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DohnaM, etal. BMJ Open Resp Res 2021;8:e000985. doi:10.1136/bmjresp-2021-000985
To cite: DohnaM, RenzDM,
StehlingF, etal. Coil
embolisation for massive
haemoptysis in cystic
brosis. BMJ Open Resp Res
2021;8:e000985. doi:10.1136/
bmjresp-2021-000985
Received 8 May 2021
Accepted 26 July 2021
For numbered affiliations see
end of article.
Correspondence to
Dr Martha Dohna;
dohna. martha@ mh- hannover.
de
Coil embolisation for massive
haemoptysis in cystic brosis
Martha Dohna ,1 Diane Miriam Renz,2 Florian Stehling,3
Christian Dohna- Schwake,4 Sivagurunathan Sutharsan,5 Claus Neurohr,6
Hubert Wirtz,7 Olaf Eickmeier,8 Jörg Grosse- Onnebrink,9 Axel Sauerbrey,10
Volker Soditt,11 Krystyna Poplawska,12 Frank Wacker,2 Michael Johannes Montag13
Cystic fibrosis
© Author(s) (or their
employer(s)) 2021. Re- use
permitted under CC BY- NC. No
commercial re- use. See rights
and permissions. Published by
BMJ.
ABSTRACT
Introduction Massive haemoptysis is a life- threatening
event in advanced cystic brosis (CF) lung disease with
bronchial artery embolisation (BAE) as standard of care
treatment. The aim of our study was to scrutinise short-
term and long- term outcomes of patients with CF and
haemoptysis after BAE using coils.
Methods We carried out a retrospective cohort study of
34 adult patients treated for massive haemoptysis with
super selective bronchial artery coil embolisation (ssBACE)
between January 2008 and February 2015. Embolisation
protocol was restricted to the culprit vessel(s) and three
lobes maximum. Demographic data, functional end-
expiratory volume in 1 s in % predicted (FEV1% pred.)
and body mass index before and after ssBACE, sputum
colonisation, procedural data, time to transplant and time
to death were documented.
Results Patients treated with ssBACE showed signicant
improvement of FEV1% pred. after embolisation (p=0.004)
with 72.8% alive 5 years post- ssBACE. Mean age of
the patients was 29.9 years (±7.7). Mean FEV1% pred.
was 45.7% (±20.1). Median survival to follow- up was
75 months (0–125). Severe complication rate was 0%,
recanalisation rate 8.8% and 5- year- reintervention rate
58.8%. Chronic infection with Pseudomonas aeruginosa
was found in 79.4%, Staphylococcus areus in 50% and
Aspergillus fumigatus in 47.1%.
Discussion ssBACE is a safe and effective treatment
for massive haemoptysis in patients with CF with good
results for controlling haemostasis and excellent short-
term and long- term survival, especially in severely affected
patients with FEV<40% pred. We think the data of our
study support the use of coils and a protocol of careful and
prudent embolisation.
INTRODUCTION
Survival of patients with cystic fibrosis (CF)
has risen from merely a few months in the
1950s1 to a median age of survival of more
than 40 years in developed countries today.2
Patients born in the 21st century have an esti-
mated life expectancy of over 50 years. As the
number of adult patients with CF is estimated
to increase by 72%–78% until 2025 in high-
income countries, concomitant rise of compli-
cations associated with advanced lung disease
is likely.3 Functional end- expiratory volume in
1 s in % predicted (FEV1% pred.) serves as the
main outcome parameter to monitor CF.
Massive life- threatening haemoptysis
occurs frequently in older patients and in
severe disease with an average annual inci-
dence of 0.87%. Of all patients with CF,
1%–4.1% experience at least one episode of
massive haemoptysis during their lifetime.4 5
The process of chronic neutrophilic inflam-
mation in CF lung disease is understood to
cause bronchial and non- bronchial systemic
arteries (NBSAs) to undergo major hyper-
trophy over time.5 6 Prevailing theories for
the development of haemoptysis suggest
combined inflammatory and mechanical
stress weakening the walls of hypertrophied
and friable submucosal bronchial arteries,
which then erode and bleed into airways.5
If left untreated, mortality rates for massive
haemoptysis in CF are as high as 75%.7
Mortality is not attributed to massive blood
loss but rather to asphyxia through alveolar
tamponade.
