Background: Case d escription: We report ed a case of massive hemoptysis (woman aged 63 years). We discuss ed the results and treatment of the patient, and review ed the literature. The patient was treated successfully with BAE via the access of radial artery using polyvinyl alcohol particles. Hemoptysis was controlled. The patient was followed up since surgery, and there was a recurrence of bleeding at 6 months following embolization. Up to now, no hemoptysis or other complications occurred.[f1] Conclusion: Nevertheless, few cases have been reported. More clinical and experimental research es are needed to confirm the safety and effectiveness in the treatment of hemoptysis.[f2]
Keywords: radial artery; bronchial artery embolization; massive hemoptysis
Hemoptysis[f3] is a general clinical manifestation considered as the expectoration of blood that derive s from the lower respiratory tract . There are many causes leading to h emoptysis such as including tuberculosis, bronchiectasis and lung cancer [2, 3]. In most cases, the hemoptysis is moderate and resolved with conservative therapy. [f4]However, more than 300 mL of expectorated blood in a period of 24 hours is universally accepted as the d efinition of massive hemoptysis in most case s Conservative medical or surgical treatment for massive hemoptysis are ineffectual,  the mortality rate of massive hemoptysi[f5] s is up to 40% when surgery is performed urgently .. M assive hemoptysis is a life-threatening respiratory emergency that needs urgent treatment . A former stud y has report ed the mortality rate was up to 80 % mainly due to asphyxiation .[f6] Nowadays, there is no global consensus about the optimal treatment of patients with massive hemoptysis, and there are no considerable patients studied . Conservative medical or surgical treatment for massive hemoptysis are ineffectual, the mortality rate of massive hemoptysis is up to 40% when surgery is performed urgently . Complementarily, bronchial artery embolization (BAE) is an optional method in the management of massive hemoptysis .
few have been reported catheter was introduc ed into the radial artery using the Seldinger technique for the management of hemoptysis. Here, we describe a case of massive hemoptysis caused by tuberculosis successfully treated with BAE via the access of radial artery.
A 63-year-old woman was admitted to the emergency department with massive hemoptysis after n o significant relief withmedical treatment (anti-inflammatory as well as symptomatic and supportive care) . Hemoptysis symptomsbecame progressively severe 3 days before the accession to the emergency department a nd the total amount of hemoptysis was about 500 mL. Moreover, she had complained of more than 6-month history of intermittent hemoptysis . CTA ( computed tomography angiography) examination was refused by patient and their families, and the informed consent was signed after communication. After blood cell analysis, the biochemistry analysis, blood gas analysis and monitoring of vital signs, the patient was subjected to BAE for hemostasis after communication with family members.
A standardized BAE procedure was applied [9, 12]. A 5F cobra catheter (Glide, Terumo, Japan) was introduced into the right femoral artery using the Seldinger technique. A flush catheter was advanced into the upper portion of the descending thoracic aorta to identify the bleeding arteries. The embolization was performed with
PVA ( poly vinyl alcohol) particles. Right intercostal artery (Figure 1 A), right bronchial artery (Figure 1 B), right subclavian arterial branch (Figure 2 A), right internal thoracic artery (Figure 2 B) and right thyrocervical trunk (Figure 3 A) was embolized. However, this approach was ineffective when BAE was performed via the access to femoral artery .  Ang iography displayed a lesion vessel along with arteriovenous fistula 3 B). Thus, we decided to change the direction of catheter for BAE. We tried to insert the 5F cobra catheter into the right radial artery to perform BAE (Figure 4 A). The shape of 5F cobra catheter was changed to match the lesion artery easily, following BAE performance (Figure 4 B– C). Angiography displayed that the lesion artery was completely embolized, indicating a good outcome (Figure 4 D).
