The effect of Angio-CT on the efficacy of hemoptysis patients with non-bronchial systemic arteries—a retrospective study

Introduction

Hemoptysis is a common clinical manifestation associated with various respiratory and pulmonary vascular disorders, including bronchiectasis, pulmonary infections, malignancies, chronic obstructive pulmonary disease, pulmonary sequestration, and vascular malformations (1). Moderate to severe hemoptysis carries substantial clinical risks, such as airway obstruction, asphyxia, and acute hemorrhage, which can be life-threatening (2,3). Bronchial artery embolization (BAE) has emerged as a first-line treatment for acute hemoptysis, offering a minimally invasive alternative to surgery with a short-term success rate of approximately 90% (4). BAE is particularly suitable for patients who are ineligible for operation, those who are intolerant to surgical interventions, or those with significant underlying health issues, as BAE results in less trauma compared to other treatment options, especially surgical procedures (5,6). While the bronchial artery is the predominant source of hemoptysis, non-bronchial systemic arteries (NBSA) may also contribute to bleeding. Failure to detect NBSA involvement during initial BAE can lead to incomplete hemostasis or hemoptysis recurrence (7).

Angiogram computed tomography (Angio-CT) is an innovative imaging modality that combines real-time angiography with high-resolution computed tomography (CT) scanning during interventional procedures by integrating a flat-panel angiography system with a CT scanner. This hybrid approach enhances precision in interventional therapy (8,9). Studies indicated that Angio-CT ac achieves therapeutic outcomes similar to cone-beam CT (CBCT) in post-transcatheter arterial chemoembolization (post-TACE) radiofrequency ablation while significantly reducing radiation exposure (10,11). Furthermore, Angio-CT not only excels in TACE applications but also enhances the identification of responsible blood vessels during BAE for hemoptysis. The enhanced CT scanning of patients’ arteries during the BAE procedure provides superior visualization of targeted vessels compared to traditional computed tomographic angiography (CTA) (12).

To systematically assess the clinical value of Angio-CT in the management of NBSA-related hemoptysis, we designed this comparative study evaluating the safety, efficacy, and long-term outcomes between BAE guided by Angio-CT and conventional BAE. As the first investigation focusing on the application of Angio-CT in NBSA-related hemoptysis, our findings are expected to provide evidence-based guidance for optimizing treatment strategies in hemoptysis patients. We present this article in accordance with the STROBE reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2024-694/rc).

Methods

Study population

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (No. 0755-01). Informed consent was obtained from all participants. This study conducted a retrospective analysis of patients with hemoptysis who underwent BAE in Huazhong University of Science and Technology, Tongji Medical College Affiliated Union Hospital between January 2020 and June 2024. The inclusion criteria were as follows: (I) adult patients; (II) diagnosed with hemoptysis and bleeding volume ≥30 mL per day. The exclusion criteria were as follows: (I) a history of BAE treatment for hemoptysis in the past; (II) incomplete clinical data or loss to follow-up; (III) severe dysfunction cardiopulmonary function or hepatic and renal function; (IV) technical failure; (V) women in pregnancy or lactation. Following the inclusion and exclusion criteria, a total of 100 patients were eventually included in this study. The enrolled patients were divided into two groups based on the therapy they received: BAE combined with Angio-CT group and conventional BAE group. After 1-month post-discharge, we conducted follow-up assessments with the patient through outpatient visits or telephone consultations. Subsequently, we performed telephone follow-ups every 6 months. The follow-up endpoints include hemoptysis recurrence and patient death, and all patients were followed up until August 31, 2024. Hemoptysis recurrence is defined as the patient experiencing hemoptysis again and the amount of hemoptysis is greater than or equal to 30 mL. A total of 100 patients were included in this study, with 40 (40%) patients in the conventional BAE group and 60 (60%) patients in the Angio-CT combined group. 40 patients experienced hemoptysis due to NBSA, comprising 14 patients from conventional BAE group and 26 patients Angio-CT group. The baseline characteristics of the patients are listed in Table 1.

