Bronchial artery malformations are rare entities that have been described as aneurysmal or as racemose hemangiomas (1). Previously described etiologies include bronchiectasis, cystic fibrosis, Osler Weber Rendu Syndrome, sarcoidosis (2), silicosis, pulmonary artery agenesis, conditions causing high flow states such as athersclerosis or surgically created shunts, (3) and infections by tuberculosis and syphilis. Reported treatments have included endovascular embolization and surgical resection. Brachytherapy remains unexplored for treating bronchial artery malformations.
This 48-year old male presented with two episodes of massive hemoptysis. At the intial presentation, fiberoptic bronchoscopy revealed a friable 1mm “cone shaped” exophytic lesion on the posterior wall of the proximal left upper lobe bronchus. This was treated with local injection of epinephrine; however, the patient refused further evaluation or treatment at that time. He was admitted ten months later with hemoptysis and expectorated >400 ml during the initial 24 hours of his admission. He had no bleeding diathesis, bronchiectasis, malignancy, or tuberculosis. Physical exam revealed diffuse inspiratory crackles in the lower and anterior left lung. Laboratory studies and echocardiogram were unremarkable. Chest radiograph and CT scan showed patchy infiltrates, consistent with blood, but no vascular abnormality. Rigid bronchscopy revealed adherent clot that was removed by suction and the exophytic lesion began bleeding bright red blood in a pulsatile fashion. The tip of lesion was treated with Nd:YAG laser (380 joules) and the bleeding stopped. The proximity of the pulmonary artery limited the amount of laser therapy we applied. Exhaustive bronchial arteriography did not reveal bronchial or intercostal arteries feeding this area or any other vascular abnormalities. He had no further hemoptysis and was discharged two days later. Ten days later, fiberoptic bronchoscopy revealed erythema, but no evidence of the exophytic lesion, at the bleeding site. We were not confident that the Nd:YAG laser therapy had completely treated the underlying vessel. After careful consideration of the therapeutic options, the lesion was treated with high dose rate afterload intraluminal radiation (brachytherapy, 8 Gy at 1cm, 4 cm length centered at the lesion). Bronchoscopy 10 weeks later showed complete resolution of the vascular abnormality.
Endobronchial brachytherapy involves the placement of radioactive material within a catheter that is localized to the lesion being treated. This therapy has been almost exclusively described for palliation of malignancies that cause bronchial obstruction. Massive hemoptysis and fistula formation are the two most reported serious complications and range in incidence from 0-42% (4). Histopathologically, both early and late radiation effects support our rationale for using endobronchial radiation to treat this bronchial vascular lesion. The early vascular effects involve constriction of the microvasculature, arterioles and even small arteries and venules in response to endothelial cell injury (5). Radiation-induced vascular sclerosis, a late effect, is caused by intimal proliferation in medium and small arteries and arterioles that constricts blood vessel lumens (5).
Endobronchial brachytherapy appears to be a viable alternative to sclerose small localized bronchial artery malformations. While the risk-benefit ratio must be evaluated on a case by case basis, this noninvasive approach may help avoid surgical exploration with the possibility of pneumonectomy.
M.A. Rasmus, None.