Severe hemoptysis of pulmonary arterial origin - Signs and role of multidetector row CT angiography

Background: Hemoptysis of pulmonary arterial origin is a diagnostic challenge in patients admitted to a respiratory ICU (RICU) for treatment of hemoptysis. Its early accurate recognition and treatment reduce morbidity and prevent mortality. Multidetector row CT angiography (MDCTA) is an accurate method for imaging the systemic vascular network. Our aim was to assess the MDCTA signs and role in managing hemoptysis of pulmonary arterial origin. Methods: We performed a retrospective clinical and radiologic analysis of all consecutive patients who were referred for severe hemoptysis to our RICU and were treated by endovascular means between January 2004 and December 2006. We reviewed all of those cases with hemoptysis of pulmonary arterial origin. Results: Of 272 patients who were referred for severe hemoptysis to the RICU, 189 patients were treated by endovascular means. Thirteen patients (nine men, four women; mean age, 45 years) had hemoptysis of pulmonary arterial origin. Signs of pulmonary arterial hemoptysis seen on MDCTA were of the following three types: pseudoaneurysm (n = 5); aneurysm of the pulmonary artery (n = 3); or the presence of a pulmonary artery in the inner wall of a cavity (n = 5). Hypertrophy of the bronchial arteries seen on MDCTA associated with any of these signs predicted the necessity to treat both the bronchial and pulmonary arteries. Pulmonary artery vasoocclusion was performed as a first treatment in eight patients with such an association (n = 1) or without such an association (n = 7) along with bronchial artery embolization. The remaining five patients were treated with systemic artery embolization, followed by surgery (n = 1) pulmonary artery vasoocclusion (n = 3), and death from massive hemoptysis (n = 1). Conclusions: MDCTA performed prior to endovascular treatment allows the correct identification and early appropriate management of severe hemoptysis of pulmonary arterial origin.