The Effectiveness of Gelfoam as the Sole and Primary Embolization Agent in the Management of Hemoptysis: A Retrospective Study from a Tertiary Care Center

INTRODUCTION

Coughing up of blood is a dramatic symptom of lung disease when present clinically, its seriousness compounded by the nature of the underlying pathology causing it. Hemoptysis is the expectoration of blood from the airways or lung parenchyma below the level of the glottis.^[1,2] While several disease conditions have been listed as being capable of causing hemoptysis – pneumonia, inflammation in the lower respiratory system, chronic obstructive pulmonary disease, bronchiectasis, cystic fibrosis and neoplasia in the respiratory tree, and tuberculosis and its sequelae emerge as the leading cause for hemoptysis in resource-limited settings like India.^[1-4] Percutaneous transthoracic needle biopsies of lung masses have also been associated with hemoptysis as a procedure-related complication.^[5] In a case report, pulmonary actinomycosis has been documented as a cause for recurrent hemoptysis,^[6] while fistulous communication between the aorta and tracheobronchial tree can also result in large volume, life-threatening hemoptysis.^[7] Hemoptysis is termed life-threatening when the volume of blood is clinically large enough to bring about respiratory compromise. An 80% mortality rate is associated with life-threatening hemoptysis related mainly to asphyxiation.^[8]

MATERIAL AND METHODS

RESULTS

On immediate follow-up (within 48 h post-procedure), total cessation of hemoptysis was achieved in 27 patients. Partial response with regression in hemoptysis was noted in 3 patients, which slowly improved with medical management [Table 1]. A single major complication was noted, where a patient developed paraparesis following the interventional procedure due to spinal cord ischemia. Care had been taken to avoid the artery Adamkiewicz and the other spinal arteries; however, spinal ischemia could have been caused by the opening of the spinal collateral during the process of embolization. The weakness, however, was transient, and the patient gradually improved with physiotherapy and medical management and regained Grade 4 power around 3 weeks after the procedure. Other minor complications noted were chest discomfort (12) and puncture site hematoma (1).

Repeat bronchial artery embolization (BAE) was required in one patient due to the opening of a prominent feeder, leading to recurrence of significant hemoptysis (this occurred 2 weeks following the procedure) [Figure 1]. It was necessary to undertake a second embolization procedure for the patient; embolization was carried out using PVA particles with no further episodes of bleeding following the second procedure.

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Figure 1:

(a-d) Selective bronchial artery angiograms showing a dilated right bronchial artery with abnormal hypervascularity and tortuosity.

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DISCUSSION

Near-complete control of hemoptysis was achieved in 27 patients (90%) following BAE. We compared our data with other prominently cited published literature regarding the BAE with gel foam that focused on the immediate bleeding control rate. The immediate success rates were lower up to the year 2000 (generally <90%). Higher success rates following this could be attributed to newer advances in medical therapy and the availability of better catheter and the cath-lab systems.

The complication rates, as seen in these studies, have generally shown a declining trend over the years.^[20-22] Our study had one major complication in the form of spinal cord ischemia leading to transient paraparesis. Other minor complications were chest discomfort and puncture site hematoma. Repeat BAE was required in a patient due to the opening up of a prominent feeder, leading to recurrence of significant bleed 2 weeks following the procedure. Overall, these results show an excellent safety profile of the procedure with a low incidence of clinically significant complications.

CONCLUSION

The study reiterates BAE to be an effective technique to control acute, life-threatening hemoptysis. Previous studies have concluded that PVA is preferred over Gelfoam, with Gelfoam even being recommended as a supplementary agent following embolization with PVA due to its temporary occlusive effect. It is imperative still to note that the requirement of a microcatheter system for use with PVA particles coupled with the higher cost of the particles itself raises the financial burden of an embolization procedure. Considering the majority of patients with hemoptysis due to tuberculosis belong to lower strata of society, and expensive embolization procedures may not be within reach of those in greatest need. With a high percentage of complete occlusion of target vessels following initial embolization and low risk of major complications resulting from non-target embolization, as noted in this study, Gelfoam may even be considered as a sole and primary embolization agent in developing nations like India where embolization with PVA particles or embospheres is still reserved for the privileged.