EARLY SURGICAL INTERVENTION CAN BE NECESSARY: PERSISTENT MASSIVE HEMOPTYSIS DESPITE EMBOLIZATION AND BLOCKADE

Abstract

SESSION TITLE: Critical Care 5 SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/09/2018 01:15 PM - 02:15 PM INTRODUCTION: Massive hemoptysis is a life-threatening condition due to the potential for asphyxiation or exsanguination. Commonly causes are bronchiectasis, bronchogenic carcinoma and infectious etiologies such as tuberculosis and pneumonia. Management involves localization of the bleeding source via bronchoscopy or computerized tomographic (CT) angiography with subsequent non-surgical or surgical intervention to control the bleeding. We present a case of massive hemoptysis secondary to bronchiectasis, unresponsive to bronchoscopic intervention and bronchial artery embolization (BAE), requiring definitive surgical lobectomy. CASE PRESENTATION: A 67-year-old male was admitted for evaluation of persistent hemoptysis in setting of moderate chronic obstructive pulmonary disease (COPD) and recent percutaneous biopsy of liver mass. Examination revealed rales in right lower lung base. CT of the thorax showed emphysematous changes with multiple blebs and lower-lobe honeycomb fibrotic thickening. Continued episodes of hemoptysis prompted bronchoscopic evaluation. Right lower lobe visualization revealed active bleeding from lateral and posterior segments. Despite epinephrine administration and iced saline lavage, bleeding persisted. Balloon tamponade with an endobronchial blocker was introduced into the right lower lobe and left in place. Interventional radiology consulted for arteriographic embolization. Balloon deflation after 24 hours revealed active persistent bleed. Cardiothoracic surgery was consulted and performed an emergent lobectomy. Gross pathology revealed no pleural disruption to support the notion that liver biopsy might have precipitated hemoptysis. Microscopy revealed reactive pneumocytes and significant airway ectasia. DISCUSSION: Angiography followed by BAE is the preferred management for massive hemoptysis in poor surgical candidates. In COPD both bronchiectatic and cryptogenic hemoptysis responds favorably to BAE. It has been reported as definitive treatment in both cystic and non-cystic fibrosis bronchiectasis. BAE is effective in controlling hemoptysis with success rates ranging from 70-90%. Recurrence rates vary from 10 to 57%.(1) Early recurrences occur secondary to lack of localization and inadequate embolization of all the feeding vessels. Despite high operative risks, our patient was managed with emergent lobectomy due to persistent bleeding. Emergent surgery in massive hemoptysis is associated with mortality rates up to 40%. BAE can be used as a bridge to stabilize patients before surgical treatment with an elective mortality rate 18%. (2) A retrospective analysis comparing the mortality and morbidity cohort of patients who underwent surgery after BAE vs those with early surgical intervention found no difference in outcomes.(3) CONCLUSIONS: Early surgical consultation is warranted for life-threatening massive hemoptysis in the setting of unsuccessful endobronchial blockade and BAE. Reference #1: Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol. 2017;23(4):307-17. Reference #2: Fruchter O, Schneer S, Rusanov V, Belenky A, Kramer MR. Bronchial artery embolization for massive hemoptysis: long-term follow-up. Asian Cardiovasc Thorac Ann. 2015;23(1):55-60. Reference #3: Alexander GR. A retrospective review comparing the treatment outcomes of emergency lung resection for massive hemoptysis with and without preoperative bronchial artery embolization. Eur J Cardiothorac Surg. 2014;45(2):251-5. DISCLOSURES: No relevant relationships by Francis Christian, source=Web Response No relevant relationships by Sardar Ijaz, source=Web Response No relevant relationships by Kellie Jones, source=Web Response No relevant relationships by Erin Shirley, source=Web Response