A 28 year-old man referred to the emergency department of our hospital with recurrent episodes of hemoptysis in the past few weeks. He was a known case of cervical malignant melanoma from 6 years ago, and had pulmonary metastases from one year ago. He had received 5 complete chemotherapy courses; the last one was 3 months ago. The patient had recurrent episodes of hemoptysis and the amount of blood in the most severe episode was about 100cc.
Medical treatment was not effective for reducing the frequency or severity of hemoptysis. The patient also complained of malaise and fatigue as well as minor dyspnea and recurrent coughs with faint streaks of blood. He did not complain of fever, nausea or vomiting and did not give any history in favor of tuberculosis, but his father did have a history of tuberculosis.
Likewise, the history of tobacco addiction was negative in the patient. At the time of admission, there was no sign of hypoxemia in the pulse oximetry of the patient.
Vital signs were as follows: respiratory rate: 24/min, pulse rate: 88/min, blood pressure: 110/88mmHg and body temperature: 37.5  C.
Physical examination revealed no lymphadenopathy in the cervical region. The patient had normal heart sounds but reduced pulmonary sounds at the base of both lungs. There were no abnormal findings in the physical examination elsewhere. Laboratory results at the time of admission showed hemoglobin of 11.8mg/dl, hematocrit of 38.7% and normal coagulation tests. Electrolytes, blood gases and renal function tests were all normal. Primary supportive treatments were started right after admission and then a CXR and a pulmonary CT-scan were obtained.
CXR showed multiple nodules and masses of different sizes scattered in both lung parenchyma (Figure 1).
CT-scan showed right-sided pleural effusion as well as nodules which were also found on CXR. There was evidence of consolidation and alveolar infiltration around one of the nodules at the posterior segment of the right upper lobe (Figure 2A,B,C).
The patient then underwent bronchoscopy which revealed bloody exudates in the orifice of the right main bronchus. No endobronchial lesion was detected. In cytological evaluation of bronchial exudate, there was no evidence of atypical cells. The culture of this exudate was negative as well, and there was no sign of acid fast bacilli. Laboratory data after a week showed hemoglobin of 10mg/dl and hematocrit of 34%. With regard to the recurrence of hemoptysis during hospitalization, the patient was considered for BAE and transferred to the endovascular unit of our teaching hospital. After prepping the patient under heart monitoring, and local anesthesia, right femoral artery was punctured using Seldinger's technique and a 5-French arterial sheath was introduced. Non-selective angiography was preformed after putting a guide wire and a pigtail catheter into the aortic arch. No abnormal finding was detected in aortogram but the approximate anatomical situation of bronchial artery was revealed. After changing the pigtail catheter, and with the use of a 4-French Cobra (C1) catheter, the common trunk of the right and left bronchial arteries was selectively catheterized at the vicinity of the 5th thoracic vertebra and along the left main bronchus. Bronchial arteries had normal diameter and course. There were also fine vessels and abnormal blush along the right and left bronchial arteries coinciding with the location of metastatic pulmonary nodules in both lungs (Figure 3).
Under continuous fluoroscopy and after confirming the suitable location of the catheter tip, embolization of the common trunk of both bronchial arteries was concomitantly performed using 300-500 micron polyvinyl alcohol (PVA) particles. A control arteriography was performed afterwards which showed embolization of all of the end branches of both bronchial arteries (Figure 4A,B).
The catheter was then removed and after withdrawing the arterial sheath, hematoma at the puncture site was controlled.
After 4 hours, the patient was transferred to the ward without any problem and was discharged after 2 days. There was no recurrent episode of hemoptysis during hospitalization and in the next 2 months after embolization.