Original Research
Vascular and Interventional Radiology
November 23, 2012

Pulmonary Artery Occlusion With Ethylene Vinyl Alcohol Copolymer in Patients With Hemoptysis: Initial Experience in 12 Cases

Abstract

OBJECTIVE. The purpose of this study was to evaluate the feasibility and efficacy of pulmonary artery occlusion with ethylene vinyl alcohol copolymer in patients with hemoptysis.
MATERIALS AND METHODS. We reviewed the cases of 12 consecutively registered patients (10 men, two women; age range, 21–83 years; mean, 54.5 years) who were treated for hemoptysis by pulmonary artery occlusion with ethylene vinyl alcohol copolymer. The indications, immediate hemoptysis control, and clinical tolerability were analyzed.
RESULTS. The underlying diseases were necrotizing pneumonia in four patients, necrotizing aspergillosis in one patient, complex aspergilloma in two patients, active tuberculosis in two patients, lung cancer in two patients, and Behçet disease in one patient. Ethylene vinyl alcohol copolymer was used alone in nine patients and with steel coils in three patients. The main indications were a small-necked pulmonary artery pseudoaneurysm in five patients, necrotic process in four patients, presence of systemic reperfusion of a pulmonary artery pseudoaneurysm in one patient, absolute necessity for anticoagulation therapy in one patient, and need to complete pulmonary artery aneurysm sac occlusion in one patient. The injection procedure was well tolerated. Hemoptysis of pulmonary arterial origin was controlled in all but one patient, who had progression of the infectious disease and underwent surgery. In two patients, hemoptysis recurred from systemic arteries and was treated with embolization of the systemic arteries in one patient and surgery in the other patient.
CONCLUSION. Ethylene vinyl alcohol copolymer embolization for hemoptysis of pulmonary arterial origin is feasible and efficacious. Use of this embolization agent is beneficial in patients with pulmonary artery injuries, especially those with small-necked lesions.
Erosion of the pulmonary artery is the source of life-threatening hemoptysis in less than 10% of patients with hemoptysis and requires specific and prompt treatment. Trans catheter pulmonary artery occlusion is considered the first line of treatment. Steel or platinum coils are usually used for selective occlusion of the pulmonary artery in patients with hemoptysis of pulmonary artery origin [1, 2]. Liquid agents (alcohol, N-butylcyanoacrylate) have been used successfully in patients with pulmonary artery aneurysm or pseudoaneurysm. These agents, however, require rapid delivery, which can be the origin of nontarget collateral embolization. Ethylene vinyl alcohol copolymer (Onyx, Microtherapeutics) has been widely used as a liquid embolic material for the treatment of intracranial aneurysms, especially wide-necked saccular aneurysms [3] and cerebral arteriovenous malformations [4]. It has also been used as a complement to coils for managing visceral artery aneurysms, peripheral arteriovenous malformations, and pulmonary arteriovenous malformations [5, 6]. We previously reported on our experience with 15 consecutively treated patients who underwent ethylene vinyl alcohol copolymer treatment of hemoptysis of systemic origin [7]. To our knowledge, the use of this agent to occlude the pulmonary artery involved in hemoptysis has not been reported. In this study, we evaluated our preliminary experience with ethylene vinyl alcohol copolymer for pulmonary artery occlusion in patients with hemoptysis of pulmonary artery origin.

Materials and Methods

We reviewed the clinical charts of 12 consecutively registered patients (10 men, two women; age range, 21–83 years; mean, 54.5 years) referred to our radiology referral center for hemoptysis over the 4-year period April 2006–May 2010. Ethylene vinyl alcohol copolymer (Onyx, Microtherapeutics) was used for endovascular control of hemoptysis of pulmonary artery origin.
Chest MDCT angiography (MDCTA) was used to evaluate hemoptysis in every case. MDCTA evaluation of systemic (bronchial and nonbronchial) and pulmonary vascularization was performed with a 16-MDCT scanner, as previously detailed [8]. Neither institutional review board approval nor patient consent was required for this retrospective study. Our institution does not require review board approval for retrospective studies.
Embolization with ethylene vinyl alcohol co polymer was performed during the entire period either by two radiologists (25 and 15 years of experience in embolization) or in their presence. All patients underwent conventional angiography by digital subtraction technique (Multistar, Siemens Healthcare). In the MDCTA data, the pulmonary artery to be occluded was identified, and endovascular treatment by a pulmonary artery approach through a femoral vein was started. A 7.0-French sheath was placed in the right femoral vein in 11 patients and the right internal jugular vein in one patient. A 7.0/5.0-French guiding catheter (Lumax, Cook Medical) was passed through the sheath to reach the right cardiac cavities, pulmonary artery trunk, and the segmental or subsegmental pulmonary artery causing the bleeding. A triaxial microcatheter then was inserted for delivery of the embolization agent.

