An Interventionalist's Guide to Hemoptysis in Cystic Fibrosis.

Massive hemoptysis occurs in a minority of patients with cystic fibrosis, with an annual incidence of 1%. Although rare, massive hemoptysis can be a severe and potentially fatal complication of this disease. Beyond the acute life-threatening event, hemoptysis in patients with cystic fibrosis has been associated with faster decline in lung function, accelerated need for lung transplant, and increased mortality. The bronchial arteries are the culprit vessels in over 90% of cases of hemoptysis. This normally quiescent vascular system undergoes remarkable hypertrophy, collateralization, and angiogenesis before the onset of hemoptysis, introducing numerous pitfalls for the interventionalist. However, in experienced hands, bronchial artery embolization is a safe and potentially lifesaving therapy. Preprocedural noninvasive imaging, specifically computed tomographic angiography, has been repeatedly validated for helping to localize the likely site of bleeding, characterizing pertinent arterial anatomy, and promoting efficient and effective intervention; it has been recommended for all stable patients with hemoptysis. Success in the angiographic suite requires a thorough understanding of normal and variant bronchial arterial anatomy, appropriate patient selection, and a meticulous embolization technique. A meticulous approach to imaging and intervention, conscientious of both visualized and nonvisualized collateral pathways and nontarget vessels, can minimize potentially devastating complications. This review summarizes the current literature, modern procedural techniques, and emerging controversies, serving to guide an evolving approach to management of patients with cystic fibrosis and hemoptysis. ©RSNA, 2018.

Spatial relationships of the bronchial arteries to the left recurrent laryngeal nerve in the sub-aortic arch area.

PURPOSE: To safely perform lymphadenectomy in the sub-aortic arch area during esophagectomy for esophageal cancer, we investigated the spatial relationships between the bronchial arteries (BAs) and the left recurrent laryngeal nerve (LRLN). METHODS: For this macro-anatomical study, 72 cadavers were used. RESULTS: Of the 195 dissected BAs, 15 (7.7%) arteries ran dorsally across the LRLN. Such a running pattern of the BA was found in 15 (20.8%) of the 72 cadavers. Fourteen (93.3%) of the 15 arteries ran anteriorly along the left side of the esophagus, and 13 (86.7%) passed further to the lateral side of the left main bronchus to reach the ventral surface of the tracheobronchus; we named this running pattern "Type III". Of the 51 arteries with the Type III pattern, 25.5% ran across the dorsal side of the LRLN. CONCLUSION: Approximately 20% of the cadavers had BAs running dorsally to the LRLN in the sub-aortic arch area. Most of these arteries had the Type III pattern. One-quarter of the BAs with the Type III pattern showed this running pattern. Care must be practiced to safely perform lymphadenectomy for esophageal cancer in patients with Type III BAs.

An applied anatomical study of bronchial artery.

The aim of this study was to reveal the external features of the bronchial artery (BA) system, so as to provide morphological basis for clinic. The BAs in 48 adult cadavers were dissected and analyzed. The number of BAs in 48 cases was 118. The incidence of BA arising from thoracic aorta, right posterior intercostal artery, and right subclavian artery was 69.49, 27.12, and 3.39%, respectively. The origin of BAs in individual specimen might be single, two, or all of them, respectively. According to the different origin and/or origins of BAs, it could be divided into five categories. As for the course of BAs, in this study, all the left BAs arising from thoracic aorta passed forward around the left side of esophagus and then entered left pulmonary hilum; most (n = 15) of the right BAs arising from thoracic aorta passed forward around the left side of esophagus and then entered right pulmonary hilum; a few (n = 8) of the right BAs arising from thoracic passed forward the right side of esophagus and bronchus and then entered right pulmonary hilum. Besides, in our group, the special courses were that right intercostal-bronchial trunk (RICBT) arising from thoracic aorta passed between vertebra and esophagus and gave off BA which curved forward around the right side of esophagus and then entered right pulmonary hilum, common bronchial trunk (CBT) arising from thoracic aorta passed forward around the left side of esophagus laying anterior to bronchus or posterior to bronchus, then dividing into a left and a right BAs entering right and left pulmonary hilum, respectively. In 4 cadavers, the RICBT gave off the radiculomedullary artery and BA in turn, so radiculomedullary artery has the same origin with BA. Of all BAs, the mean diameter of right posterior intercostal artery, CBT, left BA, and right BA was 2.17 ± 0.84, 1.79 ± 0.57, 1.44 ± 0.50, and 1.39 ± 0.38 mm, respectively. The information gained from this study will be of value in clinic application.

