ARRS 2022 Abstracts

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E1877. Coils In The Air-way: Massive Hemoptysis Due To Bronchovascular Fistula
Authors
  1. Brianna Oliver; University of Michigan
  2. Taylor Schoenheit; University of Michigan
  3. Hassan Anbari; University of Michigan
Background
Massive hemoptysis is categorized as 100 mL/hr or anywhere from 100–600 mL in 24 hours with respiratory or hemodynamic compromise. Both diagnostic and interventional radiology are often involved in the initial diagnosis and management of massive hemoptysis. It is essential radiologists recognize both common and uncommon etiologies of hemoptysis from both bronchial and pulmonary arteries, as the mortality rate from massive hemoptysis is high. There are many etiologies for hemoptysis, with the most common causes for massive hemoptysis in the adult population being infection/inflammation and cancer. A rarer cause, but one that can be quickly devastating, is a bronchovascular fistula; therefore, radiologists need to understand this etiology and possible treatment.

Educational Goals / Teaching Points
The goals of this exhibit are to understand classification of hemoptysis and initial clinical evaluation; identify the possible causes of massive hemoptysis and radiologic associations; understand the technical aspects of pulmonary artery embolization, pitfalls, and how to identify different potential hemorrhagic etiologies; and understand the findings associated with bronchovascular fistula and potential treatment.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Massive hemoptysis is most commonly initially evaluated clinically and with bronchoscopy. Initial imaging evaluation is often performed with CTA, which could show nonspecific parenchymal changes, abnormally hypertrophied pulmonary or bronchial arteries, and, very rarely, active bleeding with contrast. When a vascular etiology is suspected, this can be further evaluated and possibly treated with intervention radiology under guidance from conventional angiography and digital subtraction angiography. Once identified, a combination of catheters and microcatheters are used to obtain distal access for further evaluation and possible treatment. Due to the large variety of etiologies of hemoptysis, care must be taken to ensure flow is fully evaluated with appropriate angiography prior to embolization, as off-target embolization can be devastating. As with this case, intraprocedural imaging finds can be used in conjunction with clinical picture and bronchoscopy to help evaluate rare or unexpected etiologies.

Conclusion
Massive hemoptysis is a clinical condition that carries a high morbidity and mortality. Imaging is often used in close conjunction with clinical evaluation and bronchoscopy to evaluate etiology and potential treatments. In hereditary hemorrhagic telangiectasia (HHT), pulmonary arteriovenous malformations are common reasons for hemoptysis, with bronchovascular fistula being a very rare etiology. This diagnosis was aided by the multidisciplinary team that treats HHT in our institution. Endovascular therapy can often be successful in these patients and serve as a possible bridge to other options such as surgery.