Superselective Pulmonary Artery Embolization for Refractory Massive Hemoptysis Post-Bronchial Artery Embolization: A Bail-Out Measure.

PURPOSE: The objective of the study was to evaluate the outcomes of segmental/subsegmental superselective pulmonary artery embolization (PAE) as a measure to control refractory hemoptysis after bronchial artery embolization (BAE).

MATERIAL AND METHODS: It was a prospective case series with subset analysis. Between January 2022 and July 2024, 50 patients with recurrent hemoptysis after BAE were evaluated using CT angiography. If major systemic arterial supply was identified, repeat BAE was performed for recanalized or new arteries (34/50 patients). Persistent systemic-to-pulmonary shunts (SPS) (identified using CTA and diagnostic arteriograms) were treated with selective PAE using microcoils (in 7 patients out of 34). Four were males, 3 females; ages 20-55 years. Six out of 7 patients had chronic pulmonary aspergillosis and one had post-tuberculosis sequelae. Most patients had undergone multiple prior BAE procedures (2-3 sessions; embolizing 2-8 arteries). No aneurysms or other vascular anomalies were identified in the selected pulmonary artery branches. All were on appropriate medical management for their underlying disease. Technical success was assessed by occlusion of the target pulmonary artery branch. Clinical outcomes were assessed by immediate control of hemoptysis with no recurrence of massive bleed in the follow-up period of 6-12 months.

RESULTS: SPS was localized to the left upper lobe (4 patients), left lower lobe (1), right lower lobe (1), and right upper lobe (1) in the diseased regions. Bronchial arteries supplied systemic flow in 3 patients, while non-bronchial systemic arteries (NBSAs) were involved in 4 patients (more than one vessel supply was identified in two cases). In 4 patients, only one selective branch of PA was embolized using microcoils; in three patients, two separate branches were embolized. Technical success was 100%, with effective control of hemoptysis in all cases. One patient had mild hemoptysis after two weeks, managed with intravenous voriconazole and oral tranexamic acid. No complications were observed.

CONCLUSION: Superselective PAE may be considered as a safe and effective bail-out measure for refractory massive hemoptysis persisting after BAE in selected patients. [Level of Evidence: Level 3, Non-randomized controlled cohort].