Bronchial artery embolization procedures

All patients will undergo a routine CTA examination prior to BAE operation. All BAE procedures were performed by experienced interventional radiologists with at least five years of expertise. In the Angio-CT group, patients underwent BAE guided by Angio-CT—an advanced imaging modality developed at our institution as an alternative to CBCT for arterial assessment. The procedural protocol was as follows: after local anesthesia, vascular access was obtained via the right femoral artery. A 5F catheter (Cobra catheter, Rosch left gastric catheter, or Mikaelsson catheter; Cook, USA) was introduced into the descending aorta for initial angiography to identify bilateral bronchial arteries. Selective catheterization of the bronchial arteries was then performed, followed by contrast injection to evaluate vascular morphology (including arterial tortuosity and hypertrophy) and detect potential contrast extravasation, indicative of active bleeding. If bronchial artery angiography revealed no abnormalities, we systematically evaluated potential NBSA sources—including intercostal, subclavian, and internal mammary arteries—using the same catheterization approach. Once the primary vessel responsible for hemoptysis is identified, we would use one or more embolic materials based on the thickness of the blood vessels , such as polyvinyl alcohol (PVA), gelatin sponges (GS), or spring coils, to occlude the vessel according to its diameter (the typical sizes for PVA particles and GS ranged from 300 to 700 µm), while the standard size for spring coils was depended on the diameter of the offending vessels (usually 1–2 mm thicker than blood vessels, commonly using 2–8 mm spring coils). For enlarged arteries and where the bleeding point was located deeply, we would utilize a 2.4F microcatheter for super-selection. It is worth noting that when the blood vessel to be occluded shares the same trunk as the intercostal artery or when the intercostal artery needs to be occluded, we would inject lidocaine to observe whether the patient experiences symptoms such as numbness in the fingertips to ensure that non-target embolization won’t occur. The key difference in intraoperative procedures between the two groups is that patients in the Angio-CT group will receive enhanced CT scans during operation to better localize the responsible artery. In addition, the treatment method that only treats the embolization of NBSA without embolization of the bronchial artery is called hemoptysis treatment. We presented a series of imaging studies from one of the patients, including preoperative CTA, intraoperative Angio-CT, pre-embolization digital subtraction angiography (DSA), and post-embolization DSA (Figure 1).

Figure 1 Imaging of patients with hemoptysis based on Angio-CT. (A) Preoperative CTA; (B) intraoperative Angio-CT demonstrating thickening of the intercostal arteries (red arrow); (C) DSA of the right intercostal artery showing abnormal staining (red circle); (D) DSA following embolization of the right intercostal artery. Angio-CT, angiogram computed tomography; CTA, computed tomography angiography; DSA, digital subtraction angiography.

Definitions

Clinical success was defined as either complete cessation of hemoptysis or a substantial decrease (>50%) in hemoptysis volume during the post-procedural hospitalization period. Technical success was achieved when the catheter or microcatheter was successfully positioned in the target artery, followed by complete occlusion of the vessel through embolization. Major complications were categorized as procedure-related adverse events (e.g., non-target embolization or spinal artery thrombosis) requiring extended hospitalization, causing permanent disability, or resulting in mortality (13). Hemoptysis-free survival was defined as the duration from the date of BAE to the occurrence of hemoptysis recurrence or death. Recurrence was defined as the patient experiencing hemoptysis again during follow-up, with a hemoptysis volume of ≥30 mL. This condition significantly impacts their daily life and necessitates interventions such as BAE or endoscopic treatment.

Statistical analysis

All results were expressed as either mean or median along with the interquartile range (IQR). A two-tailed unpaired Student’s t-test was utilized to analyze continuous variables between the two groups, while the Chi-squared test was employed to compare categorical data. Hemoptysis-free survival and overall survival were illustrated using Kaplan-Meier curves. The log-rank test was used to assess the differences in hemoptysis-free survival and overall survival between the two groups. All analyses were conducted using SPSS software, version 26.0 (IBM, Armonk, New York), while survival curves were plotted using GraphPad Prism software. A two-sided P value of less than 0.05 was considered statistically significant.

