Embolization of bronchial artery of anomalous origin: Management of two cases presenting with hemoptysis

Life-threatening hemoptysis is one the most challenging condition encountered in critical care. Bronchial artery embolization (BAE) has become an established procedure, in the management of massive and recurrent hemoptysis. Bronchial arteries have variable anatomy. The reported prevalence of bronchial arteries with an anomalous origin ranges from 8.5 -35%. We are describing two patients who presented with hemoptysis and were effectively managed with bronchial artery embolization. Both these patients had anomalous origin of bronchial artery from the internal mammary artery, one from the Right Internal Mammary Artery (RIMA) and one from the Left Internal Mammary Artery (LIMA). The procedures were performed under general anesthesia. In the first case a double lumen endobronchial tube was used while in the second case, the patient was managed without tracheal intubation. The first patient was dyspnoeic; saturation was poor and was unable to maintain her airway probably due to profuse blood in her airways. We used a double lumen tube in her to isolate the diseased lung from the healthier lung. We gave her muscle relaxants and mechanical ventilation so that a stable lung field could be provided during embolization. The second patient was quite stable and comfortable while breathing room air. We decided not to interfere with his airway. A back-up plan and preparation for urgent airway control and lung isolation was done inside the catheterization laboratory.From the management point of view, an unstable patient with life-threatening hemorrhage needs airway control and lung isolation. A stable patient with minimum to moderate bleeding may be managed safely under general anesthesia with the patient spontaneously breathing.