The right intercostobronchial trunk: anatomical study in respect of posterior intercostal artery origin and its clinical application.

PURPOSE: The right bronchial artery usually arises from the descending thoracic aorta as a common trunk with the right intercostal artery and forms the right intercostobronchial trunk. Both, the third right posterior intercostal artery and the right intercostobronchial trunk, are described as the most constant vessels. The focus of the study was to determine the characteristics of the right intercostobronchial trunk regarding the origins of the posterior intercostal arteries from the thoracic aorta. METHODS: Posterior intercostal arteries and the right bronchial arteries were dissected in 43 human cadavers, preserved after Thiel's embalming method with intraarterial infusion of red colored latex. RESULTS: Postmortem examination gave valued information on the right intercostobronchial trunk present in 58% of cases. The right intercostobronchial trunk was mapped and new classification regarding the origin of the posterior intercostal arteries from the thoracic aorta suggested type A, B and C, the latter ones into subtypes 1 and 2. Type A was proportional to the origin level of the PIA and its corresponding intercostal space. Size of outer diameter at the origin did not indicate the right bronchial artery branch. In subtype 2 of type B the proximal posterior intercostal artery diameter that gave off right bronchial artery was thicker than distal one. CONCLUSIONS: The right bronchial artery originates from the second to the fifth posterior intercostal artery forming the right intercostobronchial trunk. Various origin and types of origin, diameter and course of the right intercostobronchial trunk described and analyzed in the study offer valuable information on the procedures involving the right intercostobronchial trunk.

A new anatomical classification of the bronchial arteries based on the spatial relationships to the esophagus and the tracheobronchus.

PURPOSE: To reveal the patterns of the mediastinal course of the bronchial arteries (BAs). METHODS: The BAs were dissected to determine the positional relationships of their mediastinal courses with the tracheobronchus and the esophagus in 72 adult cadavers. RESULTS: The mediastinal courses of the 227 BAs found in this study were classified into 4 types. There were 61 and 163 BAs passing the right side (Type I) and the left side (Type II reaching dorsal surface (n = 98), or Type III reaching ventral surface (n = 65) of the tracheobronchus) of the esophagus, respectively. Three BAs originated from the subclavian artery (Type IV). All Type I BAs were right BAs, whereas 91.8% of the Type II BAs were left BAs. However, 43.1 and 56.9% of the Type III BAs were the right and left BAs, respectively. CONCLUSION: The classification of the mediastinal course of the BAs determined by the spatial relationships to the tracheobronchus and the esophagus may be clinically useful, because each category of this classification can be determined during esophagectomy and indicates whether the BA is a right or left BA.

Bronchial arteries: anatomy, function, hypertrophy, and anomalies.

The two main sources of blood supply to the lungs and their supporting structures are the pulmonary and bronchial arteries. The bronchial arteries account for 1% of the cardiac output but can be recruited to provide additional systemic circulation to the lungs in various acquired and congenital thoracic disorders. An understanding of bronchial artery anatomy and function is important in the identification of bronchial artery dilatation and anomalies and the formulation of an appropriate differential diagnosis. Visualization of dilated bronchial arteries at imaging should alert the radiologist to obstructive disorders that affect the pulmonary circulation and prompt the exclusion of diseases that produce or are associated with pulmonary artery obstruction, including chronic infectious and/or inflammatory processes, chronic thromboembolic disease, and congenital anomalies of the thorax (eg, proximal interruption of the pulmonary artery). Conotruncal abnormalities, such as pulmonary atresia with ventricular septal defect, are associated with systemic pulmonary supply provided by aortic branches known as major aortopulmonary collaterals, which originate in the region of the bronchial arteries. Bronchial artery malformation is a rare left-to-right or left-to-left shunt characterized by an anomalous connection between a bronchial artery and a pulmonary artery or a pulmonary vein, respectively. Bronchial artery interventions can be used successfully in the treatment of hemoptysis, with a low risk of adverse events. Multidetector computed tomography helps provide a vascular road map for the interventional radiologist before bronchial artery embolization.

The normal anatomy and variations of the bronchial arteries: evaluation with multidetector computed tomography.