Procedural Technique With Ethylene Vinyl Alcohol Copolymer

The embolization agent used (Onyx) is a liquid embolic material designed for endovascular use. It is an ethylene vinyl alcohol copolymer dissolved in the organic solvent dimethylsulfoxide. When it comes into contact with an aqueous solution, the embolization material precipitates and forms a soft spongy polymer cast, initially with an outer layer, with a semiliquid center. The agent is supplied in ready-to-use vials; each vial contains ethylene vinyl alcohol polymer, dimethylsulfoxide, and tantalum powder for opacity.
TABLE 1: Summary of Findings
The technique first involved placement of a highly compliant dimethylsulfoxide-compatible microcatheter. Once the catheter was properly positioned, its dead space was filled with 0.3 mL of the solvent dimethylsulfoxide, which prevented precipitation of the liquid polymer in the lumen of the delivery catheter. Ethylene vinyl alcohol copolymer (high density [HD] 18 or 34) was introduced into the microcatheter. Once a sufficient volume (usually 0.3 mL) was injected, the agent approached the end of the microcatheter. To avoid vasospasm, the injection rate was 0.16 mL/min for the first minute. The injection rate was increased without exceeding the recommended rate of 0.3 mL/min. A 2.4-French microcatheter (Progreat, Terumo Europe) was used for all procedures.

Data Analysis

We recorded whether ethylene vinyl alcohol copolymer was used as the first embolization procedure or was used for persistent hemoptysis or rebleeding after a previous embolization. For each situation we recorded the type of material used in association with ethylene vinyl alcohol copolymer for occlusion of the targeted pulmonary artery. The tolerance and embolization results were recorded. The embolization results were assessed as good occlusion when hemoptysis did not recur during hospitalization in the ICU.

