Asian Cardiovasc Thorac Ann 2001;9:200-203
© 2001 Asia Publishing EXchange Pte Ltd
Management of Life-Threatening Hemoptysis
Lim Yeong Phang, FRCS,
Daniel Wong, FRCR,
Thirugnanam Agasthian, FRCS
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Departments of Surgery and Radiology Tan Tock Seng Hospital Singapore, Republic of Singapore
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For reprint information contact: Lim Yeong Phang, FRCS Tel: 65 436 7598 Fax: 65 224 3632 email: yplim{at}magix.com.sg Department of Cardiothoracic Surgery, National Heart Centre, 17 Third Hospital Avenue, Mistri Wing, Singapore 168752, Republic of Singapore.
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Abstract
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From June 1993 to June 1998, 50 patients were admitted with life-threatening hemoptysis (> 150 mL blood in 24 hours) due to pulmonary tuberculosis in 40, malignancy in 5, nontuberculous bronchiectasis in 4, and lung sequestration in 1. All patients had bronchial angiography with one session of embolization in 35 and more than one session in 11; no embolization was required in 4 cases. Surgery was necessary for recurrent hemoptysis in 6 patients. There were significant recurrences in 19 patients, of whom 5 died. Predictors of recurrence were the presence of mycetoma and presentation in a state of collapse. The fatal recurrences all took place within 1 week of the initial embolization and were probably due to incomplete embolization. In patients restudied after significant recurrences within 1 week of embolization, new vessels needed to be embolized in addition to previously treated vessels. It is postulated that some bleeding vessels may be missed at initial angiography, possibly due to vasospasm or low flow, and these may resume bleeding when the patient's hemodynamic status improves. An angiogram within 24 hours of embolization could identify such patients and they should be offered surgery if they are fit.
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INTRODUCTION
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It has been estimated that 5% of patients with hemoptysis present with massive hemoptysis.1 Life-threatening hemoptysis is defined as sufficient to cause mortality by virtue of airway obstruction, exsanguination, or hypotension. Mortality ranges from 30% to 70%, depending on the amount and rate of blood loss and the pulmonary reserve of the patient. Definitions of massive hemoptysis range from 100 to 600 mL discharged per 24 hours.2 Bronchial artery embolization has been established as the primary therapy since it was performed by Remy and colleagues3 in 1973. However, bronchial artery embolization is palliative; surgery remains the definitive treatment. Embolization produces good results with success rates varying from 54% to 91% in acute situations.4 The role of surgery is therefore limited to patients in whom embolization fails or definitive treatment is required. Nevertheless, there is a recurrence rate of 10% to 20% after embolization, and some episodes may be fatal.1,5,6 This study was initiated to assess the long-term outcome of bronchial embolization and identify risk factors for recurrence of hemoptysis after embolization in order to devise a strategy to avoid mortality.
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PATIENTS AND METHODS
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A retrospective review was carried out of the records of patients who presented with life-threatening hemoptysis (defined as more than 150 mL per episode) in a 5-year period from June 1993 to June 1998. Bronchial angiog-raphy was undertaken for hemoptysis in 85 patients; sufficient documentation was obtained for 77, of whom 50 were identified as having hemoptysis of more than 150 mL per episode. All 50 patients had bronchial angiography with or without embolization as an initial procedure, except for one who had been diagnosed with right upper lobe mycetoma 2 months previously. Additional procedures such as bronchoscopy or computed tomography of the thorax were performed as decided by the primary respiratory physician. The patients were also referred to the duty thoracic surgeon. Bronchial angiograms were reviewed by an interventional radiologist. There were 44 males and 6 females, with a mean age of 60 years (range, 20 to 92 years). The mean amount of hemoptysis was 360 mL. Seven patients presented in a state of hemodynamic collapse from massive hemoptysis. The etiology of hemoptysis is shown in Table 1
. Comorbidity comprised diabetes mellitus (10), hypertension (8), ischemic heart disease (8), alcoholism (3), opium dependence (3), cerebrovascular disease (2), chronic renal failure (1), and mitral regurgitation (1).
Embolization was performed with PVA particles (Target Therapeutics, Fremont, CA, USA), Ivalon particles (Nycomed SA, Paris, France), or Gelfoam (Upjohn, Kalamazoo, MI, USA) according to the interventional radiologist's preference. A total of 84 vessels were embolized in 46 patients: 24 had l vessel embolized, 14 had 2 vessels embolized, 2 had 3 vessels embolized, and 6 had 4 vessels embolized. Of these 84 vessels, 22 were non-bronchial systemic vessels. Embolization was not carried out in 4 patients: the vessel was too small to cannulate in 1, the vessel was dissected and occluded in 1, and the other 2 had normal bronchial angiograms. Data were analyzed using SPSS software (SPSS Inc., Chicago, IL, USA).
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RESULTS
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The overall mortality was 22% (11/50). The causes of mortality were recurrent hemoptysis in 5 patients, pulmonary sepsis in 3, advanced malignancy in 1, and 2 patients died after surgery. The initial embolization success rate was 53% (24/45); 5 of these 24 (21%) had minor recurrences after the initial successful embolization. The overall embolization success rate was 71% (32/45). The hemoptysis resolved in 3 of the 4 patients who did not undergo embolization. The outcome in patients with pulmonary tuberculosis is shown in Table 2. The initial embolization success rate was 21/36 (58%) for patients with tuberculosis, and the mortality in this subgroup was 7/40 (17.5%). All patients with mycetoma were operated upon. Three of the 4 patients with nontuberculous bronchiectasis were embolized only once; the hemoptysis resolved in 2 cases, 1 subsequently underwent surgery (hemoptysis recurred), and the other was embolized a second time before the hemoptysis resolved. Of the 5 patients with malignancy, 3 were successfully embolized although 1 died later from sepsis; the other 2 patients had normal bronchial angiograms and both died from recurrent hemoptysis. The patient who had massive hemoptysis from pulmonary sequestration was successfully embolized but suffered hemodynamic collapse during the procedure and could not be resuscitated.
