DOI:10.2214/AJR.04.1961
AJR 2006; 186:649-655
© American Roentgen Ray Society
Bronchial and Nonbronchial Systemic Arteries in Patients with Hemoptysis: Depiction on MDCT Angiography
Myung Jin Chung1,
Ju Hyun Lee1,
Kyung Soo Lee1,
Young Cheol Yoon1,
O Jung Kwon2 and
Tae Sung Kim1
1 Department of Radiology, Samsung Medical Center, 50, Ilwon-Dong, Kangnam-Ku,
Seoul 135-710, Korea.
2 Division of Pulmonary and Critical Care Medicine, Department of Medicine,
Sungkyunkwan University School of Medicine, Seoul 135-710, Korea.
Received December 24, 2004;
accepted after revision February 10, 2005.
Supported by grant R11-2002-103 from the Korea Science and Engineering
Foundation.
Address correspondence to K. S. Lee
(kyungs.lee{at}samsung.com).
Abstract
OBJECTIVE. In this pictorial essay, we show the usefulness of MDCT
angiography for visualization of the bronchial and nonbronchial systemic
feeder vessels responsible for hemoptysis.
CONCLUSION. By providing thin-section transaxial, multiplanar
reconstruction, and 3D images, CT angiography using MDCT allows comparable or
better images than conventional angiography with respect to the depiction of
bronchial or nonbronchial systemic arteries. CT angiography is particularly
useful for visualizing the ectopic origin of bronchial arteries and
nonbronchial systemic collateral arteries.
Keywords: bronchial arteries • CT technique • hemoptysis • lung • lung disease • MDCT angiography
Introduction
Bronchial artery embolization is regarded as the therapeutic method of
choice for the management of massive hemoptysis
[1], and rapid identification
of the site and the cause of bleeding using noninvasive imaging techniques is
an essential aspect of embolotherapy
[2,
3]. Thus, CT depiction of the
bronchial and nonbronchial systemic arteries responsible for hemoptysis,
before interventional procedures are pursued, could provide useful information
for subsequent intervention [4,
5]. In this pictorial essay, we
show the usefulness of MDCT angiography for the visualization of bronchial and
nonbronchial systemic feeder vessels responsible for hemoptysis.
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Fig. 1A —Enlarged right intercostobronchial trunk in 38-year-old man with
multi-drug-resistant pulmonary tuberculosis. Lung window coronal
reconstruction image (2.0-mm thickness) shows multiple thin-walled cavities in
right lung and bronchiectasis (arrows) in right upper lobe.
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Fig. 1B —Enlarged right intercostobronchial trunk in 38-year-old man with
multi-drug-resistant pulmonary tuberculosis. Selective right bronchial
angiogram shows enlarged right intercostobrachial trunk. Hypertrophied
inferior branch (arrows, right bronchial artery) supplies right
bronchial tree.
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Fig. 1C —Enlarged right intercostobronchial trunk in 38-year-old man with
multi-drug-resistant pulmonary tuberculosis. Mediastinal window transaxial CT
scan (1.25-mm thickness) obtained at level of main bronchi shows enlarged
right bronchial artery arising from aorta (arrow). Also note its
branches (arrowheads) along right airway with dotlike
appearances.
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Fig. 1D —Enlarged right intercostobronchial trunk in 38-year-old man with
multi-drug-resistant pulmonary tuberculosis. Mediastinal window oblique
coronal image (2.0-mm collimation) shows right intercostobronchial trunk
(arrow) and intercostal artery (arrowhead) arising from
aorta.
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Fig. 1E —Enlarged right intercostobronchial trunk in 38-year-old man with
multi-drug-resistant pulmonary tuberculosis. Volume-rendering image clearly
shows right intercostobronchial trunk (arrow) and intercostal
arteries (arrowheads) arising from aorta.
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Anatomy of Bronchial Arteries
Normal bronchial arteries are small vessels that arise directly from the
descending thoracic aorta and supply blood to the airways of the lung,
esophagus, and lymph nodes [1,
3,
6]. Bronchial arteries show
substantial anatomic variations with respect to their origins, branching
patterns, and courses. The right intercostobronchial trunk (Figs.