Beyond the acute life- threatening event,
haemoptysis in patients with CF has been
associated with faster decline in lung func-
tion, accelerated need for lung transplant
and increased mortality.5 8–10
Key messages
►Key question of this study is short- term and long-
term outcome of patients with cystic brosis (CF)
and massive haemoptysis using coils for bronchial
artery embolisation.
►Super selective bronchial artery coil embolisation is
safe, has good short- term and long- term outcomes,
and signicantly improves FEV1% predicted.
►Data of this study merit rethinking of overall aim and
treatment of massive haemoptysis in patients with
CF, especially as life expectancy but also concomi-
tant complications like haemoptysis are rising.
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2DohnaM, etal. BMJ Open Resp Res 2021;8:e000985. doi:10.1136/bmjresp-2021-000985
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The relative risk of dying for patients with massive
haemoptysis and FEV >50% pred. was 7.4 compared with
those with similar pulmonary impairment but without
massive haemoptysis.5 Today, endovascular embolisation
of hypertrophied bronchial arteries (bronchial artery
embolisation (BAE)) is standard of care treatment in life-
threatening haemoptysis according to the CF Foundation
guidelines.6 11–17 In most studies, absorbable and non-
absorbable embolisation materials such as gelfoam parti-
cles, polyvinyl alcohol (PVA) or N- butyl-2- cyanoacrylate
had been used,6 8 12–20 but there are little data concerning
coil embolisation.21
Although BAE can be life- saving, patients with CF
who have undergone BAE with microsphere particles
(m- BAE) for haemoptysis are at much higher risk of
respiratory function aggravation, death and need for
lung transplant. They are more likely to die or to undergo
lung transplant than to present with recurrent major
haemoptysis.22 Patients with CF who underwent BAE
with blood- dependent materials had a higher mortality
than matched controls without haemoptysis and without
BAE.23
We report on patients with CF with massive haemoptysis
treated with super selective bronchial artery coil embo-
lisation (ssBACE) of hypertrophied bronchial arteries.
The aim of our study was to scrutinise long- term clinical
outcome in patients with CF embolised with metallic coils
alone.
METHODS
Patients
We performed a retrospective cohort study with chart
review and pseudonymous analysis of a total of 34 consec-
utive patients with CF lung disease and massive haemop-
tysis who received at least one ssBACE in our institution
between January 2008 and February 2015. All patients
were referred to our hospital with severe life- threatening
and/or repetitive haemoptysis in which conservative
treatment had failed. Massive haemoptysis was defined
as >240 mL in 24 hours or recurrent bleeding of substan-
tial volume (>100 mL/day) for a few days or weeks.13 24
Indication for ssBACE was defined following the criteria
set by the Cystic Fibrosis Consensus Committee on Pulmo-
nary Complications of Cystic Fibrosis: (1) major haemop-
tysis as previously defined, (2) mild or chronic haemopt-
ysis that interferes with lifestyle and (3) haemoptysis that
interferes significantly with airway clearance manoeu-
vres.13 Demographic data, FEV1% pred. and body mass
index (BMI) before and after ssBACE, sputum coloni-
sation, procedural data, time to transplant and time to
death were documented.
Patients or public were not involved in the design,
conduct, reporting or dissemination plans of our
research.
Embolisation
After two cases of lobar necrosis and lobectomy after use
of microparticles in the 1990s, our centre returned to the
use of coils in BAE. This enabled us to achieve haemo-
stasis yet ensuring preservation of vital lung tissue.
