Outcomes of Bronchial Artery Embolization for Life-Threatening Hemoptysis in Patients with Chronic Pulmonary Aspergillosis

RESEARCH ARTICLE Outcomes of Bronchial Artery Embolization for Life-Threatening Hemoptysis in Patients with Chronic Pulmonary Aspergillosis Beomsu Shin1☯, Won-Jung Koh1☯, Sung Wook Shin2, Byeong-Ho Jeong1, Hye Yun Park1, Gee Young Suh1,3, Kyeongman Jeon1,3* a1111111111 a1111111111 a1111111111 a1111111111 a1111111111 1 Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea, 2 Department of Radiology, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea, 3 Department of Critical Care Medicine, Samsung Medical Centre, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea ☯ These authors contributed equally to this work. * Abstract OPEN ACCESS Citation: Shin B, Koh W-J, Shin SW, Jeong B-H, Park HY, Suh GY, et al. (2016) Outcomes of Bronchial Artery Embolization for Life-Threatening Hemoptysis in Patients with Chronic Pulmonary Aspergillosis. PLoS ONE 11(12): e0168373. doi:10.1371/journal.pone.0168373 Editor: Sanjay Haresh Chotirmall, Lee Kong Chian School of Medicine, SINGAPORE Background Bronchial artery embolization (BAE) is an important treatment option for short-term control of hemoptysis in patients with simple aspergilloma (SA). However, there are no data on the outcomes of BAE in patients with chronic pulmonary aspergillosis (CPA). In this study, the clinical characteristics and outcomes of BAE were investigated and compared in patients with CPA and SA. Received: July 16, 2016 Methods Accepted: November 29, 2016 We retrospectively analyzed the clinical data of 64 patients (55 [86%] with CPA and 9 [14%] with SA) who underwent BAE for life-threatening hemoptysis. The clinical characteristics and outcomes of BAE in CPA patients were compared to those of patients with SA. Published: December 22, 2016 Copyright: © 2016 Shin et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability Statement: All relevant data are within the paper. Funding: The authors received no specific funding for this work. Competing Interests: The authors are employed by Samsung Medical Center. There are no patents, products in development, or marketed products to declare. This does not alter the authors’ adherence to all the PLOS ONE policies on sharing data and materials. Results The most common angiographic abnormality was hypervascularity (n = 60, 94%), followed by contrast extravasation (n = 50, 78%) and systemic-pulmonary shunt (n = 48, 75%), with similar incidence rates in both groups. Immediate success was achieved in 41 (64%) BAE procedures, but it was incomplete in 23 (36%) cases due to difficulty with the approach and/ or overuse of contrast medium. Clinical failure of BAE was observed in only one (2%) patient. Complications following BAE were observed in four (6%) patients. Recurrence of hemoptysis was seen in a total of 33 patients (52%) within a median of 2.0 (0.3–10.0) months, and repeat BAE was performed in 25 (76%) of these cases. In comparing the outcomes of patients with CPA and SA, there were no differences in the rates of success of initial BAE, incomplete embolization, or clinical failure in the two groups. However, recurrence of hemoptysis tended to be higher in patients with CPA (55%) than in those with SA (33%). PLOS ONE | DOI:10.1371/journal.pone.0168373 December 22, 2016 1 / 10 BAE in Patients with CPA Abbreviations: BAE, bronchial artery embolization; CPA, chronic pulmonary aspergillosis; CT, computed tomography; IQR, interquartile range; SA, simple aspergilloma; TB, pulmonary tuberculosis. In addition, antifungal medications following BAE were more commonly prescribed in the CPA group (56%) compared to the SA group (0%). Conclusions BAE was a safe and effective procedure for the management of life-threatening hemoptysis in patients with CPA. However, recurrence of hemoptysis was common, especially in patients with CPA. Therefore, definitive treatment for CPA following successful BAE should be considered to ensure the long-term success of the embolization in these patients. Introduction The chronic forms of pulmonary aspergillosis refers to a spectrum of diseases, from simple aspergilloma (SA) to progressive cavitary disease,[1–4] a progressive pulmonary disorder that causes significant respiratory and systemic symptoms.[5] SA can exist for years without causing symptoms, although a minority of patients will experience hemoptysis.[6] In contrast to SA, progressive diseases such as chronic cavitary pulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, and chronic fibrosing pulmonary aspergillosis have high morbidity rates and are often complicated by subacute or massive hemoptysis.[1–6] SA, chronic cavitary pulmonary aspergillosis, chronic necrotizing pulmonary aspergillosis, and chronic fibrosing pulmonary aspergillosis are now collectively referred to chronic pulmonary aspergillosis (CPA).[7–14] CPA can be complicated by life-threatening hemoptysis. Bleeding is usually occurs from systemic arteries supplying to the lungs, including bronchial, intercostal, subclavian, or internal mammary arteries.[15–17] Therefore, bronchial artery embolization (BAE) is an important treatment option for short-term control of hemoptysis significant enough to threaten clinical stability in patients with pulmonary aspergillosis.[1–3] Major complications of BAE are rare, and the immediate clinical success rate defined as hemorrhage cessation ranges from 85% to 100%, although recurrence of hemoptysis occurs in 10% to 33% of patients.[17] However, the outcomes of BAE in patients with CPA have never been studied, and there are limited data on BAE outcomes in patients with pulmonary aspergilloma.[18–21] Therefore, we investigated the clinical characteristics and outcomes of BAE in CPA patients with life-threatening hemoptysis compared to those of patients with SA. Methods Data were collected from all patients with a clinical and radiological suspicion of pulmonary aspergillosis who underwent BAE for life-threatening hemoptysis at Samsung Medical Center (a 1,979-bed, university-affiliated, tertiary referral hospital in Seoul, South Korea) between January 2005 and January 2015. During the study period, a total of 530 patients underwent BAE for life-threatening hemoptysis. Of these patients, 92 patients were suspected to have pulmonary aspergillosis based on clinical and radiological findings. The medical records of these patients were reviewed, and a retrospective analysis was conducted. All patients with documented life-threatening hemoptysis preceding the BAE whose outcome could be ascertained for at least 6 months after BAE were included in the study. To qualify as ‘life-threatening’ hemoptysis, (...truncated)