1A,
1B,
1C,
1D, and
1E), which usually arises from
the right posterolateral aspect of the thoracic aorta, is the most constant
vessel [3,
4,
6]. The left bronchial arteries
usually originate from the anterior surface of the thoracic aorta or from the
concavity of the aortic arch, pass forward beside the lateral wall of the
esophagus, and cross the peribronchial space from the level of the left main
bronchus toward the hilum [1,
3,
4,
7] (Figs.
2A,
2B,
2C, and
2D). When a bronchial artery
originates from the descending aorta at the level of the fifth or sixth
thoracic vertebra, it is said to have an orthotopic origin; when its origin is
at the descending aorta other than at the expected site, at the aortic arch,
or at any aortic collateral vessel, with an intrapulmonary course along the
major bronchi, it is called ectopic
[8] (Figs.
3A,
3B,
3C, and
3D).
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Fig. 2A —Double left bronchial arteries in 51-year-old man with
bronchiectasis. Lung window coronal reconstruction image (2.0-mm collimation)
shows bronchiectasis and mucus plugging (arrows) in both lower lobes.
Also note findings of bronchiolitis with small nodules and tree-in-bud pattern
(arrowheads).
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Fig. 2B —Double left bronchial arteries in 51-year-old man with
bronchiectasis. Selective bronchial arteriograms obtained at levels of T5
(B) and T8 (C) show hypertrophied left bronchial arteries
supplying both bronchiectatic lower lobes. Upper left bronchial artery arises
as common trunk (arrow in B indicates catheter tip located in
common trunk) with right bronchial artery from aorta. Selective lower left
bronchial arteriogram shows arterial supply (arrows, C) to
bronchiectatic left lower lobe and retrograde filling of hypertrophied
esophageal branch of right inferior phrenic artery (arrowhead,
C) via collateral pathways from left bronchial artery. Patient
underwent coil embolization of right bronchial and right inferior phrenic
arteries.
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Fig. 2C —Double left bronchial arteries in 51-year-old man with
bronchiectasis. Selective bronchial arteriograms obtained at levels of T5
(B) and T8 (C) show hypertrophied left bronchial arteries
supplying both bronchiectatic lower lobes. Upper left bronchial artery arises
as common trunk (arrow in B indicates catheter tip located in
common trunk) with right bronchial artery from aorta. Selective lower left
bronchial arteriogram shows arterial supply (arrows, C) to
bronchiectatic left lower lobe and retrograde filling of hypertrophied
esophageal branch of right inferior phrenic artery (arrowhead,
C) via collateral pathways from left bronchial artery. Patient
underwent coil embolization of right bronchial and right inferior phrenic
arteries.
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Fig. 2D —Double left bronchial arteries in 51-year-old man with
bronchiectasis. Volume-rendering image shows clearly hypertrophied upper
(arrows) and lower (arrowheads) left bronchial arteries.
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Fig. 3A —Hypertrophied ectopic right bronchial artery in 51-year-old woman
with bronchiectasis in both lungs. Lung window coronal reconstruction CT image
(2.0-mm collimation) shows extensive bilateral bronchiectasis and
bronchiolitis (small nodules and tree-in-bud pattern) in both lungs.
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Fig. 3B —Hypertrophied ectopic right bronchial artery in 51-year-old woman
with bronchiectasis in both lungs. Selective right bronchial arteriography
image shows enlarged and tortuous right bronchial artery
(arrows).
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Fig. 3C —Hypertrophied ectopic right bronchial artery in 51-year-old woman
with bronchiectasis in both lungs. Mediastinal window oblique coronal
reconstruction image (2.0-mm thickness) shows ectopic right bronchial artery
(arrowhead), which is 3.2 mm in diameter, arising from right internal
mammary artery (arrow). Selective right internal mammary angiogram
was not obtained because aortogram (not shown) failed to show this vessel.
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Fig. 3D —Hypertrophied ectopic right bronchial artery in 51-year-old woman
with bronchiectasis in both lungs. Volume-rendering image shows right
bronchial artery (arrowheads) arising from right internal mammary
artery (arrows).