Results

Table 1 shows the severity and cause of hemoptysis. During the study period, we treated 320 patients for hemoptysis of systemic artery origin and 27 patients for hemoptysis of pulmonary artery origin, 12 (44.4%) of them with ethylene vinyl alcohol copolymer. In these 12 patients, the underlying diseases were necrotizing pneumonia in four patients, necrotizing aspergillosis in one patient, complex aspergilloma in two patients, active tuberculosis in two patients (Rasmussen aneurysm), lung cancer in two patients, and Behçet disease in one patient.
The anatomic lesions were pulmonary artery pseudoaneurysm in nine patients, irregular pulmonary artery in the inner aspect of the necrosis in two patients, and a pulmonary artery aneurysm in one patient (Table 1). The indications for using a liquid material for embolization were selective occlusion of a small neck of the pulmonary artery pseudoaneurysm and lack of safety of vasoocclusion with coils (Figs. 1A, 1B, 1C, 1D, and 1E) in five patients (numbers 3, 7, 9, 10, 11); necrotic process necessitating occlusion of the aneurysm sac lumen and the afferent and efferent part of the feeding artery for lateral pseudoaneurysms in four patients (numbers 1, 2, 4, 5); systemic irrigation of the pulmonary artery pseudoaneurysm in one patient (number 8); the absolute necessity for anticoagulation therapy for a heart valve in one patient (number 6); and safe, complete vasoocclusion of the aneurysm in one patient with Behçet disease (number 12). Treatment of patient 8 entailed a simultaneous approach to the systemic and pulmonary arteries (Figs. 2A, 2B, 2C, 2D, and 2E), but occlusion of the aneurysmal sac with satisfactory propagation of the liquid made the systemic embolization unnecessary. In the care of patient 6, occlusion by coils would have required formation of a clot, which would have been altered by anticoagulation therapy; we chose ethylene vinyl alcohol copolymer because its mechanism of occlusion does not involve formation of a clot.
Fig. 1A 52-year-old man (patient 3) admitted to ICU after cardiorespiratory arrest secondary to massive hemoptysis that persisted despite two sessions of bronchial angiography and embolization.
A, MDCT angiogram shows right lower lobe condensation and necrotic cavity (arrowheads) and posterobasal right lobe pseudoaneurysm (arrow).
Fig. 1B 52-year-old man (patient 3) admitted to ICU after cardiorespiratory arrest secondary to massive hemoptysis that persisted despite two sessions of bronchial angiography and embolization.
B, Right lower lobe pulmonary angiogram shows aneurysm (arrow) developing on posterobasal subsegmental artery.
Fig. 1C 52-year-old man (patient 3) admitted to ICU after cardiorespiratory arrest secondary to massive hemoptysis that persisted despite two sessions of bronchial angiography and embolization.
C, Superselective angiogram obtained after microcatheterization of subsegmental artery of right lower lobe shows aneurysm (arrow) with probable distal pulmonary artery (arrowheads).
Fig. 1D 52-year-old man (patient 3) admitted to ICU after cardiorespiratory arrest secondary to massive hemoptysis that persisted despite two sessions of bronchial angiography and embolization.
D, Control angiogram obtained after ethylene vinyl alcohol copolymer administration shows good contrast of copolymer agent and progression of agent within distal pulmonary artery (arrowheads).
Fig. 1E 52-year-old man (patient 3) admitted to ICU after cardiorespiratory arrest secondary to massive hemoptysis that persisted despite two sessions of bronchial angiography and embolization.
E, Control angiogram shows good occlusion of aneurysm. No recurrence of hemoptysis was observed. Patient died 1 week later of multiorgan failure.
Progression of the liquid was satisfactory in all patients. Because there were no catheterization problems in five patients, the dead space of the microcatheter was prefilled with ethylene vinyl alcohol copolymer before the microcatheter was inserted while the patient was on the operating table. The microcatheter was introduced through the 5-French catheter to deliver the agent directly without washing of the microcatheter with dimethylsulfoxide. The occlusion procedure was clinically uneventful in all patients.
Hemoptysis was controlled during hospitalization in all but two patients (numbers 4 and 6) (Table 2). Progression of the infectious disease led to the development of a pulmonary artery pseudoaneurysm in patient 4. Treatment was emergency surgery for the diagnosis and control of hemoptysis, and the final diagnosis was necrotizing pneumonia secondary to Escherichia coli infection. After occlusion of the subsegmental artery in patient 6, hemoptysis recurred in 1 week, and the bronchial arteries were treated. During hospitalization, two patients (numbers 3 and 11) died of multiorgan failure without recurrence of hemoptysis. Hemoptysis recurred 3 months after initial treatment in patient 1 and 8 months after treatment in patient 6. The recurrence was due to systemic hypervascularization related to the presence of ethylene vinyl alcohol copolymer in the necrotic area of the lung and sequelae of pneumonia in patient 1 and to the persistence of chronic infectious disease related to complex aspergilloma in patient 6. Both patients were treated by bronchial artery embolization for the first recurrence. The second recurrence of hemoptysis was uncontrolled in both patients and required emergency surgery.
Fig. 2A 69-year-old man (patient 8) admitted to ICU because of massive hemoptysis of more than 1000 mL. Pretreatment MDCT angiography was performed. Diagnosis was pulmonary tuberculosis.
A, Oblique coronal reformatted image shows pulmonary artery pseudoaneurysm (arrow) surrounded by lung necrosis (arrowheads) within lower segment of lingula.
Fig. 2B 69-year-old man (patient 8) admitted to ICU because of massive hemoptysis of more than 1000 mL. Pretreatment MDCT angiography was performed. Diagnosis was pulmonary tuberculosis.
B, Angiogram of lower segment of left pulmonary artery (A5) shows interruption of pulmonary artery (arrow) but does not show pulmonary artery pseudoaneurysm.
Fig. 2C 69-year-old man (patient 8) admitted to ICU because of massive hemoptysis of more than 1000 mL. Pretreatment MDCT angiography was performed. Diagnosis was pulmonary tuberculosis.
C, Angiogram with catheter in more distal position clearly shows pulmonary artery pseudoaneurysm (arrowheads) surrounded by contrast medium within necrotic area. Lack of finding in B is related to systemic vascularization through bronchial arteries.
Fig. 2D 69-year-old man (patient 8) admitted to ICU because of massive hemoptysis of more than 1000 mL. Pretreatment MDCT angiography was performed. Diagnosis was pulmonary tuberculosis.
D, Control angiogram after delivery of ethylene vinyl alcohol copolymer shows pulmonary artery pseudoaneurysm (arrows) with cast through collaterals (arrowheads).
Fig. 2E 69-year-old man (patient 8) admitted to ICU because of massive hemoptysis of more than 1000 mL. Pretreatment MDCT angiography was performed. Diagnosis was pulmonary tuberculosis.
E, Unenhanced oblique frontal MDCT image obtained immediately after endovascular treatment shows ethylene vinyl alcohol copolymer in pulmonary artery pseudoaneurysm (arrow) and enhancement of necrotic process (arrowheads) related to extravasation of contrast medium during treatment. Final diagnosis was active pulmonary tuberculosis complicated by Rasmussen aneurysm. Treatment of tuberculosis was started; hemoptysis did not recur during 4-month follow-up period.

