015.Patients’images of MDCTA,treatment modalities,and outcome were discussed.Results A total of 108 patients underwent MDCTA scans.Etiology of hemoptysis was mainly bronchiectasis(44%),tuberculosis sequelae(26%)and tumor(18%).MDCTA visualized 197 traceable BAs and also suggested the involvement of 35 nonbronchial systemic arteries.The mean diameter of BAs,measured at the level of the bronchial bifurcation in the mediastinum,was 2.8±1.2 mm.The mean diameter of BAs,for 52 patients who only received conservative treatment,was 2.9±1.1 mm,and was not significantly larger than that of BAs for 56 patients who underwent bronchial artery embolization(BAE)for continued bleeding which did not resolve after conservative treatment(2.7±1.1 mm,P=0.94).The technical success rate of embolization was 95%(53/56).Clinical success rate during follow-up was achieved in 50(94%)of 53 patients who had undergone embolization.Conclusions MDCTA provides useful information for identifying the anatomical characteristics of bleedingrelated BAs and nonbronchial systemic arteries for the management of patients with severe hemoptysis.However,MDCTA could not determine the individuals who need BAE through measuring diameter of BAs.

Bronchial artery embolization for hemoptysis:A systematic review and meta-analysis

Objective:To assess the safety and efficacy of bronchial artery embolization(BAE)for hemoptysis.Methods and materials:Databases with articles published in English,including Pubmed,Embase,Web of science and Chochrane library,were comprehensively searched to get accurate,up-to-date and sufficient literature about BAE for hemoptysis until March 2020.The technical success rates,immediate control rates,recurrence rates,mortality rates,and total complication rates(minor and major complication rates)extracted from the articles were pooled to estimate and assess the efficacy and safety of BAE using random-effect and fixed-effect models.Results:21 articles published between 2008 and 2019,which include a total of 2511 patients,were studied to evaluate the safety and efficacy of BAE.The technical success and immediate control rates are 99.9%(95%CI:99%-100%)and 99.5%(95%CI:97.8%-99.2%),respectively.This study showed hemoptysis recurrence in 23.7%(95%CI:18.5%-28.9%)with a mortality rate of 2%(95%CI:0-3%).Additionally,the assessment of complications revealed a total complication rate of 13.4%(95%CI:7.6-19.2%),in which 0.2%(95%CI:0.2-0.4%)were major complications and 10%(95%CI:4.7-9.6%)were minor complications.Conclusion:BAE is an effective,safe,and feasible procedure with a low complication rate for hemoptysis patients.However,recurrence of hemoptysis is still at high risk after BAE due to different underlying diseases.

Imaging evaluation of hemoptysis in children

Hemoptysis is an uncommon but distressing symptom in children. It poses a diagnostic challenge as it is difficult to elicit a clear history and perform thorough physical examination in a child. The cause of hemoptysis in children can vary with the child's age. It can range from infection, milk protein allergy and congenital heart disease in early childhood, to vasculitis, bronchial tumor and bronchiectasis in older children. Acute lower respiratory tract infections are the most common cause of pediatric hemoptysis. The objective of imaging is to identify the source of bleeding, underlying primary cause, and serve as a roadmap for invasive procedures. Hemoptysis originates primarily from the bronchial arteries. The imaging modalities available for the diagnostic evaluation of hemoptysis include chest radiography, multi-detector computed tomography(MDCT), magnetic resonance imaging(MRI) and catheter angiography. Chest radiography is the initial screening tool. It can help in lateralizing the bleeding with high degree of accuracy and can detect several parenchymal and pleural abnormalities. However, it may be normal in up to 30% cases. MDCT is a rapid, non-invasive multiplanar imaging modality. It aids in evaluation of hemoptysis by depiction of underlying disease, assessment of consequences of hemorrhage and provides panoramic view of the thoracic vasculature. The various structures which need to be assessed carefully include the pulmonary parenchyma, tracheobronchial tree, pulmonary arteries, bronchial arteries and non-bronchial systemic arteries. Since the use of MDCT entails radiation exposure, optimal low dose protocols should be used so as to keep radiation dose as low as reasonably achievable. MRI and catheter angiography have limited application.