Results

Basic characteristics

Among all patients with hemoptysis, lung cancer (30/100, 30%) is the most common cause, followed by bronchiectasis (25/100, 25%). There were no statistically significant differences between the two groups in terms of patients’ age, gender, volume of hemoptysis, underlying etiology, history of smoke, history of hypertension, types of embolic materials and the specific blood vessels (all P>0.05). The results are presented in Table 1.

Technical success and clinical success

Technical success was achieved in all patients. There were no statistically significant differences in the clinical success rates between the conventional BAE group (90.0%) and the Angio-CT group (91.7%) (P=0.78).

Adverse reaction

All patients did not experience any serious adverse reactions. Among the patients in the two groups, nausea, vomiting, low-grade fever, poor appetite, and chest pain were the most frequently reported adverse reactions, all of which were closely associated with common post-thrombotic syndrome. Most patients’ adverse reactions can be relieved or disappear in a short period of time. Additionally, there were no significant differences in the occurrence of these common adverse reactions between two groups (P=0.68). The results are presented in Table 2.

Follow-up

As of the follow-up endpoint on August 31, 2024, the median follow-up time for all patients was 17 months. In the conventional BAE group, 11 (27.5%) patients experienced recurrent hemoptysis, whereas in the Angio-CT combined group, only 7 (11.7%) patients had a recurrence of hemoptysis. And hemoptysis-free survival was significantly improved in the Angio-CT combined group compared to conventional BAE group (P=0.04) (Figure 2). Additionally, we categorized patients based on the presence of NBSA. The results indicated that among patients with NBSA, the Angio CT group exhibited a higher recurrence rate without hemoptysis compared to the traditional BAE group (P=0.04). In contrast, there was no significant difference in recurrence rates between the two groups of patients without NBSA (P=0.68) (Figure 3A,3B).

Figure 2 Comparison of hemoptysis-free survival between two groups. Angio-CT, angiogram computed tomography; BAE, bronchial artery embolization.

Figure 3 Comparison of hemoptysis-free survival of NBSA or non-NBSA. (A) Patients with NBSA; (B) patients without NBSA. Angio-CT, angiogram computed tomography; BAE, bronchial artery embolization; NBSA, non-bronchial systemic arteries.

Discussion

BAE has emerged as a safe and effective first-line intervention for hemoptysis management across various etiologies and severity levels (14-16). However, post-procedural recurrence rates remain substantial, ranging from 10–30% in reported series (17,18). The principal factors contributing to recurrence include incomplete initial embolization, subsequent vessel recanalization, and undetected NBSA contributions (5). Angio-CT, an innovative hybrid imaging platform integrating DSA with conventional CT, provides enhanced vascular visualization. Recent evidence demonstrates its superior efficacy in BAE procedures for hemoptysis control (12). This technology synergizes cross-sectional CT imaging with real-time fluoroscopy, enabling improved intraprocedural vessel identification that translates to higher technical success and lower recurrence rates (9).

Our study revealed a marked disparity in recurrence rates between treatment approaches: 27.5% (11/40) in conventional BAE versus 11.7% (7/60) in the Angio-CT cohort. Notably, among NBSA cases, recurrence rates differed dramatically (35.7% vs. 7.7%, respectively). These findings underscore that recurrence mechanisms extend beyond technical factors (incomplete embolization or missed NBSA) to include the fundamental limitation of BAE as a symptomatic rather than curative treatment (19). Importantly, Angio-CT implementation significantly reduced hemoptysis recurrence across all follow-up periods while maintaining comparable overall survival and mortality rates between groups - findings consistent with existing literature (20,21).

