Bronchial artery embolization for coughing up blood (hemoptysis)

Why people cough up blood

Hemoptysis means coughing up blood from the lungs or airways. In India the commonest causes include old tuberculosis scarring with a fungal ball, bronchiectasis, active tuberculosis, other lung infections and lung cancer. In these conditions the bronchial arteries, which normally supply the airways, enlarge and form fragile vessels that bleed under high pressure. Most episodes are small, but a large bleed (often defined as more than a few hundred millilitres a day) can threaten life by flooding the airways.

First steps are emergency care

If you are coughing up significant blood, go to an emergency department. Doctors protect the airway, lie you with the bleeding side down if it is known, give oxygen, correct clotting problems, and may give tranexamic acid. A CT angiogram of the chest then maps the bleeding source and the arteries involved. BAE is used when bleeding is large, repeated, or not controlled by medicines.

How BAE is done

BAE usually takes 1 to 2 hours.

• A CT angiogram identifies the bronchial arteries and other arteries feeding the diseased lung.
• Under local anaesthetic, a catheter enters the artery at the groin or wrist and is guided under X-ray to the bronchial arteries.
• Contrast dye shows enlarged, tortuous arteries and the bleeding area.
• A smaller microcatheter is placed beyond any branches to the spinal cord, and the artery is blocked with tiny particles, coils or glue.
• Other arteries that feed the area from outside the bronchial system are also checked and treated if needed.

What the evidence shows

A meta-analysis of 12 studies (three randomised trials and nine cohorts) with 1,231 patients compared BAE with conservative treatment. BAE gave higher clinical success (92.2% against 80.9%), lower recurrence (26.5% against 34.6%) and lower hemoptysis-related mortality (0.8% against 3.2%), with major complications in 0.2% ^[1]. A larger meta-analysis of 32 studies and 6,032 patients found technical success in 97.2%, clinical success in 93.2%, recurrence in 24.8%, and a major complication rate of 0.1%. Clinical success was lower in people with lung cancer than in benign disease, and glue or coils had lower recurrence than gelatin sponge ^[2].

Risks

Chest pain, difficulty swallowing and fever for a few days are common and settle with medicines. Major complications are rare, at about 0.1 to 0.2% in pooled data ^{[1, 2]}, and include spinal cord injury from embolization of a vessel that also supplies the spinal cord (avoided by careful technique), stroke, bowel or skin ischaemia and damage at the access site.

After BAE: treating the cause

BAE controls the bleeding, but the cause remains. Tuberculosis needs full treatment, bronchiectasis needs chest physiotherapy, antibiotics and control of infections, and a fungal ball or a localised damaged lobe may need surgery when you are fit. Bleeding returns in about a quarter of people ^[2], and repeat embolization is possible. Stopping smoking and regular follow-up with a chest physician are important.

Cost and insurance

Health insurance can cover these procedures, subject to your policy terms. The cost depends on the hospital, the devices used and the length of stay, and is explained once the plan is made after consultation and a review of your scans. Cashless treatment can be arranged with major Indian health insurers and TPAs, and credit treatment is available for CGHS and Singareni beneficiaries. Eligibility is confirmed after a policy check.