British Journal of Radiology (2006) 79, e171-e173
© 2006 British Institute of Radiology
doi: 10.1259/bjr/43298285
Bronchial artery arising from the left gastric artery in a patient with massive haemoptysis
H S In, MD
J-I Bae, MD
A-W Park, MD
Y W Kim, MD
and
S J Choi, MD
Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, 633-165, Gaegeum 2-dong, Busanjin-gu, Busan 614-735, Republic of Korea
Correspondence: Jae-Ik Bae, Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, 633-165, Gaegeum 2-dong, Busanjin-gu, Busan 614-735, Republic of Korea. E-mail: jaeikbae{at}naver.com.
 |
Abstract
|
|---|
This report describes a bronchial artery originating from the left gastric artery in a patient with recurrent massive haemoptysis caused by chronic pulmonary tuberculosis. The artery was not evident on the initial angiographic work-up including thoracic aortography, but it was evident in the selective angiography upon follow-up study. Haemoptysis was successfully controlled with transarterial embolisation. The left gastric artery should be included as a location for the possible origin of the bronchial artery.
|
Introduction
|
|---|
Massive haemoptysis is one of the most dreaded of all respiratory emergencies and is defined as a pulmonary haemorrhage of or more than 300 ml within 24 h [1–10]. In patients with chronic inflammatory lung disease complicated by massive haemoptysis, bronchial artery embolisation has become an accepted treatment option [1–3]. Persistent haemoptysis after successful bronchial artery embolisation is often due to the failure to recognize the involvement of non-bronchial collaterals (NBC) [4, 5] or bronchial arteries of anomalous origin (BAAO) [6]. BAAO are defined as arteries with origins outside the descending thoracic aorta between the T4 and T6 vertebrae with an intrapulmonary course along the major bronchi. It is well recognized that BAAO can arise from the aortic arch, the subclavian artery, the internal mammary artery, the thyrocervical trunk, the intercostal artery, or the descending thoracic aorta [6–10]. Systemic non-bronchial collaterals enter the parenchyma via the pulmonary ligament or through adherent pleura and have courses that are not parallel to the bronchi [5–7]. However, the bronchial artery arising from the left gastric artery (LGA) is extremely rare. We describe a bronchial artery arising from the LGA and suggest possible explanations of its origin.
|
Case report
|
|---|
A 62-year-old man presented with active haemoptysis exceeding 300 ml during 1 h. He had a history of pulmonary tuberculosis. The chest radiograph and CT showed pulmonary parenchymal scarring with pleural thickening involving the entire left thorax and right apex caused by chronic tuberculosis (Figure 1
). Angiographic work-up included a thoracic aortography and showed an enlarged right intercostobronchial artery, but the left bronchial artery could not be found despite further examination. Selective studies of possible systemic arteries revealed multiple NBC arising from the left intercostal and the inferior phrenic arteries. The inferior phrenic arteries originated directly from the aorta (Figure 2). They supplied areas of increased vascularity within some of which systemic artery to pulmonary artery shunting was evident. Transcatheter embolisation of the right bronchial artery and multiple NBC were performed using absorbable gelatin sponge (Spongostan; Ferrosan, Soeborg, Denmark) and bleeding ceased immediately, so further intervention and angiographic assessment were not performed.
View larger version (130K):
[in this window]
[in a new window]
|
Figure 1. Plain chest radiography demonstrates right apical scarring and severe parenchymal destruction of left lung with irregular pleural thickening.
|
|
View larger version (79K):
[in this window]
[in a new window]
|
Figure 2. Left inferior phrenic arteries(arrows) arising from (a) the right inferior phrenic artery and (b) directly from the aorta are enlarged and hypertrophied. Abnormal hypervascularity in the left lower lung with systemic-pulmonary shunting is evident.
|
|
7 days following the first procedure, massive haemoptysis recurred abruptly. The left bronchial artery was still not evident on the second angiographic work-up, which included a thoracic aortography, thus selective angiographies of the branches arising from the upper abdominal aorta were performed. A selective angiography of the LGA revealed a branch which ascended to the left pulmonary hilum through the mediastinum and entered a hypervascular area in the left middle lung (Figure 3). Haemoptysis was successfully controlled with embolisation of the branch using polyvinyl alcohol particles (Contour; Boston-Scientific, Natick, MA) with a diameter of 350–500 µm and absorbable gelatin sponge. The patient had no further episode of haemoptysis during the following 8 month period.
