Risk factors of hemoptysis recurrence after bronchial artery embolization and patient feedbacks

Bo Yang, Awei Huo, Ling Li, Huaiming Qiu

¹Department of Radiology, General Hospital of Central Theater Command of the People?s Liberation Army, PLA, Wuhan, China

DOI : 10.5606/tgkdc.dergisi.2025.27140

Abstract

Background: The aim of this study is to identify risk factors for recurrence of hemoptysis after bronchial artery embolization and to evaluate patient feedbacks on this intervention.

Methods: Between August 2013 and October 2022, a total of 122 patients (83 males, 39 females; mean age: 59.7±17.3 years; range, 13 to 91 years) who underwent bronchial artery embolization were retrospectively analyzed. The endpoint event was hemoptysis recurrence or death. Baseline data of the patients, technical and clinical success rates, complications, postoperative recovery time in hospital and patient satisfaction and re-acceptance rates were evaluated via a questionnaire.

Results: During follow-up, 24 patients died. A total of 50 patients experienced recurrence, and the overall recurrence rate was 40.98%. Patients with embolization of single culprit artery had a higher recurrence-free survival rate (p=0.049). Of 97 respondents, 81 were satisfied with the result of the procedure and 84 gave consent for re-intervention, if necessary.

Conclusion: Bronchial artery embolization is a safe and effective method of hemoptysis suppression, particularly for those with embolization of single culprit artery. Better suppression of hemoptysis and strengthening communication with patients in the perioperative period can improve the patient satisfaction.

Abstract

Hemoptysis is caused mainly by airway or lung disease, which leads to bleeding of the lower respiratory tract or lung tissue and is discharged by coughing.[1] Even a small a mount of hemoptysis can quickly block the airway, attenuate ventilation and cause rapid oxygenation index reduction, thus endangering the patient's life. Therefore, early airway opening, timely bleeding control and limiting its spread are crucial to saving the patient's lives.[2, 3]

Currently, bronchial artery embolization (BAE) has become the most cost-effective, minimally invasive treatment for recurrent hemoptysis.[4, 6] However, overall recurrence rates have still not significantly reduced since the 1970s.[5, 7] The reasons for recurrence after BAE are diverse, including techniques and materials used, as well as patientrelated factors.[8] A lthough t he e fficacy o f BAE h as been demonstrated, some patients still complain about their experience with the procedure, necessitating further investigation.

In the present study, we aimed to identify risk factors for recurrence of hemoptysis after BAE and to evaluate patient feedbacks on this intervention.

Methods

This single-center, retrospective study was conducted at General Hospital of Central Theater Command of the People's Liberation Army, Department of radiology between August 2013 and October 2022. A total of 122 patients (83 males, 39 females; mean age: 59.7±17.3 years; range, 13 to 91 years) who underwent BAE were included. Exclusion criteria were as follows: previous pulmonary surgery, iatrogenic hemoptysis, gastrointestinal or oropharyngeal bleeding, having bleeding tendency caused by anticoagulant or platelet and patients who refused to provide personal condition or had poor image quality. A written informed consent was obtained from each patient and/or the parents or legal guardians of the pediatric cases. The study was approved by the General Hospital of Central Theater Command of the People's Liberation Army Ethics Committee (date: 24.04.2024, no: 2024/049- 01). The study was conducted in accordance with the principles of the Declaration of Helsinki.

After BAE, all patients were immediately observed and followed progressively. Follow-up included electronic medical records, telephone conversations and outpatient inquiries. Initially, there were a total of 144 patients. Of them, 21 were lost to follow-up and one patient underwent emergent intervention for aneurysm rupture. Of a total of 122 patients included in the study, nine had unknown volume of hemoptysis, one was unconscious with active endobronchial hemorrhage, and 112 were matched for hemoptysis severity as follows: a single event of massive bleeding (>240 mL/24 h), moderate bleeding (>100 mL/24 h) or recurrent bleeding for several days, and mild bleeding (?100 mL/24 h).[4] Patients" conditions after discharge were recorded, including cause and time of death. The longest observation period reached 113 months and 24 were terminated with follow-up due to death. The study flowchart is shown in Figure 1.