Discussion

Less than 10% of hemoptysis is of pulmonary artery origin. The systemic arteries are involved in the other 90% of cases [9, 10]. In some cases, however, both systemic and pulmonary arteries can be the source of hemorrhage. The underlying diseases of patients with hemoptysis of pulmonary arterial origin are categorized into three groups. The first group consists of infective diseases such as active tuberculosis (Rasmussen aneurysms), aspergillosis, and necrotizing pneumonia. The second group is pulmonary artery erosion by necrotic tumor processes, and the third group is vasculitis associated with pulmonary artery aneurysm disease, especially Behçet disease and Hughes-Stovin syndrome. The other causes are much rarer than these three groups and include the aftermath of Swan-Ganz catheter placement in adults [11] and rupture of a pulmonary arteriovenous malformation [12].
TABLE 2: Hemoptysis Control
Pulmonary artery occlusion for control of hemoptysis must follow two rules. First, the presence of an irregular pulmonary artery feeding the pseudoaneurysm in necrotic tissue has to be respected during occlusion with coils or other material with radial forces, such as Amplatzer plugs. This artery has a fragile wall, and the deployment of material with a radial force within the irregular pulmonary artery can rupture the artery and cause massive hemoptysis. We have found this complication during deployment of a steel coil for occlusion of a pseudoaneurysm of a segmental pulmonary artery in a necrotic tumor. Hemoptysis was immediately stopped by deployment of other coils more proximally in the feeding artery, so patients treated before 2006 are not described here. For the use of coils, occlusion must be proximal to the irregular pulmonary artery.
The second rule is that the blood irrigating a pulmonary artery pseudoaneurysm or pulmonary artery aneurysm can come not only from the pulmonary artery but also from systemic arteries. Even pulmonary artery pseudoaneurysm reperfusion can occur through systemic arteries and other pulmonary artery branches. Double bleeding sources (systemic and pulmonary arteries) can be strongly suspected when MDCTA shows, in addition to the pulmonary artery pseudoaneurysm, enlargement of the systemic arteries [8]. In the case of occlusion of both arteries, vascularization is mandatory to avoid reperfusion and recurrence of hemoptysis. Use of ethylene vinyl alcohol copolymer and propagation of the cast within the pseudoaneurysmal sac and through it in other feeding arteries can prevent the systemic artery embolization that occurred in one patient.
In this preliminary study, the use of ethylene vinyl alcohol copolymer as an embolic material in embolization of pulmonary arteries was safe and effective and had no side effects. No patient had the thoracic pain and hypertension that occurred when we used ethylene vinyl alcohol copolymer in bronchial arteries [7]. The absence of this major side effect of the embolization agent is probably due to the difference in histologic features of the pulmonary and systemic arteries. No reperfusion was found in any patient. In one patient, however, the presence of ethylene vinyl alcohol copolymer outside the vessel was a factor in the development of systemic hypervascularization and recurrence of bleeding in association with the sequelae of pneumonia.
Ethylene vinyl alcohol copolymer may be an attractive alternative to the usual embolic agents in the treatment of patients with hemoptysis. Use of this liquid embolic system may improve absolute occlusion of vessels, especially in patients who need anticoagulation and have vessels that are difficult to catheterize.
The major limitation to using ethylene vinyl alcohol copolymer routinely in the treatment of patients with hemoptysis is the need to prepare the material 15 minutes before use. At our institution, if use of this material is being considered, especially to treat patients with hemoptysis of pulmonary arterial origin, the preparation is started at the beginning of the procedure. Another limitation is the price of the product.