All ssBACEs were carried out in the same institution by
the same interventionalist (MJM) with a 20- year experi-
ence and 633 bronchial artery coil embolisations. ssBACE
was performed with local anaesthesia at the puncture site
in all but two patients who arrived intubated and venti-
lated at our institution. Localisation of bleeding site was
mainly based on patient perception and on angiography
findings of hypertrophied bronchial arteries and NBSA
as the active bleeding site could not be detected. Success-
fully obtained haemostasis confirmed embolisation of the
correct thus culprit vessel. Thirty- three patients arrived
with external CT scan 0–16 months prior to intervention;
24 of these scans were contrast enhanced. If possible,
CT scans were used to identify hypertrophied bronchial
arteries and, if recent enough, bleeding site.
All interventions were carried out as ssBACE with plat-
inum coils. Aortography was performed using Cobra or
Headhunter catheters via a femoral access and 4- French
catheters with coaxial microcatheters for selective bron-
chial arteriography. Bronchial arteries >2 mm in diam-
eter were defined as hypertrophied.25 26 ssBACE of target
vessels was carried out with pushable coils using target
fibred coils (2/10–4/40 mm) or Guglielmi detachable
coils (3/6–3/30 mm). Coils were placed as distally as
possible and in addition in a central position (shown in
figure 1). When all abnormal bronchial arteries supplying
the region of interest were embolised, the procedure
was terminated. Hypertrophied bronchial arteries and
NBSA which did not lead to the culprit segment were
not occluded. A maximum of three lobes was treated per
intervention. Procedural data were documented. Compli-
cations of intervention were defined according to the
Figure 1 (A) Angiography of hypertrophied bronchial
arteries. Fat arrows and perforated arrows in image (A)
represent the position of coil material placed in image
(B). The slim arrow shows a bronchial artery without
hypertrophy supplying the same lobe in (A). Coils were
placed in a peripheral (fat arrows) and in a central position
(perforated arrow). (B) Control angiography 4 years after
embolisation. The embolised arteries remain occluded.
Hypertrophy of a formerly minor vessel (slim arrow) has
occurred.
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DohnaM, etal. BMJ Open Resp Res 2021;8:e000985. doi:10.1136/bmjresp-2021-000985 3
Open access
Society of Interventional Radiology.27 Transient intrapro-
cedural minor thoracic pain not necessitating treatment
and transient mild coughing during intervention were
not counted as complications. Pseudoaneurysm but not
haematoma at the puncture site were included as compli-
cations. Recanalisation rate was based on angiography
findings at the time of reintervention in the same lobe.
Statistics
All data were tested for normal distribution by
Kolmogorov- Smirnov test. Normally distributed data were
presented as mean±SD, and difference was calculated by
applying the paired t- test. Not normally distributed data
are presented as median (minimum–maximum), and
difference was calculated using the Wilcoxon ranked test.
A p value of <0.05 was considered statistically significant.
Software programme IBM SPSS Statistics V.26 was used.
RESULTS
Patients
A total of 36 patients underwent at least one ssBACE
between January 2008 and February 2015. Two patients
were excluded, one as the causative artery could not be
detected and the other as the patient was lost to follow- up
directly after the embolisation. All 34 included patients
had a history of massive haemoptysis and/or severe
recurrent haemoptysis. All but two patients arrived at our
hospital in stable condition, and embolisation could be
carried out with patients fully awake. Patient data were
extracted from patient charts in 10 different hospitals
Germany- wide. In two patients who had received earlier
bronchial artery interventions outside our hospital, data
referred to the first intervention in our institution.
Observation interval after first coil embolisation for
all patients alive in May 2020 was 66 months minimum
with a median interval of 89.9 months (66–125) and 20
of 32 patients alive in May 2020. Twelve patients died
during the study period; of these, 6 died during the
5- year- observation interval 0, 2, 10, 11, 32 and 45 months
after ssBACE. Five patients died of respiratory failure;
three died after lung transplant; one died with uncon-
trollable massive haemoptysis; and three patients died of
other causes.