Figure 1: Study flowchart. BAE: Bronchial artery embolization.

Bronchial artery embolization procedure

In our institution, all interventional specialists completed BAE procedure for the patients included in the study. In general, a right femoral artery puncture was preferred. Under local anesthesia, a 5F vascular sheath (5F, Terumo Corp., Tokyo, Japan) was used to complete stable catheterization, and a C3 (5F, Cook Medical Corp., IN, USA) or Yashilo (5F, Terumo Corp., Tokyo, Japan) catheter were placed in the aorta to explore the bronchial artery. Meanwhile, bronchial angiography was performed to identify the culprit artery. When the source or location of the bleeding was unknown, all suspected arteries were intubated and imaged. If other target arteries were suspected, a thorough search was conducted for alternative/additional supply vessels. Careful examination was conducted before embolization to prevent any accidental embolization of spinal arteries. Microcatheter (2.7F, Terumo Corp., Tokyo, Japan or 2.4F, Maestro®, Merit Medical Systems Inc., UT, USA) was placed in appropriate position to avoid embolization of normal arterial communication branches or to prevent reflux of embolic particles. Embolization materials included PVA (Cook Medical Corp., IN, USA) and microspheres (Merit Maestro®, Merit Medical Systems Inc., UT, USA), sometimes in combination. Coils were placed only in case of protective embolization of non-target vessels or exclusion of bronchial artery aneurysm. With the catheter stably placed in the target artery, the embolic substance was slowly injected manually. If the contrast agent was not cleared within three cardiac cycles, the embolization process would be terminated.

Arteriography and technical and clinical success

The culprit arteries for hemoptysis included the following: hypertrophic and tortuous bronchial artery, parenchymal hypervascularity associated with dense parenchymal blush, extravasation of contrast agent, bronchial-pulmonary artery shunt and bronchial artery aneurysm.

Technical success was defined as stable intubation of abnormal vessel with successful embolization of the target artery by angiography. Clinical success was defined as significant improvement in clinical symptoms, complete cessation of hemoptysis or significant reduction in hemoptysis, and no need for any further treatment within 30 days after BAE.[9] Hemoptysis discontinued within one week after BAE was defined as immediate clinical success.[3]

Complications

According to the Clavien-Dindo classification, severe complications included respiratory failure, spinal ischemia with neurological symptoms, inguinal complications, and other conditions that required further treatment or resulted in permanent adverse sequelae/death. Symptoms such as palpitations, nausea, and fever were classified as minor complications requiring no specific treatment or only symptomatic treatment.

Follow-up

The patients were classified based on whether recurrent hemoptysis occurred after BAE. The follow-up period was from the date of initial BAE to the last telephone/outpatient inquiries or date of death. The endpoint event was recurrence or death. Recurrence-free follow-up was until April 2023 (for available patients), with the recurrencefree time being the duration between the BAE postoperative hemostasis and recurrence or the final follow-up. The definition of hemoptysis recurrence was as follows: (i) confirmed recurrence of fresh hemoptysis; (ii)intermittent hemoptysis for more than two months; and (iii) multiple recurrent hemoptysis for more than three times within a year. We assessed baseline data of the patients, technical and clinical success, complications, postoperative recovery time (PRT) in hospital and BAE satisfaction and re-acceptance using a questionnaire ( Figure 2).

Figure 2: Questionnaire for follow-up. BAE: Bronchial artery embolization.

Statistical analysis

Statistical analysis was performed using the IBM SPSS version 26.0 software (IBM Corp., Armonk, NY, USA). Continuous variables were expressed in mean ± standard deviation (SD) or median and interquartile range (IQR). Categorical variables were expressed in number and frequency. Categorical variables between the groups were compared using the chi-square test or Mann-Whitney U test, while continuous variables were compared using the t-test. The Kaplan-Meier method was used to estimate the recurrence-free survival rate depending on each variable, which was subsequently compared using the log-rank test. A p value of <0.05 was considered statistically significant.