While pulmonary tuberculosis and bronchiectasis traditionally dominate hemoptysis etiologies (22,23), our cohort demonstrated a distinct pattern with relatively fewer tuberculosis cases than lung cancer patients. This epidemiological shift may reflect both the rising incidence of lung malignancies and potential underdiagnosis of tuberculosis in transferred emergency patients from peripheral hospitals. Anatomically, most hemoptysis cases originate from bronchial artery abnormalities, with NBSA accounting for a minority of cases that are frequently overlooked in conventional BAE (2,24). Our NBSA distribution (intercostal artery: 40%; subphrenic artery: 25%; thoracic artery: 7.5%; subclavian artery: 12.5%) corroborates prior anatomical studies (2,24). The clinical success rates in our series (conventional: 90%; Angio-CT: 91.7%) exceed historical benchmarks (75%) (25,26), potentially attributable to operator expertise and Angio-CT integration. Notably, NBSA cases, which typically show 60% success rates in literature (2), benefited particularly from the advanced imaging. Technical success was universally achieved (100%), consistent with contemporary reports (20,27).

The safety profiles of both treatment groups were comparable, with no statistically significant differences in adverse events observed. Consistent with established literature (28,29), patients undergoing BAE commonly experience transient post-procedural symptoms including fever (38–39 ℃), nausea/vomiting, cough, chest discomfort, and mild dysphagia. These manifestations, primarily attributable to post-embolization syndrome, were universally self-limiting in our cohort, with complete resolution typically occurring within 48 hours. The most catastrophic potential complication of BAE—spinal cord ischemia leading to paraplegia—results from inadvertent embolization of the spinal artery. This risk is anatomically determined when: (I) the bronchial artery shares a common trunk with the intercostal artery, or (II) the bleeding originates from an intercostal artery that gives rise to the spinal artery (30,31). Other non-target embolization sequelae (e.g., bronchial wall infarction or transient dysphagia) can be largely prevented through operator experience and precise technique. Notably, our study demonstrated an exemplary safety profile: no cases of spinal artery embolism occurred in either group, and while all patients experienced 1–3 expected minor adverse reactions, these resolved spontaneously within 24–48 hours. These outcomes highlight the combined protective value of procedural expertise and Angio-CT’s enhanced visualization capabilities in minimizing complications.

To date, the issues of high recurrence rates and low detection rates of NBSA involvement in patients experiencing hemoptysis after BAE operation persist. Clinically, it is widely believed that more meticulous surgical techniques can help reduce recurrence rates, independent of the type and diameter of embolic materials used. In this study, results showed that the recurrence rate was lower in patients who underwent BAE with Angio-CT compared to those who used conventional DSA, particularly among patients with NBSA. And in patients with NBSA, the Angio CT group had a higher recurrence rate of hemoptysis than the traditional BAE group. Therefore, we believe that Angio-CT is more effective in detecting all instances of NBSA and facilitating embolization and conventional DSA has certain limitations in this regard. Meanwhile, we conclude that utilizing Angio-CT during BAE operation can significantly reduce the risks associated with surgical errors and oversights. However, there are still some limitations in this study, including (I) due to regional and medical environment limitations, the sample size of this study remains relatively small, despite the extended inclusion period; (II) the retrospective nature of the study means that the identification of NBSA involvement largely depends on the surgeon’s skill level, which may introduce bias in the reported number of NBSA patients. And given the retrospective nature of this study, there may be confounding biases that have led to certain differences in etiology between the two patient groups. (III) Given the small sample size in our study, it’s essential to include more patients from multiple centers for robust statistical validation.

Conclusions

In conclusion, Angio-CT is a valuable method that enhances the performance of BAE operation and we believe that Angio-CT is more effective in detecting all instances of NBSA and facilitating embolization. It has the potential to reduce recurrence rates in patients following the procedure while maintaining efficacy. Therefore, when conditions allow, it is advisable to choose a facility equipped with Angio-CT for the BAE treatment of patients experiencing hemoptysis.

Acknowledgments

We thank all the medical workers in our department for their assistance with the study, and thank Osamah Alwalid for his help in polishing our paper.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2024-694/rc

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2024-694/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-2024-694/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-2024-694/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (No. 0755-01). Informed consent was obtained from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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