AJR 2003; 180:523-525
© American Roentgen Ray Society
Nonbronchial Collateral Supply from the Hepatic Arteries of a Patient with Hemoptysis
Ho Jong Chun1,
Seung-Schik Yoo2,
Hak Hee Kim1,
Jae Young Byun1 and
Byung Gil Choi1
1 Department of Radiology, College of Medicine, The Catholic University of
Korea, 505 Banpo-Dong, Seocho-Ku, Seoul 137-040, Korea.
2 Department of Radiology, Brigham and Women's Hospital, Harvard Medical School,
Boston, MA 02115.
Received March 22, 2002;
accepted after revision May 31, 2002.
Address correspondence to B. G. Choi.
Introduction
Massive hemoptysis is defined as expectoration of more than 300 mL of blood
within 24 hr and can lead to death, mainly by asphyxiation
[1]. Transarterial
embolization, first introduced in 1974 by Remy et al.
[2], has been accepted widely
and has emerged as a possible alternative to surgical treatment in the
management of hemoptysis. Although the bronchial arteries are typically the
primary source of bleeding, nonbronchial systemic collateral arteries may also
contribute to hemoptysis. Various nonbronchial systemic collateral arteries
have been reported as being associated with hemoptysis
[3,4,5,6];
however, hepatic arteries have not been identified to our knowledge. We report
a case in which the nonbronchial collateral supply that originated from the
hepatic arteries led to hemoptysis.
Case Report
A 39-year-old man under conservative treatment at an outpatient clinic for
pneumonia of the lower lobe of the right lung presented to the emergency
department with hemoptysis. He had a history of liver cirrhosis, proven by a
liver biopsy performed 3 months earlier. On admission, he had stable vital
signs but was anemic, with a hemoglobin level of 9.7 g/dL and a hematocrit
value of 29.6%. A chest radiograph showed consolidation in the lower lobe of
the right lung. On CT of the thorax, a lobar consolidation with multiple air
bronchograms involved the right lower lobe
(Fig. 1A). He was referred for
angiography with transarterial embolization to be performed on the day after
admission.
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Fig. 1A. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Contrast-enhanced CT scan of chest shows consolidation with
multiple air bronchograms. Subtle amount of pleural effusion (arrows)
can be observed.
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Initially, the right fourth through eighth intercostal, internal mammary,
and inferior phrenic arteries were selected with a 5-French catheter
(Bronchial; Jungsung, Sungnam, Korea), and arteriography of these arteries was
then performed. On the arteriograms, the arteries were tortuously
hypertrophied, and hypervascular stains and intermittent arteriovenous shunts
were visible (Figs.
1B,1C,1D).
The arteries were catheterized more distally using a coaxial 3-French
microcatheter (Progreat; Terumo, Tokyo, Japan) and then embolized with 355- to
500-µm particles of polyvinyl alcohol (Contour; Boston Scientific, Cork,
Ireland). We also selected the celiac trunk using a 5-French Yashiro catheter
(Terumo, Tokyo, Japan) and obtained an arteriogram. Tortuous hypertrophy of
the hepatic arteries with possible secondary involvement of the cirrhotic
liver was evident; however, no signs of remnant nonbronchial systemic
collateral arteries were detected.
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Fig. 1B. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Selective arteriogram shows that right seventh intercostal artery
(arrows) is hypertrophied and reveals hypervascular stain and
arteriovenous shunt in base of right lower lobe.
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Fig. 1C. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Right renal arteriogram shows hypertrophied inferior phrenic
artery (arrows) arising from right renal artery. Hypervascular stain
and arteriovenous shunt are visible in base of right lower lobe.
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Fig. 1D. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Right subclavian arteriogram reveals that right internal mammary
artery (arrows) is also hypertrophied and depicts associated
hypervascular stain and arteriovenous shunt involving base of right lower
lobe.
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On day 14, hemoptysis recurred with several episodes of expectoration of
more than 100 mL of blood. The patient was immediately referred to the
angiography unit and underwent a second session of transarterial embolization.
The right eighth intercostal artery was recanalized, and the right bronchial
artery was observed to be moderately hypertrophied. These arteries were again
embolized using the same technique and materials as those used for the first
session.
On day 25, the patient had two episodes of hemoptysis, but the amount of
expectorated blood (<25 mL) was minor. The patient was referred for a third
session of transarterial embolization to prevent hemoptysis from recurring and
the patient's condition from deteriorating. The right lateral thoracic and
thoracodorsal arteries were tortuously hypertrophied, and hypervascular stains
and arteriovenous shunts were present. After these arteries were successfully
embolized, thoracic aortography was finally performed using a 5-French pigtail
catheter (Cook, Bloomington, IN) with the tip located just distal to the
origin of the left subclavian artery to exclude the presence of undetected
causal arteries. On the thoracic aortogram, a focal hypervascular stain was
noted in the base of the right lower lobe
(Fig. 1E). The hepatic arteries
from the celiac trunk supplied this lung lesion, which was confirmed on a
celiac arteriogram (Fig. 1F).