Etiology and an Integrated Management of Severe Hemoptysis Due to Pulmonary Tuberculosis

Background: It is very important to enhance the therapeutic effect and prognosis of severe tuberculous hemoptysis after the determining of its etiological cause and the source of bleeding. The etiology and integrated curative effect of severe hemoptysis due to pulmonary tuberculosis among 112 inpatients were analyzed. Materials and Methods: The cause was retrospectively analysed. The integrated management effect after the follow-up of mean three years in 112 cases with severe hemoptysis being resulted from pulmonary tuberculosis from June 2008 to July 2012 was described. Active pulmonary tuberculosis ranked the first cause of lower respiratory tract bleeding (32/112, 28.5%), followed by old pulmonary tuberculosis (28/112, 25.0%), tuberculous bronchiectasis (25/112, 22.3%), purified tuberculous cavity (12/112, 10.7%), fungal infection in old pulmonary tuberculosis cavity (9/112, 7.1%), or broncholithiasis (6/112, 5.4%). Almost all suffers with severe hemoptysis were treated by an integrated management, including psychology, anticoagulants, vasoconstrictor agents. Etiological treatment including anti-tuberculosis and anti-infection was simultaneously or subsequently involved. Sixty-four inpatients with severe hemoptysis being failed to be cured by medical treatment were then received selective bronchial artery embolization. Four patients were received surgical wedge resection, lobectomy or pneumonectomy. The total cure rate added up to 98.2% after mean three years’ follow-up. The mortality was 1.8%. Conclusions: Active pulmonary tuberculosis was still responsible for the severe hemoptysis in the southeast region of China. Severe hemoptysis of pulmonary tuberculosis was also resulted from stable tuberculosis, tuberculous bronchiectasis, tuberculosis cavity, fungal infection, or broncholithiasis. Better clinical therapeutic effect could be attained by early etiological diagnosis and comprehensive treatment strategy.

380 CASES OF BRONCHIECTASIS WITH HEMOPTYSIS TREATED BY POINT-INJECTION

Hemoptysis,especially the massivehemoptysis caused by bronchiectasis is acommon,but emergent and critical diseases inclinic.Injection of Herba Houttuyniae extractinto Kongzui(LU 6)was performed to treathemoptysis according to the theory oftraditional Chinese medicine and the

Risk Factors for Hemoptysis in Pulmonary Tuberculosis Patients from Southern China: A Retrospective Study

Clinical characteristics of tuberculosis (TB) patients from southern China with pulmonary tuberculosis hemoptysis (PTH) were analyzed retrospectively in order to improve the diagnosis of TB, reduce mortality and prevent the transmission of TB. A total of 1227 cases of pulmonary TB patients hospitalized in the Third Affiliated Hospital of Sun Yat-sen University and Guangzhou Chest Hospital from January to December of 2011 were analyzed retrospectively. 1) The male/female ratio of the 1227 tuberculosis cases was 2.15:1. There were 403 cases (32.8%) of PTH with a male/ female ratio of 3.03:1. 2) The ratio of patients with PTH to those with TB was designated as Rh. The Rh in the male group (36.2%, 303 cases) was higher than that in the female group (25.6%, 100 cases, risk ratio (RR) = 1.41, P ≤ 0.001). 3) The Rh in the elderly group (≥60 years old, 20.3%, 56 cases) was lower than that in the younger patients group (20 - 39 years old, 45.4%, 189 cases, RR = 2.51, P ≤ 0.001). 4) The Rh in initial treatment group (29.6%, 296 cases) was lower than that in the retreatment group (46.9%, 107 cases, RR = 1.58, P ≤ 0.001). 5) The Rh in sputum-positive TB patients (44.5%, 297 cases) was significantly higher than that in the smear-negative TB patients (18.9%, 106 cases, RR = 2.35, P ≤ 0.001). 6) The Rh of patients with lung lesions range 0.05). 7) The Rh of patients with cavities (51.8%, 309 cases) was higher than that of patients without cavities (14.9%, 94 cases, RR = 3.48, P ≤ 0.001). Male, young, retreated, sputum-positive TB patients and those with cavitary TB were more predisposed to PTH in southern China. TB patients with such characteristics should be sensitized and accorded good care.

Hemoptysis secondary to pulmonary vein stenosis after radiofrequency ablation for atrial fibrillation: A case report and literature review

Objectives: Pulmonary vein stenosis(PVS) is a known complication after radiofrequency ablation of atrial fibrillation(RAAF) and is often misdiagnosed owing to lack of awareness regarding PVS among noncardiologists.Misdiagnosis results in unnecessary treatment;therefore, greater understanding of PVS can improve the management of these patients.Methods: We report the case of a 38-year-old man with a history of RAAF who presented with massive hemoptysis.His symptoms persisted despite undergoing transcatheter bronchial artery embolization on two occasions.Results: Pulmonary computed tomography angiography revealed a completely occluded left superior pulmonary vein. Considering the patient’s history of RAAF, we diagnosed him with RAAF-induced PVS and performed left superior lobectomy after which hemoptysis did not recur.Conclusions: Unexplained massive hemoptysis should alert clinicians regarding the possibility of RAAF-induced PVS. Balloon angioplasty and stent placement are used to treat PVS;however, their efficacy is controversial considering the high recurrence rates associated with these interventions.