INTRODUCTION: In this study, we aimed to reveal the normal anatomy and variations of the bronchial arterial system and to determine the sex distribution of these variations by retrospectively reviewing the images of patients who underwent thoracal multidetector computed tomographic angiography for various reasons. MATERIALS AND METHODS: Multidetector computed tomographic images of a total of 208 patients (151 men; mean age, 59 years) were retrospectively reviewed to assess the normal anatomy and variations of the bronchial arterial system. RESULTS: A total of 531 bronchial arteries (median, 3; minimum, 1; maximum, 5; mean, 2.5) were detected. The number (mean diameter) of the right bronchial arteries were higher than the left bronchial arteries (290 [1.43 mm] and 241 [1.26 mm], respectively; P < .05 for both number and diameter). The mean number (diameter) of the bronchial arteries were higher with men than with women (2.58 [1.45 mm] and 2.47 [1.32 mm], respectively; P < .05 for both number and diameter). The most common (24%) branching pattern was the combination of 1 right intercostal-bronchial trunk and 1 left bronchial artery, and, secondarily (13.46%), the combination of 2 right (1 intercostal-bronchial trunk and 1 bronchial artery) and 1 left bronchial arteries. Seventy-eight ectopic bronchial arteries were detected in 59 cases (28.3%). They most commonly originated from the aortic arch (37.2%), the descending aorta below the level of T6 (35.9%), or the aortic branches (16.7%). The number of right ectopic bronchial arteries was significantly higher than the left ectopic bronchial arteries (50 [64%] vs 28 [36%]; P < .01). The incidence of ectopic bronchial arteries was statistically higher with men versus women (45 [29.8%] vs 14 [24.6%]; P < .05). CONCLUSION: The origins, numbers, diameters, and courses of the bronchial arteries can vary substantially among individuals. Multidetector computed tomographic angiography enables a detailed road map of the bronchial arterial system to interventional radiologists and thoracic surgeons.

A friend to the airways: a review of the emerging clinical importance of the bronchial arterial circulation.

Lungs receive the bulk of their blood supply through the pulmonary arteries. The bronchial arteries, on the other hand, vascularize the bronchi and their surroundings. These two arteries anastomose near the alveolar ducts. Contrary to the pulmonary circulation which is fairly well studied, the bronchial arteries have been appreciated more by their absence, and in some cases, by an interruption in the pulmonary arterial flow. Therefore, a more accurate anatomical and functional knowledge of these atherosclerosis-resistant vessels is needed to help surgeons and clinicians to avoid iatrogenic injuries during pulmonary interventions. In this review, we have revisited the anatomy and pathophysiology of the bronchial arteries in humans, considering the recent advances in imaging techniques. We have also elaborated on the known clinical applications of these arteries in both the pathogenesis and management of common pulmonary conditions.

Normal anatomical features and variations of bronchial arteries: an analysis with 64-detector-row computed tomographic angiography.

OBJECTIVE: To determine the normal anatomical features and variations of the bronchial arterial system and to determine the relationship among ectopic bronchial arteries, location (right-left) of the bronchial arteries, and variations of the aortic arch in patients as well as the sex of the patients who underwent multidetector computed tomographic angiography of the thorax for various reasons. METHODS: A total of 163 patients who underwent multidetector computed tomographic angiography of the thoracic vascular structures for various reasons were analyzed retrospectively. The right and left bronchial arteries were analyzed individually, and normal anatomic features and variations were recorded. The χ and Mann-Whitney U tests were used to evaluate relationships among the patients' sex, side and number of the bronchial arteries, aortic arch variations, and bronchial artery variations. RESULTS: There were 432 bronchial arteries (right, 229; left, 203) in 163 patients (117 men, 46 women; mean age, 51.7 years). All of the patients have at least one bronchial artery (mean, 2.65; maximum, 5). The number and diameters of the bronchial arteries were statistically higher on the right side. The number of the bronchial arteries was significantly higher in the men (P < 0.05). Ectopic bronchial arteries were present in 43 (26.4%) of the 163 patients. Aortic arch variations were present in 27 (22.5%) of 120 patients with normal bronchial arteries and in 11 (25.6%) of the 43 patients with ectopic bronchial arteries. There was no statistically significant correlation between aortic arch variations and ectopic bronchial arteries (P = 0.861). CONCLUSIONS: The anatomic features of the bronchial arteries show differences between individuals and the sexes. Multidetector computed tomographic angiography allows a precise and detailed evaluation of bronchial arterial system.