Methods

Results

The mean follow-up was 41.25±30.11 (range, 1 to 113) months. Pathogenic factors included bronchiectasis, lung cancer, pneumonia, tuberculosis and cryptogenic hemoptysis. The included patients underwent a total of 140 BAE, including 13 who underwent twice, one three times, and one four times. During the initial BAE, a total of 323 bronchial arteries (165 right and 158 left) and 50 non-bronchial systemic arteries were identified. The most common angiographic findings were hypertrophic and tortuous bronchial artery with regions of hypervascularity.

In the non-recurrence group (n=72), except for three patients who underwent lung lesion resection, hemoptysis stopped within one week in 60 patients (83.3%), and seven achieved a significant reduction within 30 days. For the recurrence group (n=50), hemoptysis stopped within one week in 36 (72.0%), and eight showed a significant reduction within 30 days. Clinical success rates were 92.8% (64/69) in the non-recurrence group and 88.0% (44/50) in the recurrence group.

Overall immediate and clinical success rates were 78.7% (96/122) and 90.8% (108/119), respectively. All the patients achieved technical success. The PRT and complications were calculated for patients with initial BAE (n=97). Twenty-five patients were excluded from the analysis due to refusal of hospital observation, short-term repeated surgery, or sudden onset of other complications or death. Minor complications occurred in 36.1% (35/97) of the patients and resolved with medical treatment. Serious complications included one case of contrast-induced encephalopathy causing temporary blindness and one femoral artery pseudoaneurysm requiring vascular repair.

Although the immediate and clinical success rates of the non-recurrence group were higher than those of recurrence group, the PRT was lower in the non-recurrence group; however, the difference was not statistically significant (p=0.133, p=0.377, and p=0.156, respectively). The inter-group comparison revealed that only bronchiectasis and the number of embolized arteries were statistically significant (Table 1).

Table 1: Univariate analysis for the association between risk factors and recurrence of hemoptysis

The Kaplan-Meier survival analysis revealed that the number of embolized arteries significantly influenced recurrence-free time (p=0.049) ( Figure 3). Among 97 patients who completed the questionnaire, 83.5% were satisfied with the procedure and 86.6% would agree with re-intervention if necessary (Table 2).

Figure 3: Time to recurrence curves as depicted by the Kaplan-Meier method.

Table 2: Summary of the specific causes of the adverse results of questionnaire

Results

Discussion

Hemoptysis is a daily diagnostic challenge and associated with potentially life-threatening medical conditions.[10, 11] Bronchial artery embolization can effectively control hemoptysis caused by bronchiectasis, tuberculosis, aspergilloma, bronchogenic carcinoma and bronchitis.[12, 13] I n t he past, BAE was more like a bailout procedure than a curative treatment.[14]

In our study, overall immediate and clinical success rates were 78.7% (96/122) and 90.8% (108/119), respectively, which were slightly lower than those in previous studies.[15, 19] S ome s tudies have reported high recurrence rates of hemoptysis up to 57.5%[3, 5] and recurrence seems to be inevitable. Our study showed one-, two-, three-, and fiveyear relapse rates as 18.9% (23/122), 6.7% (8/122), 7.4% (9/122), and 3.3% (4/122), respectively, with an overall recurrence rate of 40.98%. Although the criteria for recurrence were identified in this study, personal subjective feelings and tolerance to recurrence may also cause feedback errors, particularly in those with a later intermittent small amount of hemoptysis. Moreover, patients with recurrence may have refractory underlying diseases or lack of comprehensive management after BAE, which can cause the increased recurrence rate of hemoptysis.