Treatment for hemoptysis after percutaneous closure of a large intralobar pulmonary sequestration in elderly patient

Pulmonary sequestration is a rare congenital cardiovascular malformation.[1,2]Open surgical excision is the usual treatment,although thorascopic intervention and transcatheter embolization have been reported.However,only a limited number of articles involving percutaneous closure the rare pulmonary malformations have been published in the literature.[3]What’s more,previous studies involving percutaneous pulmonary sequestration closure with repeated respiratory symptoms at the very young age suggested that the optimal therapeutic strategy has yet to be determined.[4]We hereby describe a particular case of percutaneous closure of a large intralobar pulmonary sequestration at elderly age.

Pheochromocytoma with abdominal aortic aneurysm presenting as recurrent dyspnea,hemoptysis,and hypotension:A case report

BACKGROUND Pheochromocytomas are rare endocrine tumors with various clinical manifestations,and few of them might present with profound,life-threatening conditions.CASE SUMMARY We report the case of a 65-year-old man who complained of sudden dyspnea and hemoptysis for half a day.There was no obvious cause for the patient to have dyspnea,coughing,or coughing up to approximately 100 mL of fresh blood.Finally,he was diagnosed with pheochromocytoma crisis(PCC),coexisting with an abdominal aortic aneurysm(AAA).CONCLUSION We report a case of pheochromocytoma presenting with recurrent hemoptysis,dyspnea and hypotension coexisting with an AAA.It not only proved the uncommon manifestations of pheochromocytoma but also directed clinicians to consider PCC among the possible diagnoses when meeting similar cases.Moreover,surgical excision is the most beneficial method for the treatment of pheochromocytoma coexisting with AAA when the situation is stable.

Giant left ventricular pseudoaneurysm presenting with hemoptysis

Left ventricular (LV) pseudoaneurysm is a late mechanical complication of myocardial infarction (MI). A giant LV pseudoaneurysm is a rare presentation. We report a case of a giant LV pseudoaneurysm in a post MI patient, who presented with hemoptysis. Hemoptysis is a rare clinical presentation of LV pseudoaneurysm. The patient had successful surgical repair of the aneurysm and had a favorable outcome in 9 mo’ follow-up. The imaging modalities and surgical treatment of a pseudoaneurysm is discussed.

A Case of Thoracic Aortic Aneurysm with Hemoptysis as the First Symptom

This article reports a case of thoracic aortic aneurysm with hemoptysis as the first clinical manifestation, hemoptysis as the first clinical manifestation is very uncommon and to the best of our knowledge, only twenty of such cases have been previously reported. The case report presented here constitutes the longest course of the disease reported in medical literature, and good recovery after thoracic endovascular aortic repair, may help us to increase the understanding and diagnosis of the disease.

Hemoptysis developing soon after use of sildenafil:an observation on two cases

Dear Sir, Our group from Pamukkale University Hospital would like to present an observation on hemoptysis that was probably associated with sildenafil usage in two patients. Since hemoptysis occurred immediately the drug was taken and has not recurred following the discontinuation of the drug. We think that after eliminating other risk factors, sildenafil might be a probable cause of transient hemoptysis.

Recurrent Hemoptysis in a Young Man

Hughes-Stovin syndrome is a scarce entity associating pulmonary artery aneurysms and deep venous thrombosis. It was considered to be a form of Behcet’s syndrome at its initial feature. We present a case of a 27-year-old man having a Hughes-Stovin syndrome. The patient had a history of left ilio-femoral thrombosis and suffered from recurrent oral ulcers. He presented with recurrent hemoptysis. A giant pulmonary aneurysm was confirmed by chest CT scan. A right femoral thrombosis was shown on the inferior legs doppler ultrasonography. The patient was treated by steroids and cyclophosphamide and proposed to an embolization to prevent recurrence of symptoms.