Variations of bronchial artery origin in 600 patients: Systematic analysis with multidetector computed tomography and digital subtraction angiography.

ABSTRACT: To identify and evaluate the spectrum and prevalence of variations in bronchial artery (BA) origin by multidetector computed tomography (MDCT) and digital subtraction angiography (DSA) in a large population with hemoptysis.From July 2008 to June 2015, data from 600 individuals with hemoptysis who underwent MDCT and DSA were retrospectively analyzed. The pattern of BA origin was investigated and classified according to distribution.A total of 1674 BAs were evaluated, 866 were right BA and 808 were left BA. Most BAs originated from the upper descending thoracic aorta, classified as orthotopic origin (n = 1464, 87.5%). Among ectopic origin BAs (n = 210, 12.5%), concavity of the aortic arch was the most common (n = 107). The most common distribution pattern was a single artery in each side (n = 262). According to our classification, Type I was most common (n = 457), including BAs originating in orthotopic fashion from the descending thoracic aorta. Type II (n = 2) was defined as BAs originating from the aortic arch or ascending aorta. Type III (not found) was defined as BAs originating from subclavian arteries, common carotid arteries, and their branch vessels. Type IV (n = 92) was Type I and II combined, Type V (n = 41) was Type I and III combined, Type VI (not found) was Type II and III combined, and Type VII (n = 8) was Type I, II, and III combined.Variations of BA origin could be systematically described in detail.

The airway vasculature: recent advances and clinical implications.

It is increasingly recognised that the airway circulation plays an important role in airway diseases, either through a change in blood flow or through microvascular leakage. Most of the information available regarding the anatomy and physiology of bronchial blood flow and its regulation has necessarily derived from animal studies. However, there have recently been important advances in understanding airway blood flow in airway disease in humans through the development of non-invasive methods and in the quantification of microvascular leakage using plasma markers. These studies have shown that bronchial blood flow is increased in patients with asthma but not in those with chronic obstructive pulmonary disease, confirming previous pathology investigations. Changes in bronchial blood flow may in part reflect the generation of new vascular vessels, a process known as "angiogenesis" which is caused by airway inflammation. Angiogenesis and the resulting plasma leak affect airway physiology, drug clearance and its bioavailability. This review discusses the anatomy, physiology and regulation of bronchial blood flow in the normal and diseased lung, In addition, it analyses the effect of current medical treatment and discusses the potential use of new anti-angiogenesis medications. The development of non-invasive assessment of bronchial blood flow and the study of angiogenesis have provided a tool to investigate airway physiology in vivo; these advances will contribute to a better understanding of inflammatory airway diseases as well as the implication of these findings to management.

[Normal and abnormal systemic pulmonary circulation: CT imaging features]. / Vascularisation systémique normale et pathologique du poumon: sémiologie tomodensitométrique.

In most cases, treatment of life-threatening hemoptysis requires systemic arterial embolization, bronchial or not. Knowledge of the normal and pathological features of this systemic arterial network as depicted on multidetector row CTA, is an essential key because this examination has become the main imaging study prior to any interventional procedure. This article will review the indications for chest CTA, technical considerations and protocol in the evaluation of the systemic pulmonary circulation, as well as the imaging features of this circulation with emphasis on the normal and pathological imaging features to better correlate with the clinical presentation.

Rare multiple combined anomaly of the vertebral vessels and bronchial artery.

Reported herein is a rare case of multiple vascular anomalies involving the vertebral vessels and the bronchial artery. In the present case the vertebral artery, which normally originates from the subclavian artery, arose directly from the cranial side of the aortic arch, just between the left common carotid and subclavian artery. Furthermore, the bilateral entry of the vertebral artery deviated to the upper level of the transverse foramen of the cervical vertebrae (C5). In addition, the left vertebral vein went through the transverse canal via the 5th and 7th transverse foramen, and drained into the left venous angle. Another conspicuous variation observed in this cadaver was the bronchial artery stemming from the left subclavian artery. This phenotype is an additional branch of bronchial arteries, which in normal cases arises from the descending aorta. These two anomalies could be explained by the deviation of the anlage for the left subclavian artery. The present report should be of interest for the clinician with regard to vascular anomalies in the neck and thoracic region, and may give insight into elucidating the developmental mechanism of angiogenesis.