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Four kinds of classic bronchial artery branching patterns have been
described: one right intercostobronchial trunk and two left bronchial arteries
(40%); one right intercostobronchial trunk and one left bronchial artery
(21%); one intercostobronchial trunk, a right bronchial artery, and two left
bronchial arteries (20%); and one intercostobronchial trunk, a right bronchial
artery, and one left bronchial artery (10%)
[3]. In approximately
60–70% of cases, there are two left bronchial arteries, and the upper
left bronchial artery appears to follow a more horizontal course within the
mediastinum [7]. Occasionally,
right and left bronchial arteries arise from the aorta as a common trunk
[3] (Figs.
2A,
2B,
2C,
2D,
4A,
4B, and
4C).
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Fig. 4A —Common trunk of lower right bronchial artery in 55-year-old woman
with bronchiectasis. Selective bronchial arteriograms obtained at levels of T5
(A) and T6 (B) show hypertrophied right bronchial arteries;
upper right bronchial artery arises as intercostobronchial trunk
(arrow, A) and lower artery (arrow, B) arises
as common trunk with enlarged left bronchial artery (arrowheads,
B).
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Fig. 4B —Common trunk of lower right bronchial artery in 55-year-old woman
with bronchiectasis. Selective bronchial arteriograms obtained at levels of T5
(A) and T6 (B) show hypertrophied right bronchial arteries;
upper right bronchial artery arises as intercostobronchial trunk
(arrow, A) and lower artery (arrow, B) arises
as common trunk with enlarged left bronchial artery (arrowheads,
B).
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Fig. 4C —Common trunk of lower right bronchial artery in 55-year-old woman
with bronchiectasis. Volume-rendering image shows clearly common trunk
(arrow) of lower right bronchial artery and left bronchial artery.
Also note hypertrophied upper right bronchial artery
(arrowheads).
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Causes of Massive Hemoptysis and Causes of Bronchial Artery Aneurysm
Pulmonary tuberculosis (Figs.
1A,
1B,
1C,
1D, and
1E), bronchogenic carcinoma,
bronchiectasis (Figs. 2A,
2B,
2C,
2D,
3A,
3B,
3C, and
3D), cystic fibrosis, and
aspergillosis are the common causes of massive hemoptysis. Less frequent
causes include lung abscess, pneumonia, chronic bronchitis, interstitial
pulmonary fibrosis, pulmonary artery aneurysm (Rasmussen aneurysm), congenital
cardiac or pulmonary vascular anomalies, aortobronchial fistula, and ruptured
bronchial artery aneurysm
[1–3].
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Fig. 5A —Left bronchial artery aneurysm in 31-year-old man with chronic
destructive tuberculosis in both upper lobes. Patient had previously undergone
right bronchial artery embolization. Mediastinal window transaxial CT scan
(1.25-mm thickness) obtained at level of azygos arch shows aneurysmal
dilatation (solid arrow) of left bronchial artery. Also note enlarged
branches of right bronchial artery (arrowheads) and calcified lymph
nodes (open arrows) in right lower paratracheal area.
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Fig. 5B —Left bronchial artery aneurysm in 31-year-old man with chronic
destructive tuberculosis in both upper lobes. Patient had previously undergone
right bronchial artery embolization. Mediastinal window coronal reconstruction
image (2.0-mm thickness) shows aneurysmal dilatation (arrow) in left
bronchial artery, which arises from aortic arch (arrowhead).
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Fig. 5C —Left bronchial artery aneurysm in 31-year-old man with chronic
destructive tuberculosis in both upper lobes. Patient had previously undergone
right bronchial artery embolization. Volume-rendering image shows aneurysm
(arrow) and hypertrophied left bronchial artery (arrowheads)
distal to it.
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Fig. 6A —Nonbronchial systemic arterial supply in 60-year-old woman with
bronchiectasis in left lower lobe. Selective arteriogram shows enlarged left
inferior phrenic artery (arrows) supplying bronchiectatic left lower
lobes with fistulous connection to left pulmonary artery
(arrowheads).