The Role of Multislice Computed Angiography of the Bronchial Arteries before Arterial Embolization in Patients with Hemoptysis

Purpose: To evaluate the role of multislice computed angiography of the bronchial arteries and nonbronchial systemic arteries in patients with hemoptysis when performed before arterial embolization procedure. Materials and Methods: Twenty-eight patients with hemoptysis underwent multislice CT angiography of the bronchial arteries with dual-source 64 × 2 detector row scanner before embolization. The transverse CT images as well as the multiplanar reconstructions, the maximum intensity projections and the three-dimensional CT images were used for the depiction of bronchial arteries (the total number of the bronchial arteries, the abnormal bronchial arteries, their origin at the aorta and the diameter of the ostium). The presence of nonbronchial systemic arteries regarded as causing hemoptysis was also evaluated. Digital angiography and selective arteriograms of abnormal bronchial and nonbronchial systemic arteries were performed based on the findings of multislice computed tomography (MDCT). Results: Seventy-eight (40 right and 38 left) bronchial arteries were detected at computed angiography (CTA). Forty of the seventy-eight bronchial arteries that were detected at CTA, were considered abnormal. On selective angiography 38 of these bronchial arteries were regarded as causing hemoptysis. Two of these arteries could not be selectively catheterized and therefore could not be evaluated. All 38 bronchial arteries regarded as causing hemoptysis at selective angiography were detected prospectively at CTA as abnormal. Four bronchial arteries that were found to be responsible for hemoptysis had diameter <2 mm. Twelve nonbronchial systemic arteries were considered to be abnormal on CTA scans. Ten of these twelve nonbronchial systemic arteries were regarded on selective angiography as causing hemoptysis. Two of these arteries were found normal on angiography. All 10 nonbronchial arteries regarded as causing hemoptysis were detected at CTA scans. All bronchial and nonbronchial arteries causing hemoptysis were successfully embolized. Conclusion: MDCT angiography allows detailed identification of abnormal bronchial and nonbronchial systemic arteries using a variety of reformatted images, providing a precise road map for the interventional radiologist.

Curative effect of silybin combined with pituitrin-phentolamine for pulmonary tuberculosis complicated by acute hemoptysis

Objective: To study the curative effect of silybin combined with pituitrin-phentolamine for pulmonary tuberculosis complicated by acute hemoptysis. Methods: A total of 78 patients with pulmonary tuberculosis complicated by acute hemoptysis who were treated in this hospital between December 2013 and April 2017 were divided into control group (n=39) and silybin group (n=39) by random number table. Control group received pituitrin-phentolamine hemostasis therapy, silybin group received pituitrin-phentolamine combined with silybin therapy, both were treated for 1 week. The differences in peripheral blood liver function and coagulation index levels as well as serum oxidative stress index contents were compared between the two groups of patients before treatment and after 1 week of treatment. Results:Before treatment, the differences in peripheral blood liver function and coagulation index levels as well as serum oxidative stress index contents were not statistically significant between the two groups. After 1 week of treatment, peripheral blood liver function indexes ALT, AST, ALP and STB contents of silybin group were lower than those of control group;peripheral blood coagulation indexes PT, APTT and TT levels were lower than those of control group whereas Fib level was higher than that of control group;serum oxidative stress indexes AOPPs and LHP contents were lower than those of control group whereas GSH-Px and T-AOC contents were higher than those of control group. Conclusion: pituitrin-phentolamine combined with silybin therapy can effectively protect the liver function, optimize the coagulation function and reduce the oxidative stress response in patients with pulmonary tuberculosis complicated by acute hemoptysis.

Bronchial Artery Embolization for Hemoptysis： A Retrospective Observational Study of 344 Patients

Background：Hemoptysis is a significant clinical entity with high morbidity and potential mortality.Both medical management （in terms of resuscitation and bronchoscopic interventions） and surgery have severe limitations in these patients population.Bronchial artery embolization （BAE） represents the first-line treatment for hemoptysis.This article discusses clinical analysis,embolization approach,outcomes and complications of BAE for the treatment of hemoptysis.Methods：A retrospective analysis of 344 cases,who underwent bronchial arteriography at Tianjin Haihe Hospital between 2006 and 2013.Several aspects of outcome were analyzed：Demographics,clinical presentation,radiographic studies,results,complications and follow-up of BAE.Results：Three hundred and forty-four consecutive patients underwent bronchial arteriography,336 of 344 patients （97.7%） performed BAE; there were 1530 coils for 920 arteries embolized; the main responsible sources for bleeding were right bronchial artery （29.7%）,left bronchial artery （21.6%）,combined right and left bronchial trunk （18.4%）,right intercostal arteries （13.3%）; 61 patients （17.7%） had recurrent hemoptysis within 1 month after undergoing BAE,74 patients （21.5%） had recurrent hemoptysis over 1 month after undergoing BAE; The common complications of BAE included subintimal dissection,arterial perforation by a guide wire,fever,chest pain,dyspnea,etc.The follow-up was completed in 248 patients,28 patients had been dead,21 patients still bleed,92 patients had lost to follow-up.Conclusions：The technique of BAE is a relatively safe and effective method for controlling hemoptysis.The complications of BAE are rare.Although the long-term outcome in some patients is not good,BAE may be the only life-saving treatment option in patients who are poor surgical candidates.

