The case of Dr. Ramón Saiz
The complete procedure of bronchial artery embolization made by the Dr. Ramón Sáiz, interventional radiologist at Son Llàtzer Hospital (Palma de Mallorca, Spain), can be seen in the online surgical training app SurgSchoolIn this case, hemoptysis secondary to bronchiectasis in the right lower lobe is treated by selective catheterization and embolization with a liquid agent.
La bronchial artery embolization (BAE) It is the treatment of choice for significant or recurrent hemoptysis, especially when bronchial hypertrophy is demonstrated on CT angiography. It is a minimally invasive technique that allows for rapid control of bleeding, avoiding urgent pulmonary surgery.
Clinical context and indication
The pre-procedure CT angiography showed a hypertrophic right bronchial artery with vascularization directed to the right lower lobe, in the context of bronchiectasis and hemoptysis.
In these patients, the bleeding usually originates from the systemic bronchial system and not the pulmonary system, which justifies the indication of selective bronchial embolization as a first-line treatment for moderate or severe hemoptysis.
Classical indications:
- Massive or life-threatening hemoptysis.
- Recurrent hemoptysis refractory to medical treatment.
- Bronchiectasis with hypertrophied bronchial arteries.
- Bronchial vascular tumors or malformations.
Technical planning and strategy
The planning includes a detailed review of the CT angiography to identify:
- Anatomical origin of bronchial arteries.
- Vascular hypertrophy.
- Possible anatomical variants.
- Risk of spinal cord branches (anterior spinal artery).
In this case, ultrasound-guided right femoral access and placement of a 5 Fr introducer, standard in thoracic interventional procedures, are chosen.
The initial selection of the cobra catheter allows for stable catheterization of the bronchial origin.
Selective catheterization and distal navigation
After identifying the hypertrophic right bronchial artery on diagnostic arteriography, the Dr. Ramón Sáiz A 2.4 Fr microcatheter with a 0.016” hydrophilic microguidewire is advanced to achieve a distal superselectivity.
This step is critical for two reasons:
- Reduce the risk of unwanted embolization.
- Allow deep penetration of the embolizing agent into the pathological bed.
Careful progression beyond the main pedicle and into distal branches of the right lower lobe optimizes the hemostatic outcome.
Continuous fluoroscopic control and lateral collimation improve visualization and safety.
Embolization with liquid agent
Once the correct position of the microcatheter is confirmed, a control arteriography is performed which demonstrates pathological vascularization of the right lower lobe.
The following steps are taken embolization with liquid embolant diluted 1:4, by continuous and controlled injection.
Technical highlights:
- Uninterrupted injection to avoid premature intraluminal polymerization.
- Reflux monitoring.
- Stop the injection when controlled reflux occurs.
The safety margin is assessed before starting the injection, confirming the absence of proximal critical branches.
After completing the embolization, wait approximately one minute for the material to consolidate before removing the microcatheter with a controlled, dry pull, minimizing the risk of adhesion.
Critical points and risks
The main potential complications of bronchial artery embolization include:
- Unwanted embolization to spinal branches.
- Spinal cord ischemia.
- Post-embolization chest pain.
- Recanalization or recurrence of hemoptysis.
Prevention is based on:
- Thorough study of the CT angio.
- Careful diagnostic arteriography.
- Superselectivity with microcatheter.
- Control of reflux during injection.
Identifying potential spinal branches is the most critical step before any injection.
Tips & Pearls in Bronchial Embolization
Never embolize from a proximal position without adequate superselectivity.
Inject the liquid embolizing agent continuously, avoiding pauses that could cause unwanted occlusion of the microcatheter.
Confirm microcatheter stability before starting the injection.
Wait long enough before removing the microcatheter to avoid pulling on material that has not yet consolidated.
Frequent errors
Do not thoroughly review the CT angiography before the procedure.
Underestimating the importance of reflux control.
Removing the microcatheter too soon after embolization with liquid agent.
Embolizing in an insufficiently distal position, favoring early recurrence.
Results and monitoring
Well-performed bronchial embolization offers high rates of immediate control of hemoptysis, with the possibility of recurrence depending on the underlying disease.
In bronchiectasis, re-embolization may be required if new hypertrophied vessels reappear.
Follow-up includes respiratory clinical monitoring and, if necessary, further imaging evaluation.
For whom is this procedure especially useful?
Stopinterventional radiology residents interested in vascular thoracic pathology.
To young assistants who wish to perfect microcatheter superselectivity techniques.
To experienced interventional radiologists seeking to optimize results in complex hemoptysis through embolization with a liquid agent.