Conclusion

Ethylene vinyl alcohol copolymer appears to be helpful for treating patients with small-necked pulmonary artery pseudoaneurysms, pseudoaneurysms associated with necrosis, and pseudoaneurysms with a fragile wall. Further studies are necessary to determine the indications and limitations of the use of this agent for liquid embolization in patients with hemoptysis.

References

1.
Khalil A, Parrot A, Fartoukh M, Marsault C, Carette MF. Large pulmonary artery aneurysm rupture in Hughes-Stovin syndrome: multidetector computed tomography pattern and endovascular treatment. Circulation 2006; 114:e380–e381
2.
Picard C, Parrot A, Boussaud V, et al. Massive hemoptysis due to Rasmussen aneurysm: detection with helicoidal CT angiography and successful steel coil embolization. Intensive Care Med 2003; 29:1837–1839
3.
Molyneux AJ, Cekirge S, Saatci I, Gál G. Cerebral Aneurysm Multicenter European Onyx (CAMEO) trial: results of a prospective observational study in 20 European centers. AJNR 2004; 2:39–51
4.
Van Rooij WJ, Sluzewski M, Beute GN. Brain AVM embolization with Onyx. AJNR 2007; 28:172–177
5.
Bratby MJ, Lehmann ED, Bottomley J, et al. Endovascular embolization of visceral artery aneurysms with ethylene-vinyl alcohol (Onyx): a case series. Cardiovasc Intervent Radiol 2006; 29:1125–1128
6.
Castaneda F, Goodwin SC, Swischuk JL, et al. Treatment of pelvic arteriovenous malformations with ethylene vinyl alcohol copolymer (Onyx). J Vasc Interv Radiol 2002; 13:513–516
7.
Khalil A, Fartoukh M, Bazot M, Parrot A, Marsault C, Carette MF. Systemic arterial embolization in patients with hemoptysis: initial experience with ethylene vinyl alcohol copolymer in 15 cases. AJR 2010; 194:270; [web]W104–W110
8.
Khalil A, Fartoukh M, Tassart M, Parrot A, Marsault C, Carette MF. Role of the MDCT in identification of the bleeding site and the vessels causing hemoptysis. AJR 2007; 188:[web]W117–W125
9.
Khalil A, Parrot A, Nedelcu C, Fartoukh M, Marsault C, Carette MF. Severe hemoptysis of pulmonary arterial origin: signs and role of multidetector row CT angiography. Chest 2008; 133:212–219
10.
Khalil A, Fartoukh M, Parrot A, Bazelly B, Marsault C, Carette MF. Impact of MDCT angiography on the management of patients with hemoptysis. AJR 2010; 195:772–778
11.
Burrel M, Real MI, Barrufet M, et al. Pulmonary artery pseudoaneurysm after Swan-Ganz catheter placement: embolization with vascular plugs. J Vasc Interv Radiol 2010; 21:577–581
12.
Ference BA, Shannon TM, White RI, Zawin M, Burdge CM. Life-threatening pulmonary hemorrhage with pulmonary arteriovenous malformations and hereditary hemorrhagic telangiectasia. Chest 1994; 106:1387–1390

Information & Authors

Information

Published In

American Journal of Roentgenology
Pages: 207 - 212
PubMed: 22194499

History

Submitted: July 22, 2010
Accepted: May 19, 2011

Keywords

  1. hemoptysis
  2. lung cancer
  3. necrotizing pneumonitis
  4. pseudoaneurysm
  5. pulmonary artery

Authors

Affiliations

Antoine Khalil
Department of Radiology, Tenon Hospital, 4 rue de la Chine, 75020 Paris, France.
Antoine Parrot
Respiratory ICU, Tenon Hospital, Paris, France.
Muriel Fartoukh
Respiratory ICU, Tenon Hospital, Paris, France.
Michel Djibre
Respiratory ICU, Tenon Hospital, Paris, France.
Marc Tassart
Department of Radiology, Tenon Hospital, 4 rue de la Chine, 75020 Paris, France.
Marie-France Carette
Department of Radiology, Tenon Hospital, 4 rue de la Chine, 75020 Paris, France.
Pierre et Marie Curie University, Paris, France.

Notes

Address correspondence to A. Khalil ([email protected]).

Metrics & Citations

Metrics

Citations

Export Citations

To download the citation to this article, select your reference manager software.

Articles citing this article

View Options

View options

PDF

View PDF

PDF Download

Download PDF

Media

Figures

Other

Tables

Share

Share

Copy the content Link

Share on social media