Early peak recurrence within the first month of BAE is usually due to incomplete embolization.[20, 21] In the present study, six patients had recurrence within one month, four required re-intervention and achieved clinical success, and two died of suffocation caused by hemoptysis within two days. Repeated digital subtraction angiography (DSA) of four patients revealed incomplete embolization as the cause of recurrence. Therefore, timely computed tomography angiography (CTA) which can pre-locate the culprit artery is necessary to improve the surgical process.[22, 24] Previous studies have shown that malignant diseases may contribute to higher recurrence rates. This is attributed to malignancy with rapid progression, neovascularization, local necrosis and inflammation of feeding arteries.[3, 17] I n o ur s tudy, 11 deaths with non-recurrence occurred, of which five died from lung cancer, six died from other causes including cerebral hemorrhage, myocardial infarction and unknown factors. For recurrence, four patients were diagnosed with lung cancer and all of them died, and only two died of asphyxia caused by recurrence. Our study showed that lung cancer patients were not more prone to relapse, which resulted from limited number of cases or untrue feedback.

In the current study, there were more patients with bronchiectasis (63.1%, 77/122), and these patients were more prone to recurrence, which is consistent with previous reports.[16, 25] However, Kaplan-Meier survival curve and log-rank tests did not show a significant increase in terms of recurrence-free rate over time in patients with bronchiectasis.

In this study, patients with embolization of a single culprit artery had a higher recurrence-free survival rate, despite the result being marginally significant. For non-recurrence, 14 patients had underlying diseases including bronchiectasis (21.4%), lung cancer (14.3%), infection (42.9%), tuberculosis (7.1%) and cryptogenic hemoptysis (14.3%). Seven patients had no complications while six had mild complications. One patient had contrast encephalopathy and expressed dissatisfaction and difficulty in re-receiving BAE. Only six underwent computed tomography (CT) scan, with no progression of lesions. Three relapsed and one died during the follow-up, and CT scan of one living patient showed intractable lung infection. The underlying causes of continued stubborn existence may be the promoting factors of bronchial artery thickening and tortuous and vascular hyperplasia. Fourteen patients with embolization of a single culprit artery had achieved clinical success and long-term therapeutic effect. The possible reason may that BAE blocked the arterial inflow into the inflamed area, thereby reducing perfusion pressure and the possibility of recurrence.[26, 27] Although the primary goal of BAE is to stop bleeding, the occlusion of culprit artery also plays a therapeutic role.

Patients can experience surgical perception under awake conditions during BAE, which was not a focus in previous literature. Among 97 respondents, 18 expressed dissatisfaction with BAE (88.9%, 16/18) or did not accept it again (72.2%, 13/18). The main complaints were poor hemoptysis suppression (83.3%, 15/18), and some patients complained about operation duration, process and complications. During the process, one complained about chest pain and palpitation, and another developed nausea and accelerated heart rate. Despite timely comforted, they were still scared after BAE and clearly refused reintervention. This finding highlights the importance of preoperative communication with patients and postoperative follow-up. Calming patients' anxiety can alleviate the fear of unknown things and ensure a smooth completion of BAE, which can improve the acceptance of the operation and cooperation between physicians and patients. In the present study, 15 patients underwent repeated BAE, with 13 receiving two interventions. Among these patients, 92.3% (12/13) achieved clinical success, although 38.5% (5/13) experienced recurrent hemoptysis. Three expressed dissatisfaction and one refused BAE again. One patient underwent three BAEs, but still trusted BAE. Another patient received four BAEs and died during follow-up. None of the patients experienced any serious complications. The main limitations to the present study include its single-center, retrospective design with a relatively small sample size. In addition, follow-up data were obtained from family members which may have caused a bias. Further well-designed, large-scale studies are needed to confirm these findings. In conclusion, bronchial artery embolization targeting a single culprit artery can achieve higher hemoptysis-free survival rates compared to embolization of multiple culprit arteries. Based on our findings, we suggest strengthening communication with patients in the perioperative period to reduce tension and improving intraoperative coordination. However, whether this is associated with hemoptysis recurrence needs further research.

Data Sharing Statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Author Contributions: Idea/concept: B.Y., H.Q.; Design, critical review: All authors.; Control/supervision: H.Q.; Data collection and/or processing: A.H., L.L.; Analysis and/or interpretation, writing the article: B.Y.; Literature review: B.Y., A.H.

Conflict of Interest: The authors declared no conflicts of interest with respect to the authorship and/or publication of this article.

Funding: The authors received no financial support for the research and/or authorship of this article.

Discussion