massive hemoptysis is a life - threatening medical emergency with mortality rates ranging as high as 75% .
transcatheter embolization of bronchial arteries has been regarded as an effective and safe method for the management of massive hemoptysis .
chronic pulmonary thromboembolism ( pte ) is one of these causes , though its exact incidence remains unknown .
compensatory hypertrophy of bronchial arteries is known to occur in chronic pte and pulmonary hypertension .
however , the exact mechanism of hemoptysis in these patients is unclear . bleeding due to the rupture of smaller vessels or bleeding from hypertrophied bronchial arteries
though bronchial artery embolization has been proposed to be effective in the management of hemoptysis , the ideal treatment for hemoptysis in patients with chronic pte remains uncertain .
we report one case of hemoptysis in chronic pte with pulmonary arterial hypertension ( pah ) treated successfully with bronchial artery embolization .
a 30-year - old male patient presented to the emergency department of our institute with recurrent bouts of hemoptysis for 1 week , along with shortness of breath .
, he was found to have tachycardia ( pulse rate : 100 bpm ) and tachypnea ( respiratory rate : 30 breaths / min ) with decreased oxygen saturation ( 85% in room air ) .
the patient underwent computed tomography ( ct ) and bronchial angiography that showed two bronchial arteries on the right side , which were hypertrophied and tortuous ( measuring ~2.6 mm and 2.4 mm , respectively , in maximum caliber ) [ figure 1a ] .
in addition , there was a thrombus in the right pulmonary artery , extending from its origin till the subsegmental branches [ figure 1b ] . the right pulmonary artery was reduced in caliber with the dilated main and left pulmonary arteries .
two - dimensional echocardiogram ( 2d echo ) was done for the patient that showed severe pah with dilated right atrium and ventricle .
on bronchoscopy , active bleeding with clots was seen in the segmental bronchus of the right lower lobe .
( a , b ) coronal maximum intensity projection ( mip ) images of ct bronchial angiography showing hypertrophied right bronchial arteries ( arrows in a ) .
one of the bronchial arteries was arising from the intercostobronchial trunk from the descending aorta ( not shown here ) .
origin of the second right bronchial artery was , however , not clear on ct angiography .
a thrombus was seen in the right pulmonary artery ( arrow in b ) extending till the subsegmental branches the patient was taken up for bronchial angiography .
the second bronchial artery was being reconstituted by the internal mammary artery and was hypertrophied [ figure 3 ] .
both the bronchial arteries were embolized with polyvinyl alcohol ( pva ) ( 500 - 700 m ) and gelfoam slurry .
no other significant systemic collateral was identified on diagnostic runs of the bilateral subclavian arteries .
digital subtraction angiogram of the right intercostobronchial trunk ( anteroposterior projection ) showing hypertrophied and tortuous bronchial artery .
postembolization angiogram showed no opacification of the distal bronchial artery ( image on the right side ) digital subtraction angiogram of the right internal mammary artery showed hypertrophied second right bronchial artery arising from the internal mammary artery .
chronic pte is associated with compensatory hypertrophy of the bronchial arteries and bronchopulmonary collaterals . increased
incidence of bronchial artery hypertrophy on ct angiography has been reported in chronic pte and pah .
though hemoptysis can occur due to hypertrophied bronchial arteries secondary to any cause , its exact incidence in chronic pte is unknown .
one systemic review of the literature reported chronic pte as a cause of moderate - to - massive hemoptysis in 0.1% of cases .
we report one case in which bronchial artery embolization was successful in managing hemoptysis in a patient with chronic pte with pah .
one patient was successfully treated while the other patient continued to have active hemoptysis due to collaterals from the subclavian artery .
reembolization was carried out for this patient but the patient died due to right ventricular failure .
it was suggested that due to the requirement of anticoagulation for pte , even mild hemoptysis in these patients should be offered immediate intervention .
however , another study reported the failure of bronchial artery embolization to prevent hemoptysis in a patient with chronic thromboembolic pah .
in chronic pte , there is a propensity for the formation of thromboemboli . at the same time
even mild hemoptysis in these patients should be given prompt treatment due to the underlying risk of progression to massive hemoptysis due to the ongoing anticoagulation therapy .
however , very limited literature is available on the management of hemoptysis in chronic pte .
no study has been carried out to evaluate the long - term effect of bronchial artery embolization in preventing hemoptysis . also , the precise mechanism of hemoptysis in chronic pte is still not clear .
thus , further studies are required to establish the role of bronchial artery embolization in chronic pte .
 bronchial artery embolization is the treatment of choice for the management of life - threatening massive hemoptysis . 
 chronic pulmonary thromboembolism ( pte ) is one of the rare causes of hemoptysis . 
 management of hemoptysis in chronic pte is a point of debate . in this article , we have reported one case of hemoptysis in chronic pte managed successfully with bronchial artery embolization . 
INTRODUCTION
CASE REPORT
DISCUSSION