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Fig. 6B —Nonbronchial systemic arterial supply in 60-year-old woman with
bronchiectasis in left lower lobe. Mediastinal window oblique coronal
reconstruction image (2.0-mm thickness) shows hypertrophied left inferior
phrenic artery (arrows) heading toward left lower lobe.
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Fig. 6C —Nonbronchial systemic arterial supply in 60-year-old woman with
bronchiectasis in left lower lobe. Volume-rendering image shows both
hypertrophied left inferior phrenic artery (arrows) and left
pulmonary artery (arrowheads) with fistulous connection.
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Bronchial artery aneurysm is considered to be caused by bronchiectasis,
mycotic origin, or Osler-Weber-Rendu syndrome. When aneurysmal dilatation of
the bronchial artery is caused by trauma, it is called a
"pseudoaneurysm." The bronchial artery aneurysm may be present in
the mediastinum or in the lung
[3].
CT Depiction and Evaluation of Bronchial Arteries
For the imaging of bronchial and nonbronchial systemic arteries, helical CT
using an MDCT scanner can be performed to image the thorax from the
supraclavicular level to the upper pole of the right kidney (coverage length,
28–33 cm along the z-axis) in a single breath-hold
[8,
9]. The recommended imaging
parameters are a beam width of 10 mm, beam pitch of 1.3–1.5, and
reconstruction thickness of 1.0–1.25 mm at 120–140 kV and
60–180 mA. A total volume of 100–120 mL (30–36 g of iodine)
of nonionic contrast medium is administered IV at a rate of 3–4 mL/sec
using an automated injector.
Stored raw data are transferred to a workstation, where 1.0- to
1.25-mm-thickness transaxial images with mediastinal window settings (width,
400 H; level, 20 H) are evaluated. Multiplanar reconstruction images are
obtained parallel to the axis of the origin of the bronchial artery to confirm
the level of the origin and allow its diameter to be measured. In addition,
multiplanar reconstruction images are obtained at various angles to evaluate
the mediastinal course and the traceability of the bronchial arteries to the
hilum. Three-dimensional images obtained using volume-rendering and
maximum-intensity-projection techniques are constructed to display the
arteries as a whole in a single image.
Bronchial arteries are identified in the posterior mediastinum as dots or
lines of increased attenuation on transaxial images
[7]. Transaxial and multiplanar
reconstruction images at various angles allow detailed delineation of the
anatomy of the bronchial arteries. The origin site of the bronchial arteries
is always depicted on transaxial thin-section images. However, the mediastinal
or hilar courses of the bronchial arteries are visualized more clearly on
multiplanar reconstruction or volume-rendering images, which are also superior
to transaxial images in terms of depicting the ectopic origins of bronchial
arteries [8,
9] (Figs.
1A,
1B,
1C,
1D,
1E,
2A,
2B,
2C,
2D,
3A,
3B,
3C,
3D,
4A,
4B,
4C,
5A,
5B,
5C,
6A,
6B,
6C,
7A,
7B, and
7C).
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Fig. 7A —Nonbronchial systemic arterial supply from left intercostal artery
in 45-year-old woman with aspergillomas. Mediastinal window transaxial CT scan
(1.25-mm collimation) obtained at level of great vessels shows two
low-attenuation aspergillomas in cavities in both upper lobes. Also note
hypertrophied left intercostal artery branches (arrows) located in
thickened pleura.
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Fig. 7B —Nonbronchial systemic arterial supply from left intercostal artery
in 45-year-old woman with aspergillomas. Mediastinal window coronal
reconstruction image (2.0-mm collimation) shows enlarged left intercostal
artery branches (arrows) heading toward aspergilloma cavity.
Aspergilloma contains calcification (arrowhead) within it.
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Fig. 7C —Nonbronchial systemic arterial supply from left intercostal artery
in 45-year-old woman with aspergillomas. Volume-rendering image shows
hypertrophied left intercostal artery (arrows) arising from aorta,
heading toward aspergilloma cavity (arrowheads).
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A bronchial artery with a diameter of greater than 2 mm is considered to be
abnormal and may be a source of hemoptysis
[3,
7]. Another important aspect in
terms of identifying the bronchial artery causing hemoptysis is its
traceability. According to a study by Yoon et al.