However, embolization of these arteries was not performed because of concern
that liver function would deteriorate. The patient underwent segmentectomy of
the base of the right lung on day 29.
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Fig. 1E. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Thoracic aortogram obtained after embolization of right lateral
thoracic and thoracodorsal arteries during third session of transarterial
embolization (23 days after initial embolization) shows focal hypervascular
lesion (arrows) involving base of right lower lobe. Image was
obtained during late arterial phase using anteroposterior projection and
injection of 40 mL of contrast medium at rate of 20 mL/sec.
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Fig. 1F. —39-year-old man with organizing pneumonia in lower lobe of
right lung. Selective hepatic arteriogram shows that hypervascular lesion
(arrows) of right lower lobe is mainly supplied by nonbronchial
systemic collaterals originating from hepatic arteries.
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During the operation, a yellowish consolidation was grossly observed in the
right lower lobe, along with moderate pleural adhesion. On histologic
examination, the lesion was mainly composed of acute and chronic inflamatory
cells with aggregates of foamy histiocytes. The foreign body reaction,
suggesting organizing pneumonia, was evident. The patient was discharged 20
days after surgery with no additional episodes of hemoptysis.
Discussion
Nonbronchial systemic collateral arteries are commonly found during
transarterial embolization in patients with hemoptysis. These arteries may
cause recurrent bleeding in patients who have previously undergone
embolization of the bronchial arteries
[7,
8]. In particular, basal lung
diseases may be frequently associated with nonthoracic systemic arteries
originating below the diaphragm. The inferior phrenic artery is the most
common abdominal branch that contributes to hemoptysis
[3], and a few abdominal
branches, including the left gastric artery, have been reported to be
associated with hemoptysis
[4].
In our patient, a nonbronchial systemic collateral supply from the hepatic
arteries, contributing to the hemoptysis, was observed. Initially, the hepatic
arteries did not appear to provide collateral supply. However, after two
sessions of transarterial embolization, the hepatic arteries evolved to supply
the basal lung lesions. We believe that the basal lung lesions, proven as
organizing pneumonia, were hypervascular and were initially supplied by the
arteries embolized during the first two sessions of transarterial
embolization. After the complete embolization of the major causal arteries,
the hepatic arteries might have been recruited for supplying the hypervascular
lung lesion. In this process, potential transpleural and transdiaphragmatic
pathways might have been established that were further facilitated by pleural
adhesion.
We found that thoracic aortography provided crucial evidence about the
presence of the nonbronchial collateral supply from the hepatic arteries.
Because the infradiaphragmatic systemic collateral arteries may supply blood
to diseased basal lung tissue, the value of probing these arteries is
apparent. However, the location and type of nonbronchial systemic collateral
arteries originating below the diaphragm vary widely; therefore,
identification would require a timeconsuming, exhaustive search. Thoracic
aortography, in this context, enables visualization of the arteries of
interest.
In conclusion, although extremely infrequent, hepatic arteries, when
associated with basal lung disease, can potentially contribute to hemoptysis.
We also found that thoracic aortography after embolization was useful in
monitoring the effectiveness of embolization.
References
- Crocco JA, Rooney JJ, Fankushen DS, DiBenedetto RJ, Lyons HA.
Massive hemoptysis. Arch Intern Med
1968;121:495
-498[Abstract/Free Full Text]
- Remy J, Voisin C, Dupuis C, et al. Treatment of hemoptysis by
embolization of the systemic circulation (in French). Ann Radiol
(Paris) 1974;17:5
-16
- Phillips S, Ruttley MS. Bronchial artery embolization: the
importance of preliminary thoracic aortography. Clin
Radiol 2000;55:317
-319[Medline]
- Sellars N, Belli AM. Non-bronchial collateral supply from the left
gastric artery in massive haemoptysis. Eur Radiol
2001;11:76
-79[Medline]
- Vujic I, Pyle R, Parker E, Mithoefer J. Control of massive
hemoptysis by embolization of intercostal arteries.
Radiology
1980;137:617
-620[Abstract/Free Full Text]
- Jardin M, Remy J. Control of hemoptysis: systemic angiography and
anastomoses of the internal mammary artery. Radiology
1988;168:377
-383[Abstract/Free Full Text]
- Vujic I, Pyle R, Hungerford GD, Griffin CN. Angiography and
therapeutic blockade in the control of hemoptysis: the importance of
nonbronchial systemic arteries. Radiology
1982;143:19
-23[Free Full Text]
- Keller FS, Rosch J, Loflin TG, Nath PH, McElvein RB. Nonbronchial
systemic collateral arteries: significance in percutaneous embolotherapy for
hemoptysis. Radiology
1987;164:687
-692[Abstract/Free Full Text]
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