AJR 2002; 179:113-114
© American Roentgen Ray Society
Treatment of Massive Hemoptysis with Intraarterial Thrombin Injection of a Bronchial Artery
Thomas Vrachliotis1 and
Robert G. Sheiman
1 Both authors: Department of Radiology, Beth Israel Deaconess Medical Center
and Harvard Medical School, 330 Brookline Ave., Boston, MA 02215.
Received December 4, 2001;
accepted after revision December 28, 2001.
Address correspondence to R. G. Sheiman.
Introduction
Embolotherapy is an important treatment option for patients with massive
hemoptysis. The materials most frequently used for bronchial artery
embolization include polyvinyl alcohol particles, Gelfoam (Upjohn, Kalamazoo,
MI), and coils [1]. Safe
delivery of the embolic material is of paramount importance to avoid
off-target embolization. We describe a case of successful bronchial artery
embolization using intraarterial thrombin mixed with nonionic contrast
material in a patient with massive hemoptysis. This technique was used because
the anatomy of the targeted bronchial artery precluded sufficient vessel
engagement for safe deployment of conventional embolic material.
Case Report
A 52-year-old woman with a history of Hodgkin's lymphoma was transferred to
our institution with massive hemoptysis. She had undergone radiation therapy
30 years previously for lymphoma, which was complicated by pulmonary fibrosis,
bronchiectasis, and pulmonary hypertension. Bronchoscopy was performed and
revealed active bleeding from the right upper lobe bronchus. Bronchial artery
embolization was requested. An arch aortogram obtained via the right femoral
approach revealed two right bronchial arteries. The most cephalad of the two
bronchial arteries was selected using a 5-French Mikaelson catheter (Cook,
Bloomington, IN). Contrast material injection revealed active extravasation
into the pleural space and the right upper lobe bronchus with no visualization
of the artery of Adamkiewicz. Acute angulation caused by the S-shape of the
selected bronchial artery (Fig.
1A) precluded advancement of the catheter beyond the ostium.
Multiple additional 5-and 4-French catheters were tried; although the
bronchial artery ostium could be repeatedly cannulated, sufficient purchase
for mechanical embolic therapy could not be achieved. A coaxial system that
included a Fastracker catheter and 0.016-inch guidewire (Headliner; Target
Therapeutics, Freemont, CA) also failed to navigate the acute angle of the
target vessel to achieve sufficient purchase. Therefore, neither Gelfoam nor
coil embolization was believed safe to use in this patient, because of the
risk of nontarget embolization. Additionally, the extent of extravasation
caused us to believe that polyvinyl alcohol particles, embospheres (Biosphere
Medical, Rockland, MA) and a Gelfoam slurry would likely be deposited into the
pleural space and bronchi with little effect on the bleeding vessel. Absolute
alcohol was also considered but was believed to be contraindicated because of
the potential deleterious effects if it were to be extravasated onto the
bronchial epithelium and pleural space.
View larger version (117K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1A. —52-year-old woman with history of Hodgkin's lymphoma. Digital
subtraction image of selective injection of right bronchial artery (open
arrow) reveals extravasation into pleura (straight arrows).
Curved arrow shows acute angulation of bronchial artery origin. Active
extravasation into right bronchus was also observed fluoroscopically.
|
|
Because a test injection of contrast material via the Fastracker catheter
at approximately 1 mL/sec failed to show reflux into the aorta and because we
had excluded the use of conventional embolic material, we elected to perform
embolization using topical thrombin. Our experience with thrombin for the
treatment of femoral pseudoaneurysms showed that clot formation from thrombin
is almost immediate and occurs on contact with moving blood. We believed,
therefore, that thrombus formation would be prompt and occur at or just beyond
our catheter tip. Hence, 1000 U of topical thrombin (Thrombin-JMI; Jones
Medical, St. Louis, MO) were reconstituted in 1 mL of normal saline. This
solution was then added to 4 mL of nonionic contrast material (Optiray 320
[ioversol]; Mallinckrodt, St. Louis, MO) and observed for 30 sec to ensure
that no precipitation of the thrombin occurred. Subsequently, the
thrombin—contrast agent mixture was injected via the Fastracker catheter
at 0.5 mL/sec under real-time fluoroscopic guidance. Complete cessation of
flow occurred after administration of 1000 U. A diagnostic hand injection of
contrast material (Fig. 1B)
showed complete absence of antegrade flow within the targeted bronchial artery
and no extravasation of free contrast material. The second right bronchial
artery was then selected with diagnostic angiography; no extravasation from
this vessel and its branches was seen. The patient was transferred to the
intensive care unit in stable condition and had an uncomplicated hospital
course. She has had no rebleeding as of 6 months after the procedure.
View larger version (124K):
[in this window]
[in a new window]
[as a PowerPoint slide]
|
Fig. 1B. —52-year-old woman with history of Hodgkin's lymphoma.
Fluoroscopic image obtained after selective thrombin injection shows
radiopaque thrombin-induced thrombus fills bronchial artery (arrow).
No forward flow or active extravasation was observed.
|
|
Discussion
Direct percutaneous thrombin injection was first suggested for treatment of
visceral and extremity pseudoaneurysms in 1986
[2]. Recently, the successful
percutaneous treatment of iatrogenic femoral
[3,4,5,6]
and nonfemoral [7,
8] pseudoaneurysms with
thrombin has renewed interest in direct thrombin injection.