Pulmonary impairment according to FEV1% pred.
before intervention was mild in 2 patients, moderate in
19 and severe in 13. During 2- year observation interval,
two patients underwent lung transplant and four patients
died. One patient died 2 weeks after embolisation with
uncontrollable haemoptysis. Two patients were lost to
follow- up 34 and 70 months after intervention, respec-
tively. Therefore, 33 patients were included in FEV1%
pred. and BMI estimates; 34 were included in 1- year
survival analyses; and 33 patients were included in 5- year
survival analyses.
There was statistically significant improvement of
FEV1% pred. after ssBACE in all patients (p value=0.004)
(shown in figure 2). Patients with FEV <40% pred.
showed improvement in 71% (p value 0.007) vs 64% of
all patients. There was no statistically significant change
in BMI before and after ssBACE (p value=0.17). Patient
data are given in table 1.
Super selective bronchial artery coil embolisation
Aortography with selective bronchial angiography was
carried out in all cases, and hypertrophied bronchial
arteries leading to the affected lobe were selectively embo-
lised with coils. Fourteen patients received one single
intervention (41.2 %). Reinterventions were carried out
in case of recurrence of haemoptysis. In two cases reinter-
ventions were primarily planned 3 and 10 days later but
counted as two interventions. Twenty patients received
at least one reintervention (58.8 %). Thirteen patients
(38.2 %) received two interventions; 2 patients (5.9%)
received three interventions; 3 patients (8.8 %) received
four interventions; and 2 patients (5.9 %) received six
interventions. Bronchial artery- to- pulmonary artery
shunting was visible in all 34 patients.
Reintervention in the same lobe was carried out in 12
patients (35.3%). At selective angiography for reinter-
vention during the 5- year observation period, recanali-
sation of a formerly treated vessel was found in three
patients after 5, 14 and 24 months, respectively, with
recanalisation of one bronchial artery in two patients
and of one NBSA in one case. The other nine patients
had to undergo reintervention due to neovascularisation
in nine cases with additional incomplete embolisation in
one case as shown in figure 1B.
No severe complications as defined by the Society of
Interventional Radiology occurred.27 Intraprocedural
transient minor stinging pain and mild coughing were
noted in some patients. In 64.7% (22 of 34) of patients,
ssBACE was carried out during fall and winter months,
from October to March. Localisation of haemoptysis
based on patient’s perception and angiography was
Figure 2 Delta FEV1% pred. is the difference of FEV1%
pred. before and after super selective bronchial artery coil
embolisation; black dots represent the delta values of each
of the 34 patients. Dots above the bold base line of 0 show
improvement in FEV1% pred. after super selective bronchial
artery coil embolisation. Dots below represent deterioration
of FEV1% pred. FEV1% pred., functional end- expiratory
volume in 1 s in % predicted.
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correct in all cases. At first intervention, the right upper
lobe was embolised in 56%, the middle lobe in 35%, the
right lower lobe in 35%, the left upper lobe in 24%, the
lingula in 15% and the left lower lobe in 21%. Procedural
data are listed in table 2.
Bacterial carrier status
Bacterial sputum colonisation is listed in table 3. Burk-
holderia cepacia was found in one patient.
DISCUSSION
To our knowledge, this is the first publication of BAE
using only coils in patients with massive haemoptysis and
CF. In the literature, coil embolisation is often not recom-
mended as it is believed to show high rates of recanalisa-
tion on the one hand and to preclude any more periph-
eral access in case of recanalisation on the other.23 28–31
We could not find robust evidence for this theory and
our recanalisation rate was low with 8.8%. Incomplete
embolisation of NBSA was the cause of recurrence in the
same lobe in only one case, and recanalisation of NBSA
was found in one case. Hypertrophied NBSA were found
in 50% of patients, but only 24% of NBSA were embo-
lised. Neovascularisation seems to play an important role
in recurrence in the same lobe as this was the cause in
69% of patients.