View larger version (171K):
[in this window]
[in a new window]
|
Figure 3. The left gastric angiography identifies the left bronchial artery(arrows) originating from the left gastric artery (arrowhead). The artery ascends to the left pulmonary hilum through the mediastinum, running along the left main bronchus and enters hypervascular area in the left lung.
|
|
|
Discussion
|
|---|
The origin of the bronchial arteries is variable, with 70–83.3% arising from the descending aorta between the caudal margin of T4 and the cranial margin of T6. Bronchial arteries originating outside this area (16.7–30%) are considered anomalous [7, 9]. These may originate from the aortic arch, the internal mammary artery, the thyrocervical trunk, the subclavian artery, the costocervical trunk, the brachiocephalic artery, the pericardiacophrenic artery, the intercostal artery, the inferior phrenic artery, or the abdominal aorta [6–10]. These can be distinguished anatomically and angiographically from NBCs in that they run along the course of the major bronchi. In contrast, NBCs enter the pulmonary parenchyma through the adherent pleura or via the pulmonary ligament, and their course is not parallel to that of the bronchi [6]. In our investigation, the bronchial artery originating from the left gastric artery has been not reported.
In this patient, the artery was missed even though we performed a thoracic aortography and selective studies of the left subclavian artery, the thyrocervical trunk, the left intercostal arteries and the inferior phrenic arteries on the first session. Unfortunately, the coeliac trunk was not opacified during the selection of the inferior phrenic artery because it originated directly from the aorta apart from the coeliac trunk, in this case, thus we initially overlooked the coeliac trunk and the LGA.
We suggest two possibilities to explain the origin of the artery. First, the artery could be a kind of BAAO, because it obviously ran along the course of the left main bronchus from the pulmonary hilum. Another possibility is that the main trunk of the left bronchial artery was occluded as a result of extensive disease within the left lung and it has then derived a collateral supply from the oesophageal artery arising from the LGA. It is well recognized that oesophagus may derive a supply from bronchial arteries [11].
In conclusion, when the bronchial artery is not easily identified despite selective angiographies of locations for the previously known origins of anomalous bronchial artery, the LGA should be evaluated as a possible site of origin.
Received for publication May 30, 2005.
Revision received January 6, 2006.
Accepted for publication January 16, 2006.
|
References
|
|---|
- Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and nonbronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review. Radiographics 2002;22:1395–409.[Abstract/Free Full Text]
- Remy J, Arnaud A, Fardou H, Giraud R, Voisin C. Treatment of hemoptysis by embolization of bronchial arteries. Radiology 1977;122:33–7.[Abstract]
- Uflacker R, Kaemmerer A, Picon PD. Bronchial artery embolization in the management of hemoptysis: technical aspects and long-term results. Radiology 1985;157:637–44.[Abstract/Free Full Text]
- Vujic I, Pyle R, Hungerford GD, Griffin CN. Angiography and therapeutic blockade in the control of hemoptysis. The importance of non-bronchial systemic arteries. Radiology 1982;143:19–23.[Free Full Text]
- Sellars N, Belli AM. Non-bronchial collateral supply from the left gastric artery in massive hemoptysis. Eur Radiol 2001;11:76–9.[CrossRef][Medline]
- Sancho C, Escalante E, Dominguez J. Embolization of bronchial arteries of anomalous origin. Cardiovasc Intervent Radiol 1998;21:300–4.[CrossRef][Medline]
- Cauldwell EM, Siekert RG, Lininger RE. The bronchial arteries: an anatomic study of 150 human cadavers. Surg Gynecol Obstet 1948;86:395–412.[Medline]
- Rabkin JE, Astafjev VI, Gothman LN, Grigorjev YG. Transcatheter embolization in the management of pulmonary hemorrhage. Radiology 1987;163:361–5.[Abstract/Free Full Text]
- Botenga ASJ. Selective bronchial and intercostal arteriography. Leiden, The Netherlands: H.E. Senfert Kroese, 1970:53–65
- McPherson S, Routh WD, Nath H, Keller FS. Anomalous origin of bronchial arteries: potential pitfall of embolotherapy for hemoptysis. J Vasc Interv Radiol 1990;1:86–8.[Medline]
- Swigart LL, Siekert RG, Anson BJ, Hambley WC, Anson BJ. The esophageal arteries; an anatomic study of 150 specimens. Surg Gynecol Obstet 1950;90:234–43.[Medline]
Top
Abstract
Introduction