Massive hemoptysis usually results from erosion into bronchial arteries
from an adjacent disease process, and embolotherapy to control bleeding has
been a well-established treatment option
[1]. Embolic materials that are
commonly used include polyvinyl alcohol particles, Gelfoam pledgets, and coils
in rare cases of massive bleeding. In our patient, in whom active bleeding
could be observed fluoroscopically, coil embolization was the initial
consideration. However, the tortuous course of the bronchial artery precluded
the use of coils because coil migration into the aorta was likely. Similarly,
we thought migration was also possible with Gelfoam pledgets. Additionally,
because of the extensive contrast material extravasation into the right upper
lobe bronchus and pleural space in our patient, particle embolization, Gelfoam
slurry, and absolute alcohol were anticipated to be ineffective embolic
agents, with the potential to cause complications. Given the critical and
continuously deteriorating condition of our patient, we believed thrombin was
the optimal choice because of the extensive experience with topical thrombin
at our institution for treatment of femoral pseudoaneurysms and the need for a
liquid embolic agent as the result of poor catheter purchase. Review of the
diagnostic arteriogram had not disclosed the artery of Adamkiewicz, and hand
injection of contrast material at 1 mL/sec showed catheter stability; both
criteria were necessary before we could decide to proceed with thrombin.
Thrombin dissolved in normal saline is radiolucent; therefore, reconstituted
thrombin mixed with iodinated contrast material in a 1:4 ratio allows
monitoring of its intraarterial administration. Although the procedure has not
been formally described, we had previously mixed topical thrombin with
iodinated contrast material and observed continued solubility and no gross
precipitation. Nevertheless, before intraarterial injection, we recommend
observation of a thrombin—iodinated contrast agent mixture for at least
30 sec, as we did in this case.
The major concerns during administration of thrombin are nontarget
embolization and an adverse immunologic response. Cope and Zeit
[2] reported one case of
angiographically proven embolism to profunda femoris branches without clinical
sequelae. Loss of the Doppler signal from the dorsalis pedis after
sonographically guided percutaneous thrombin injection in a femoral artery
pseudoaneurysm has also recently been reported
[3]. However, the Doppler
sonography signal returned with no specific treatment and without clinical
sequelae [3]. Opacification of
thrombin with iodinated contrast material appears to allow controlled
injection under fluoroscopy and thus, we believe, minimizes the possibility of
nontargeted embolization when administered via an intraarterial route.
Immunologically, it has been reported that 10% of patients exposed to
topical thrombin developed antibodies against bovine thrombin and other
coagulation factors [9]. The
authors of that report also found that patients with repeated thrombin
exposure were eight times more likely to develop antibodies to coagulation
factors. Clinically, this reaction can manifest as bleeding complications
necessitating plasmapheresis. To our knowledge, no study on the use of
thrombin to treat pseudoaneurysms has documented hemorrhagic complications.
Although intraarterial thrombin represents a new and different route of
administration, we must assume this concern is applicable. Thus, as was done
in this case, we routinely inform the patient or family members (or both) and
the referring physician of this potential risk whenever topical thrombin is
used.
Encouraging results have been reported for the percutaneous treatment of
femoral artery pseudoaneurysms with topical thrombin
[3,
4,
6]. Application has expanded to
the percutaneous treatment of pseudoaneurysms in other locations as well. To
date, we are unaware of any reports in which topical thrombin has been mixed
with iodinated contrast material and administered under fluoroscopic guidance
via an intraarterial route. We believe that topical thrombin mixed with
iodinated contrast material can be an effective and safely administered
intravascular embolic material in carefully selected patients, especially
those for whom mechanical embolization is believed to be contraindicated for
technical reasons.
References
-
Valji K. Pulmonary and bronchial arteries. In: Valji K, ed.
Vascular and interventional radiology. Philadelphia:
Saunders, 1999:259
-282
-
Cope C, Zeit R. Coagulation of aneurysms by direct percutaneous
thrombin injection AJR
1986;147:383
-387[Abstract/Free Full Text]
-
Pezzullo JA, Dupuy DE, Cronan JJ. Percutaneous injection of
thrombin for the treatment of pseudoaneurysms after catheterization: an
alternative to sonographically guided compression. AJR
2000;175:1035
-1040[Abstract/Free Full Text]
-
Liau CS, Ho FM, Chen MF, Lee YT. Treatment of iatrogenic femoral
artery pseudoaneurysm with percutaneous thrombin injection. J Vasc
Surg 1997;26:18
-23[Medline]
-
Kang SS, Labropoulos N, Mansour MA, Baker WH. Percutaneous
ultrasound guided thrombin injection: a new method for treating
post-catheterization femoral aneurysms. J Vasc Surg
1998;27:1032
-1038[Medline]
-
Sheiman RG, Brophy DP. Treatment of iatrogenic femoral
pseudoaneurysms with percutaneous thrombin injection: experience in 54
patients. Radiology
2001;219:123
-127[Abstract/Free Full Text]
-
Partap VA, Cassoff J, Glikstein R. US-guided percutaneous thrombin
injection: a new method of repair of superficial temporal artery
pseudoaneurysm. J Vasc Interv Radiol
2000;11:461
-463[Medline]
-
Araoz PA, Andrews JC. Direct percutaneous embolization of visceral
artery aneurysms: techniques and pitfalls. J Vasc Interv
Radiol 2000;11:1195
-1200[Medline]
-
Dorion RP, Hamati HF, Landis B, Frey C, Heydt D, Carey D. Risk and
clinical significance of developing antibodies induced by topical thrombin
preparations. Arch Pathol Lab Med
1998;122:887
-894[Medline]
CiteULike 
Complore 
Connotea 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
Top
Introduction
Case Report
