A 70-year-old male was treated with conservative management for a minor case of hemoptysis. However, massive hemoptysis (about 500 mL/24 hours) and hypoxemia occurred and the patient deteriorated. The patient had a history of pulmonary tuberculosis about 30 years prior, had suffered from congestive heart failure with arrhythmia for ten years, and had been treated for upper thoracic tuberculous spondylitis with posterior spinal fusion for the last 15 days.
A chest radiograph revealed severe destructive changes of both upper lobes, secondary emphysematous changes of both lower lobes and recent development of bilateral consolidations due to aspirated blood.
Embolization treatment was performed with a 5-Fr catheter and a coaxial 2.5-Fr microcatheter (Renegade; Boston Scientific, Watertown, MA) for both bronchial and other possible systemic arteries with polyvinyl alcohol (PVA) particles, 350-500 microm in diameter (Contour; Boston Scientific, Watertown, MA) and microcoils (Tornado embolization microcoil: Cook, Bloomington, IN). Two days later, the patient suffered massive hemoptysis. No evidence of recanalization of previously embolized arteries on angiography was found and additional embolization of both upper lobar pulmonary arteries was performed, because radiologically undetectable pulmonary artery bleeding was suspected. However, the patient continued to suffer from hemoptysis.
On the third trial of angiography, five hours after the second embolization, coronary angiography showed a CBF (proximal left circumflex arterial branch) from the left circumflex coronary artery to the left bronchial artery combined with a severe pulmonary artery shunt at the left upper lung. The CBF was embolized after superselection across the CBF to prevent embolization of the coronary artery (Fig. 1).
Hemoptysis was stopped immediately after the third embolization but the patient died 12 hours later due to further deterioration of hypoxemia despite intensive ventilator care.