The patient was sent to his ward after BAE. Following the embolization, his vital signs were stable, and hemoptysis symptoms were alleviated significantly. So the patient was discharged at the fifth day after surgery. Hemoptysis occurred again at
a follow-up 6 months following the surgery, the main clinical symptom was less bloody sputum. The patient was treated with anti-inflammatory, hemostasis and symptomatic treatment at a local hospital. She was discharged after her condition was improved after 1 week. Up to now, no hemoptysis or other complications occurred.
Massive hemoptysis is a life-threatening respiratory emergency that needs urgent treatment.The mortality rate is very high when massive hemoptysis is treated by conservative and the emergent surgical treatment . For these, BAE is a well-accepted and widely used intervention in the treatment of recurrent and massive hemoptysis .  Moreover,   w ith
rapid visualization by CTA and the development of embolic materials, the efficacy of BAE has improved and the complications have decreased.
Diagnostic interventions are important and necessary for the planning and success of the treatment, including detection of the cause and location of bleeding. CTA is one of the most common approaches used for the detection of hemoptysis causes . The modern CTA scan decreases the time of scanning and makes the process of scanning feasible in critically ill patients. However ï¼Œ the patient in this case refused CTA examination, thus, it is very difficult to find all the lesion vessels to increase the chances of recurrence of hemoptysis. Recurrences were observed at 6 months following embolization. The cause is likely to be emboli sed incomplete ly non-bronchial systemic arterial supply or secondary trauma result ing from t wo embolization s . 
The choice of embolic materials is vital for BAE outcomes.
P VA particles > 250 microns were applied in all the cases for BAE . Particles < 250 microns should be prohibited because the passage of agents through bronchopulmonary may result in ischemia and necrosis in the lung tissue . [16, 20] M oreover, PVA may leads to permanent occlusion relative to gelatin sponge particles.   [16, 24]
Several complications related with BAE have been reported in the previous literatures. Chest pain is the most common complication of BAE, the occurrence rate is 24-91% . There are some rare complications reported previously, including bronchoesopha-geal fistula , ischaemic colitis, pulmonary infarction, ischemia of the spinal cord and transient cor­tical blindness . Among these, the most disastrous event is spinal cord ischemia caused by spinal arterial occlusion. More than 250 microns of particles are big enough to not occlude spinal arteries distally. In the current study, the patient had no compli­cations published and mentioned above in the period of follow-up. This result suggested that it is feasible to perform BAE via the access of radial artery. This also may be due to the limited patients in the study.
In conclusion, radial artery access might increase the effectiveness and success rate of BAE, benefitting patients with hemoptysis. Nevertheless, few cases have been reported. More clinical and experimental researches are needed to confirm the safety and effectiveness in the treatment of hemoptysis, and its clinical use should be elucidated.
Figure 1 Polyvinyl alcohol particles embolized
the right intercostal artery and right bronchial artery. A. The right intercostal artery was filled with polyvinyl alcohol particles. Angiography did not display disordered vessels in the distal end, indicating that the right intercostal artery was completely embolized. B. The right bronchial artery was filled with polyvinyl alcohol particles. Angiography did not display disordered vessels in the distal end, suggesting complete embolization of the right bronchial artery . Figure 2 Polyvinyl alcohol particles embolized the right subclavian arterial branch and right internal thoracic artery. A. The right subclavian arterial branch was filled with polyvinyl alcohol particles. Angiography did not display disordered vessels in the distal end, indicating that t he right subclavian artery was completely embolized. B. The right internal thoracic artery was filled with polyvinyl alcohol particles. Angiography did not display disordered vessels in the distal end, suggesting complete embolization of the right internal thoracic artery . Figure 3 A. The right thyrocervical trunk was filled with polyvinyl alcohol particles. Angiography did not display disordered vessels in the distal end, indicating that the right thyrocervical trunk was completely embolized. B. Angiography displayed a lesion vessel at the vertebral artery side of the right subclavian artery. Figure 4
- Angiographies of radial artery access to subclavian artery.
B. The condition of cobra catheter before shaped. C. The condition of cobra catheter after shaped. D. Angiography displayed that the lesion artery was completely embolized, indicating a good outcome.