Six patients underwent surgery for hemoptysis: 4 had mycetomas with tuberculous bronchiectasis, 1 was thought to have mycetoma but histology of the cavity wall was consistent with lung abscess, and 1 had nontuberculous right middle lobe bronchiectasis and suffered a significant recurrence of hemoptysis despite embolization. Five patients underwent a right upper lobectomy, and 1 had a right middle lobectomy. There was 1 operative death in a patient who was admitted with massive ongoing hemoptysis and unstable hemodynamics at the time of surgery. There was 1 late death in a patient who collapsed suddenly on the 12th postoperative day from suspected massive pulmonary embolism. Morbidity was encountered in 4 patients: reoperation was required in 1; 2 had postoperative empyema, including 1 with bronchopleural fistula, and both of these patients underwent thoracotomy and drainage and subsequently recovered; and 1 patient was readmitted 2 weeks after discharge with a large symptomatic pleural effusion that was drained.
There were significant recurrences (requiring intervention) in 19 of the patients who had undergone embolization. The outcome and angiographic findings are shown in Table 3. Additional embolization was performed in 11 patients, of whom 7 were unfit or unsuitable for surgery, 3 refused surgery, and repeat angiography was performed in the other to localize the bleeding site. The cumulative hemoptysis control rate which is the cumulative probability of survival without recurrence is reflected in Figure 1.6 It can be seen that after 50 days, the risk of a significant recurrence tapers off. Among the patients studied angiographically after a significant recurrence, 3 were found to be bleeding from additional vessels as well as the previously embolized vessels; the mean interval before recurrence was 2 days (range, 2 to 3 days). All but 1 of the patients who were re-embolized successfully were found to be bleeding from previously treated vessels, with a mean interval of 13 days (range, 2 to 30 days) before recurrence. The patients who suffered massive hemoptysis post-embolization had a mean interval of 3 days (range, 1 to 7 days) before recurrence. Five patients had minor recurrences that did not require intervention, at 17 to 300 days post-embolization (mean, 111 days). The mean follow-up period was 19 months (range, 1 to 60 months) in the 39 surviving patients.
Univariate logistic regression analysis comparing age, presence of diabetes mellitus, chronic obstructive lung disease, hypertension, and amount of hemoptysis did not reveal any correlation with recurrence. Likewise, the number of vessels, degree of hypervascularity, size of vessels embolized, and the presence of bilateral disease did not have any statistical correlation. Presentation in a state of collapse correlated with recurrence (p = 0.038) which was noted at a mean of 3.6 days (range, 1 to 7 days) post-embolization.
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DISCUSSION
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The hemoptysis recurrence rate was 42% (19/45) and it could be classified as early (< 30 days; 15/45) or late (> 30 days; 4/45). A bimodal pattern of recurrence after embolization has been previously described.4,7,8 The patients in this series with early recurrence could be divided into 2 distinct groups: those with recurrence within 1 week of embolization and those with recurrence between 1 week and 1 month post-embolization. All of the deaths from recurrent hemoptysis occurred within 1 week after embolization. Patients who had a recurrence within 1 week of the initial embolization and underwent further study were found to be bleeding from additional vessels as well as some previously embolized vessels. This suggests that incomplete embolization was achieved initially, due to vessels being missed or ceasing to bleed during the procedure. Angiography in hypotensive patients may cause low flow or vasospasm, leading to cessation of bleeding in some vessels that may subsequently resume bleeding when the patients' hemodynamic status improves. Unfortunately, hemodynamic data during the embolization was not recorded but 3 of the 5 patients with fatal recurrences presented in a state of shock, and the other 2 had massive ongoing hemoptysis. The evidence is circumstantial but it may be prudent to repeat bronchial angiography 24 to 48 hours after the initial embolization to check for any other bleeding vessels in patients who presented in shock or were hypotensive during the procedure. This may help to reduce the mortality from recurrent hemoptysis post-embolization.
The patients who had recurrences 1 week to 1 month post-embolization were found to have bled from previously embolized vessels, suggesting recanalization or re-constitution of the embolized vessels. Surgery is still the definitive treatment in this condition, especially for patients with mycetoma and those in whom embolization was not possible or failed. Surgery in this setting is difficult as the patients have badly scarred or destroyed lungs with severe adhesions. There was no recurrent hemoptysis in the surgically treated group. Emergency operations in patients who are unstable with bronchiectasis and ongoing life-threatening hemoptysis are certainly associated with poor outcome (37% mortality).9,10 It is better to stabilize the patient first with embolization if possible, before performing surgery to prevent further hemoptysis. Those unfit for pulmonary resection may require multiple courses of embolization. Patients admitted in a state of collapse have a significant chance of recurrence post-embolization, especially in the first week. Embolization serves as a palliative measure to avoid the mortality of emergency surgery in this instance.11 Such patients should also be offered early definitive therapy to prevent recurrences, if they are fit.
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REFERENCES
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Abstract
INTRODUCTION