[9], bronchial arteries causing
hemoptysis are traceable to the hilum even when they are smaller than 2 mm in
diameter. Extravasation of contrast medium, a specific sign of bronchial
bleeding, is occasionally seen; its reported prevalence is 4–11%
[10].
CT Depiction of Nonbronchial Systemic Collaterals
Nonbronchial systemic arteries enter the lung parenchyma through the
inferior pulmonary ligament (Figs.
6A,
6B, and
6C) or through the adherent
pleura (Figs. 7A,
7B, and
7C). When enlarged vascular
structures (one or several branches of the subclavian or axillary arteries,
the intercostal arteries, or the inferior phrenic arteries) within
extrapleural fat are shown in association with pleural thickening (
3 mm)
and lung parenchyma abnormalities (Figs.
7A,
7B, and
7C), they may be regarded as
the nonbronchial systemic arteries responsible for hemoptysis
[5]. A systemic artery that
does not meet these two criteria (i.e., vascular enlargement and associated
pleural thickening) but courses to the lungs on CT images is regarded as a
nonbronchial systemic artery that is not responsible for hemoptysis.
Conventional Angiography Versus CT Angiography
By providing thin-section transaxial, multiplanar reconstruction, and 3D
images, CT angiography using MDCT allows comparable or better images than
conventional angiography with respect to the depiction of bronchial or
nonbronchial systemic arteries. CT angiography is particularly useful for
visualizing the ectopic origin of bronchial arteries and nonbronchial systemic
collateral arteries [8,
9].
References
- Uflacker R, Kaemmerer A, Picon PD, et al. Bronchial artery
embolization in the management of hemoptysis: technical aspects and long-term
results. Radiology 1985;157
: 637-644[Abstract/Free Full Text]
- Jean-Baptiste E. Clinical assessment and management of massive
hemoptysis. Crit Care Med 2000;28
: 1642-1647[CrossRef][Medline]
- Yoon W, Kim JK, Kim YH, Chung TW, Kang HK. Bronchial and
nonbronchial systemic artery embolization for life-threatening hemoptysis: a
comprehensive review. RadioGraphics 2002;22
: 1395-1409[Abstract/Free Full Text]
- Murayama S, Hashiguchi N, Murakami J, et al. Helical CT imaging of
bronchial arteries with curved reformation technique in comparison with
selective bronchial arteriography: preliminary report. J Comput
Assist Tomogr 1996; 20:749
-755[CrossRef][Medline]
- Yoon W, Kim YH, Kim JK, Kim YC, Park JG, Kang HK. Massive
hemoptysis: prediction of nonbronchial systemic arterial supply with chest CT.
Radiology 2003;227
: 232-238[Abstract/Free Full Text]
- Song JW, Im JG, Shim YS, Park JH, Yeon KM, Han MC. Hypertrophied
bronchial artery at thin-section CT in patients with bronchiectasis:
correlation with CT angiographic findings. Radiology1998; 208:187
-191[Abstract/Free Full Text]
- Furuse M, Saito K, Kunieda E, et al. Bronchial arteries: CT
demonstration with arteriographic correlation.
Radiology 1987;162
: 393-398[Abstract/Free Full Text]
- Remy-Jardin M, Bouaziz N, Dumont P, Brillet P-Y, Remy J. Bronchial
and nonbronchial systemic arteries at multi-detector row CT angiography:
comparison with conventional angiography. Radiology2004; 233:741
-749[Abstract/Free Full Text]
- Yoon YC, Lee KS, Jeong YJ, Shin SW, Chung MJ, Kwon OJ. Hemoptysis:
bronchial and nonbronchial systemic arteries at 16-detector row CT.
Radiology 2005;234
: 292-298[Abstract/Free Full Text]
- Ramakantan R, Bandekar VG, Gandhi MS, Aulakh BG, Deshmukh HL.
Massive hemoptysis due to pulmonary tuberculosis: control with bronchial
artery embolization. Radiology 1996;200
: 691-694[Abstract/Free Full Text]
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Abstract
Introduction
