J Thorac Cardiovasc Surg 2007;133:1106-1108
© 2007 The American Association for Thoracic Surgery
Massive hemoptysis: Successful treatment with surgical ligation of the thyrocervical artery
Benjamin Planquette, MDa,
Patrick Bagan, MDb,
Amanda Cox, MDb,
Judith Valcke, MDa,
Marc Riquet, MDb,*
a Department of Pulmonology, Georges Pompidou European Hospital, Paris V University, Paris, France
b Department of Thoracic Surgery, Georges Pompidou European Hospital, Paris V University, Paris, France.
Received for publication August 6, 2006; accepted for publication September 1, 2006.
* Address for reprints: Dr Riquet, service de Chirurgie Thoracique, Hôpital Européen Georges Pompidou, 20-40 rue Leblanc, 75908 Paris, France. (Email: marc.riquet{at}egp.aphp.fr).
Bronchial artery embolization (BAE) is an effective treatment for massive hemoptysis and has a primary success rate of 94% owing to blood flow interruption. The morbidity rate of BAE is low compared with that of emergency lung resection.1
We report a case of recurrent massive hemoptysis after primary BAE and further controlled by surgical ligation of the left thyrobicervical artery.
Clinical Summary
A 57-year-old man was admitted to our hospital for recurrent hemoptysis. The patient had a history of pulmonary tuberculosis with a previous episode of hemoptysis, which required a BAE, 20 years ago. Coronary artery bypass grafting (CABG) was performed following a myocardial infarction, using both right and left internal thoracic arteries. Six months later, a moderate hemoptysis (10 to 20 mL) occurred without any other symptoms, but because of increasing bleeding, the patient was admitted 4 days later. At admission, there was no respiratory distress and no fever. The chest radiograph showed retractile opacities in the left upper lobe and interstitial infiltrate in the lower left lobe. The fiber-optic bronchoscopy confirmed bleeding from the lingula. Primary angiography demonstrated that the left upper bronchus was vascularized by a collateral artery of the thyrobicervical trunk (Figure 1, A). Hyperselective catheterization of this vessel and BAE with microparticles (500-900 µm) appeared to be complete (Figure 1, B). The patient required mechanical ventilation during this procedure because of a respiratory failure due to massive hemoptysis exacerbation.
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Figure 1. A, Angiogram showing the bleeding from collateral of the left thyrobicervical artery. B, Postembolization control angiogram.
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However, bleeding confirmed by bronchoscopic examinations was still persistent in the same territory 12 hours after embolization, and surgery was deemed necessary for a radical treatment. The patient’s general status was critical and left upper lobectomy seemed a dangerous operation. A first attempt at left thyrocervical artery ligation was also proposed. The patient was operated on under general anesthesia. A 5-cm left supraclavicular cervicotomy surgical approach was used. After isolation of the left thyrocervical artery, ligation was performed by surgical clipping at its origin (Figure 2). The operation lasted 30 minutes. The hemoptysis stopped and did not recur; the patient was extubated 2 days later. A computed tomography scan was then performed and showed the presence of cavitating nodules, suggesting thoracic aspergilloma. The patient recovered a good condition, and an upper left lobectomy was performed 8 weeks later. The postoperative course was uneventful, and the patient is still doing well 10 months later.
Discussion
Thoracic surgery is not considered with that of an appropriate initial treatment for severe hemoptysis, because the mortality rate is high compared with that of extensive pulmonary resection.2 BAE is successful for immediate control of bleeding in 77% to 94% of patients with a life-threatening hemoptysis.1,2 Relapse of bleeding after first successful BAE can occur in 16% of patients.3 This recurrence rate is probably influenced by the etiologic disease and the bleeding artery. Bronchial arteries with abnormal origin occur in 8.3% of cases of recurrent hemoptysis.4 This condition is supposed to lead to a higher risk of relapse.4,5 The left thyrobicervical arterial trunk has a high risk of relapse, with a frequency rate of 8% of abnormal arteries causing severe hemoptysis (n = 2/24).4 In our case, the atypical vascularization was probably induced by the primary embolization of the bronchial artery 20 years ago and aggravated by the use of left internal thoracic artery for CABG, which could have induced the development of collaterals from the subclavian artery.
Some bronchial vascular abnormalities issuing from the subclavian artery (internal thoracic artery, thyrobicervical arterial trunk) may be directly accessible to minimally invasive surgical procedures to interrupt hemoptysis without emergent pulmonary resection. In cases of postembolization life-threatening hemoptysis recurrence, we suggest taking an angiogram to look for an ectopic artery accessible to surgical ligation.
References
- Kato A, Kudo S, Matsumoto K, et al. Bronchial artery embolization for hemoptysis due to benign diseases: immediate and long-term results. Cardiovasc Intervent Radiol 2000;23:351-357.[Medline]
- Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999;115:996-1001.[Medline]
- Moore LB, Mc Wey RE, Vujic I. Massive hemoptysis: control by embolization of the thyrocervical trunk. Radiology 1986;161:173-174.[Abstract/Free Full Text]
- Sancho C, Escalante E, Dominguez J, et al. Embolization of bronchial arteries of anomalous origin. Cardiovasc Intervent Radiol 1998;21:300-304.[Medline]
- Cohen AM, Antoun BW, Stern RC. Left thyrocervical trunk bronchial artery supplying right lung: source of recurrent hemoptysis in cystic fibrosis. AJR Am J Roentgenol 1992;158:1131-1133.[Free Full Text]