In a recent study by Ishikawa et al, ssBACE was both safe
and long- term effective in patients with haemoptysis.21
However, patients in this study suffered from a variety of
underlying diseases and emergency interventions were
excluded. Our data show that ssBACE is safe and effec-
tive as immediate and long- term treatment in massive
haemoptysis in patients with CF including emergency
interventions.
Henig et al raised concern about overall benefit as 14%
of patients with CF who undergo m- BAE died within 5
months after intervention without conclusive explana-
tion of this excess mortality.32 Martin et al reported a
30- day mortality rate of 14% after m- BAE20; Sweezey and
Fellows reported a 3- month mortality rate of 30%.23 Five
months after embolisation, only two patients (6%) had
died in our study group, one of uncontrollable haemop-
tysis and the other of respiratory failure with FEV1%
pred. of 19% before intervention. In our study group,
24- hour immediate success rate was 97%; intermediate
outcome is good with 88.2% of our patients alive after
1 year as opposed to 64.8%–68% after m- BAE.5 23 Of our
total number of patients, 72.8% were alive after 5 years as
opposed to 24%–50% after m- BAE.5 22 23 This is especially
Table 1 Patient data
All patients
(n=34)
Patients FEV1<40% pred.
(n=13)
Age (years) 29.9 (±7.7) 29.5 (±7.4)
Male/female 21/13 9/4
Delta F508 mutation homozygous (%) 53 40
BMI before ssBACE* 20.9 (±3.0) 19.8 (±3.4)
BMI after ssBACE* 21.2 (±3.1) 20.6 (±3.6)
FEV1% pred. before ssBACE* 45,7% (±20,1) 26,3% (±6,5)
FEV1% pred. after ssBACE* 49.1% (±20.1) 31.5% (±10.5)
Time interval of FEV1% pred. before ssBACE (months)* 6.3±4.0 5.2±4.4
Time interval of FEV1% pred. after ssBACE (months)* 10.3±7.0 9.1±7.7
1- year survival (%) 88.2 84.6
5- year survival* (%) 72.8 53.8
Median survival after ssBACE during follow- up (months) (n=32) 76 (0–125) 65 (2–116)
9- month non- recurrence rate (%) 64.7 76.9
Lung transplant 5- year observation interval* (%) 27.3 53.8
Time to death (months) (n=12) 29 (0–116) 34 (2–116)
Time to transplant (months) (n=11) 34 (6–120) 26 (6–43)
Insulin- dependent diabetes mellitus (%) 17.7 23.1
Splenomegaly with thrombopenia (%) 11.8 7.7
Liver cirrhosis (%) 8.8 0
ABPA (%) 8.8 0
*Number of patients: n=33.
ABPA, allergic bronchopulmonary aspergillosis; BMI, body mass index; FEV1% pred., functional end- expiratory volume in 1 s in % predicted;
ssBACE, super selective bronchial artery coil embolisation.
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Open access
important, considering that 39% of our patients had
severely impaired initial FEV <40% predicted. After
m- BAE, patients showed deterioration of lung func-
tion and higher risk of death and lung transplant.22 23 33
Massive haemoptysis itself causes significant deterioration
of lung function over the year following massive haemop-
tysis.5 Interestingly, our study group showed significant
improvement of FEV1% pred. after ssBACE, and especially
in severely compromised patients with FEV1 pred. <40%.
