This study prospectively investigated the clinical value of MDCT angiography before BAE in 57 patients for the management of hemoptysis. Also, the study was to explore the risk factors of early recurrence and the clinical and angiographic characteristics of patients with pulmonary TB history. The accuracy of MDCT angiography in the detection of culprit arteries was high (97.5%), and the efficacy of BAE with a corresponding preprocedure was acceptable. Aspergilloma was associated with an increase in the risk of early hemoptysis recurrence. Among hemoptysis patients requiring BAE, many patients (23/57, 40.4%) had a history of pulmonary TB. There were no important differences between two groups classified according to pulmonary TB history, excluded from the average number of total culprit arteries and NBSAs per patient.
Since the first introduction in 1974 by Remy et al. , BAE has been known as an effective option for the control of massive and recurrent hemoptysis until now [2, 3, 20, 21]. Identification of the source and site of the bleeding before BAE is critical to complete search of all abnormal vessels, which can improve the procedure efficiency. In the past decades, a study by Furuse et al. was designed to determine the effect of CT scan on the visibility of BAs and the depiction of its courses . However, it is not high-resolution enough to identify culprit BAs exactly. Base on the development of image quality, several reports have shown that MDCT angiography adequately provides detection and depiction of both abnormal BAs and NBSAs [7, 10–13, 22–24]. Our findings seem to be consistent with Li et al. (2019). They found that the matching rate between MDCT angiography and BAE procedure of diagnosis for arterial abnormalities was as high as 98.8% . Notably, the average number of culprit ectopic BAs and NBSAs per patient in current study is even higher than those of their results.
As mentioned in the literature review, the clinical outcomes of BAE vary from study to study, including immediate clinical success ranges from 70–99% and hemoptysis recurrence rate was as high as 9.8%-57.5% . MDCT was done in several studies, but none of these authors used MDCT angiography for the delineation of BAs and NBSAs [25–32]. In 2019, Li et al. performed the first investigation with a control group to assess the clinical effect of BAE with preprocedural MDCT angiography for the management of hemoptysis . Their study confirmed that a higher rate of immediate clinical success (97.2% vs 88.2%) was achieved in group with MDCT angiography before BAE. As compared to the control group, it can be also useful for reduction the risk of recurrent hemoptysis (11.7% vs 20.0%), especially early recurrence (3.9% vs 13.3%). Another report has shown that the clinical success rate during follow-up (1–14 months) was obtained in 94% (50/53) patients who successfully underwent BAE following MDCT angiography . The findings of the current study are not as good as the previous study, but they are acceptable. A possible explanation for these results may be the small size of sample and differences in technical success and embolic agents. Despite potential benefits, very little was found in the official literature on the recommendation of MDCT angiography as a regular examination prior to BAE. The reason for this is not clear but it may be due to lack of data on clinical outcomes of this procedure. According to the American College of Radiology and Spanish Society of Pneumology and Thoracic Surgery (SEPAR) guidelines, this technique should be conducted in patients who experience significant hemoptysis but the strength of recommendation is low [16, 17]. Until now, it is often performed by an individualized decision base on institutional availability.
Surprisingly, aspergilloma was found as a predictor for early recurrence among hemoptysis patients treated by BAE following MDCT angiography. A recent systematic review by Panda et al. (2017) summarized that technical failure due to missing culprit vessels or embolization inability might be causes of early recurrence . However, the high rate of recurrence for patients with aspergilloma has been shown in some published articles [20, 32–36]. Hwang et al. (2013) and van den Heuvel et al. (2007) reported that aspergilloma was significantly associated with re-bleeding after BAE (OR = 3.557, p = 0.003 and OR = 5.1, p < 0.05, respectively) [33, 36]. Triggered by hypoxia, vasculitis, and architectural distortion, there is an opening up of bronchial arterial and pulmonary arterial anastomotic plexus, then becoming targets of erosion and hemoptysis. It is shown that the hemorrhagic sources are often bronchial arteries and can be secondary from a variety of origin, precluding a complete devascularization . Therefore, wedge resection should be considered as a definitive treatment in massive or recurrent hemoptysis patients who can be operable . Cavernostomy and thoracoplasty were also determined the safety and efficacy for high-risk patients with aspergilloma .
The third question in this research was what the similarities and differences between patients with and without pulmonary TB history in patients with hemoptysis received BAE following MDCT angiography. Consistent with the literature, this study found that the incidence of a pulmonary TB history was a rather high rate (40.4%) [33, 36]. Two groups were similar in sex, mean age, the extent of lung diseases, grade of hemoptysis, and technical success and immediate clinical success rate . Regarding angiographic findings, our data support evidence from previous observations (i.e., Lee et al., 2007) that patients with pulmonary TB history have a significantly higher number of total culprit arteries and NBSAs than who without pulmonary TB history . According to prior studies, hemoptysis recurrence after BAE tended to be higher in patients with TB (chronic or active/reactive TB) [32, 36, 39, 40]. These outcomes are contrary to the current study, which has reported that pulmonary TB history was not related to re-bleeding. This difference may partly be explained by a small sample size and/or more quality of treatment, or that we were concentrated on pulmonary TB history patients, not on active TB.
This study has several limitations. Firstly, it has no control group. Therefore, we have compared with previous studies to evaluate the value of MDCT angiography before BAE. But randomised controlled trials will be recommended to gain an insightful picture of this technique. Secondly, only short-term outcomes were covered in the scope of this study. However, it should be noted that the recurrent event could occurs from 6 months to 1 year after BAE . Hence, further studies are needed to have comprehensive view on the efficacy of BAE with preprocedural MDCT angiography. Finally, the number of patients with aspergilloma is small (n = 10), and this might be a cause of bias in our results. In addition, the incidence of hemoptysis recurrence might vary by many factors, these findings cannot be extrapolated to all patients.