Supplementary inferior phrenic artery embolization in the interventional treatment of hemoptysis

Background Transcatheter bronchial artery embolization （BAE） is widely used for the treatment of hemoptysis and the immediate success rate is high, but there are still some hemorrhage recurrences. One of the common reasons for failure of BAE is collateral branches as blood supply. The inferior phrenic artery （IPA） is one of the most common collateral branches that is scarcely reported. Our purpose was to observe manifestations of IPA supplying to hemoptysis and evaluate the efficacy and safety of IPA embolization. Methods Angiography during interventional treatment of 178 hemoptysis patients in the past 7 years confirmed that IPA hemorrhage resulted in hemoptysis in 25 patients （26-67 years old） who had： lung cancer （11 patients）, bronchiectasis （11 patients）, chronic lung inflammation （2 patients）, and pulmonary tuberculosis （1 patient）. Among the 25 patients, 7 patients had twice interventional operations within one week and 6 patients still experienced intraoperative hemoptysis after conventional embolization of the bronchial artery, the internal thoracic artery, and the intercostal artery, then had the second interventional operation immediately. The total number of cases were 191. Selective embolization of the IPA was performed using polyvinyl alcohol microspheres, gelatin sponge particles, and microcoil. The safety and clinical significance of IPA embolization were evaluated. The Pearson X2 test and Fisher＇s exact probability test were used in this study. Results Selective IPA angiography showed increased diameter of the IPA, disorganization of the branches, and varying degrees of angiogenesis. In 11 cases, contrast material was seen in vessels supplying the tumor and in the tumor. In 9 cases, contrast material had leaked into the area supplied by the IPA; in 8 cases, non-specific flake-like deposits of contrast material were seen; and in 14 cases, abnormal communication or shunt was visualized. Lesions were closely related to the pleura in 25 patients. Fifteen lesions were close to the diaphragmatic pleura, seven close to the mediastinal pleura, and three close to the lateral pleura of the lower lung. Eleven cases had inferior thoracic pleural thickening and adhesions. The IPA was embolized in 25 cases, and the success rate of hemostasis was 100%. The IPA was not embolized in the other 166 cases, and the success rate of hemostasis was 92.17 %. In the 25 cases with IPA embolization, the involvement of the IPA in the blood supply of the hemoptysis was correlated with the duration of the disease （P=0.0344）. The involvement of IPA in the blood supply of the hemoptysis was not correlated with the characteristic of the lung lesions （benign or malignant） （P=1.0000）. Duration of follow-up was 8 months to 5 years. Hemoptysis recurred in four patients 1,2, 3, and 6 months after interventional operation, respectively, and was controlled by conservative treatment. Twenty-one patients had no recurrence of hemoptysis. Conclusions Bleeding from the IPA can result in hemoptysis and failure of BAE in the treatment of hemoptysis. If IPA hemorrhage contributes to hemoptysis, supplementary IPA embolization may be a safe and effective treatment.

Massive hemoptysis and hemothorax： a rare but fatal complication of intralobar sequestration

Intralobar sequestration （ILS） is an uncommon abnormality that accounts for 75% of all pulmonary sequestrations. Over the years there have been several reports of various presenting signs of which hemoptysis was commonly described, however, massive hemoptysis and hemothorax is extremely rare in literature. We present a case of a 45-year-old man who died of fatal complication from an ILS. This case report shows an uncommon presentation of ILS with massive hemoptysis and hemothorax resulting in a dramatic course of disease and a fatal outcome, and for this reason in the absence of trauma or other causes for massive hemoptysis, hemothorax, or lung hematoma, this possibility should be kept in mind so as to avoid misdiagnosis, and resection of the sequestered tissue should be considered in all patients.

A Rare Cause of Recurrent Fatal Hemoptysis:Dieulafoy's Disease of the Bronchus

To the Editor:Dieulafoy's disease is characterized by the tortuous arteries of abnormally large caliber running within the submucosa, which is susceptible to ulceration and bleeding.This vascular abnormality usually occurs in the gastrointestinal tract.The involvement in the respiratory system is rare.Massive hemoptysis caused by Dieulafoy's disease of the bronchus is a life-threatening condition.An immediate and effective treatment is required in emergency to improve survival.Here,we report a patient who had such a vascular anomaly in bronchus and presented with recurrent massive hemoptysis.The patient signed information consent form.