Bronchial arteries and lymphatics of the lung.

Bronchial arteries and bronchial lymphatics participate directly in the normal and pathologic conditions of the lungs and are of more than academic interest. Bronchial arteries and bronchial lymphatics usually are discussed separately, but they are linked when considered anatomically or physiologically. This article describes these highly variable structures.

Correlative anatomy for thoracic inlet; glottis and subglottis; trachea, carina, and main bronchi; lobes, fissures, and segments; hilum and pulmonary vascular system; bronchial arteries and lymphatics.

Because it is relatively inexpensive and universally available, standard radiographs of the thorax should still be viewed as the primary screening technique to look at the anatomy of intrathoracic structures and to investigate airway or pulmonary disorders. Modern trained thoracic surgeons must be able to correlate surgical anatomy with what is seen on more advanced imaging techniques, however, such as CT or MRI. More importantly, they must be able to recognize the indications, capabilities, limitations, and pitfalls of these imaging methods.

Bronchial artery embolization: anatomy and technique.

Transcatheter embolization has become a first-line therapy in the management of hemoptysis. Knowledge of the arterial anatomy and variants is the key to safe and successful procedure.

The Effect of Arterial Curvature on Blood Flow in Arterio-Venous Fistulae: Realistic Geometries and Pulsatile Flow.

Arterio-Venous Fistulae (AVF) are regarded as the "gold standard" method of vascular access for patients with End-Stage Renal Disease (ESRD) who require haemodialysis. However, up to 60% of AVF do not mature, and hence fail, as a result of Intimal Hyperplasia (IH). Unphysiological flow and oxygen transport patterns, associated with the unnatural and often complex geometries of AVF, are believed to be implicated in the development of IH. Previous studies have investigated the effect of arterial curvature on blood flow in AVF using idealized planar AVF configurations and non-pulsatile inflow conditions. The present study takes an important step forwards by extending this work to more realistic non-planar brachiocephalic AVF configurations with pulsatile inflow conditions. Results show that forming an AVF by connecting a vein onto the outer curvature of an arterial bend does not, necessarily, suppress unsteady flow in the artery. This finding is converse to results from a previous more idealized study. However, results also show that forming an AVF by connecting a vein onto the inner curvature of an arterial bend can suppress exposure to regions of low wall shear stress and hypoxia in the artery. This finding is in agreement with results from a previous more idealized study. Finally, results show that forming an AVF by connecting a vein onto the inner curvature of an arterial bend can significantly reduce exposure to high WSS in the vein. The results are important, as they demonstrate that in realistic scenarios arterial curvature can be leveraged to reduce exposure to excessively low/high levels of WSS and regions of hypoxia in AVF. This may in turn reduce rates of IH and hence AVF failure.

Major aorto-pulmonary collateral arteries of patients with pulmonary atresia and ventricular septal defect are dilated bronchial arteries.

OBJECTIVE: To test the hypothesis that major aorto-pulmonary collaterals (MAPCAs) have the same anatomy as bronchial arteries. METHODS: Two hundred and thirty-eight angiographies performed on 61 patients with pulmonary atresia, ventricular septal defect (VSD), and MAPCAs constituted the basis for this study. This represented all available angiographies performed on this patient group at our institution during the period 1972-2001. MAPCA anatomy was compared to bronchial artery anatomy as described in previous publications. RESULTS: Each patient had one to five MAPCAs (mean 3.2+/-0.94). A mean of 2.6+/-0.66 MAPCAs came from the descending aorta. MAPCAs with anatomy similar to right intercosto-bronchial arteries were found in 87% of the patients. Fifty percent of the patients had MAPCAs originating from the subclavian artery regions. These numbers were all similar to those previously described for bronchial arteries. All MAPCAs had anatomy similar to bronchial arteries. The distribution in different branching patterns of MAPCAs arising from the aorta was similar to the distribution of bronchial arteries described in previous angiographic studies (p=0.32 and p=0.24). CONCLUSIONS: In patients with pulmonary atresia and VSD, MAPCAs are likely to be dilated bronchial arteries. Bronchial arteries may have limited growth potential and their known vasoreactivity might preclude any long-term beneficial effects of unifocalization procedures.