The 9- month non- recurrence rate of 64.7% in our
cohort meets the suggested threshold of 65% success
rate 9 months after BAE set by the Society of Interven-
tional Radiology Standard of Practice Committee.27 Our
reintervention rate of 58.8% is higher than 25%–55% of
studies using m- BAE, but our observation interval was
longer and mortality was lower, which both influence
reintervention rate.13 21 34 Embolisation of hypertrophied
bronchial arteries, be it selective or more radical, will
immediately produce higher flow in other vessels. This
mechanism, together with continuous inflammation
in CF and concomitant upregulation of serum vascular
endothelial growth factor, may promote hypertrophy
of other vessels in the same region.32 Kato et al found
control of inflammation caused by the underlying disease
as the most significant factor affecting long- term results
and recurrence rates after m- BAE.14 Thus, in CF, embo-
lisation of all hypertrophied bronchial arteries at one
point may not prevent future hypertrophy of other bron-
chial arteries and possible bleeding. Extensive occlusion
of entire arterial territories might even harm patients
suffering from CF, explaining accelerated respiratory
failure after m- BAE.5 6 11 18 23 32 Vidal et al described patients
who had undergone m- BAE to be more likely to die than
to present with recurrent major haemoptysis.22 Consid-
ering these data, many patients will not suffer from recur-
rence but from respiratory failure after m- BAE. m- BAE
might cause ischaemia of larger areas of lung tissue in an
already compromised lung in CF and might impede anti-
biotic exposure of infected tissue in advanced CF lung
disease. In ssBACE, the embolised territory is smaller
and collateral vessels remain open for blood supply as
we followed a protocol of restricting intervention to the
culprit vessel only and to a maximum of three lobes per
intervention. Preservation of more vital lung tissue and
herewith possibly better antibiotic access to the affected
lung tissue might explain the striking difference in
FEV1% pred. development after ssBACE compared with
m- BAE.20 22–24 35 In our cohort, ssBACE not only achieved
sufficient haemostasis but, as important, also provided
Table 2 Super selective bronchial artery coil embolisation
procedural data
Procedural data Patients (n=34)
Recanalisation* (%) 8.8
Reintervention* (%) 58.8
Time to reintervention (months) 5 (0.5–45)
Radiation dose (µGym2) 3371 (1605–21 366)
Fluoroscopy time (min) 16.2 (6.3–41.39)
Number of coils per intervention 27 (2–58)
Number of coils per lobe 15 (2–42)
Number of vessels treated per
intervention†
1.3 (1–3)
Number of hypertrophied bronchial
arteries detected at angiography†
2.5 (1–5)
Number of bronchial arteries
occluded†
1.1 (0–2)
Number of patients with
hypertrophied NBSAs†
17
Number of patients with NBSAs
treated
5
Number of hypertrophied NBSAs
detected at angiography†
0.85 (0–3)
Number of NBSAs occluded† 0.2 (0–2)
*During 5- year observation interval.
†Refers to the rst intervention and the number per patient and
intervention.
NBSA, non- bronchial systemic artery.
Table 3 Bacterial carrier status at the time of intervention
Pathogen
% all patients
(n=34)
% patients with
FEV1<40% pred.
(n=13)
% non- survivors
without lung
transplant (n=8)
% patients with
lung transplant
(n=12)
% patients with
reintervention
(n=20)
Pseudomonas
aeruginosa
79.4 92 87.5 100 80
Staphylococcus aureus
including MRSA
50 61.5 87.5 25 45
MRSA 17.6 7.7 25 8.35 20
Aspergillus fumigatus 47.1 76.9 47.1 66.7 65
P. aeruginosa and S.
aureus
35.3 38.5 75 25 40
Achromobacter
xylosoxidans
26.5 38.4 50 16.7 30
FEV1% pred., functional end- expiratory volume in 1 s in % predicted; MRSA, methicillin- resistant Staphylococcus aureus.
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Open access
excellent long- term outcome. However, PVA being the
most commonly used microsphere embolic material, we
could not differentiate between different microsphere
materials in the literature. We therefore cannot directly
compare coils with a specific microsphere material.
In advanced CF lung disease, bronchial artery- to-
pulmonary artery shunting is common.6 8 14 36 One
hundred per cent of our patients showed shunting,
suggesting this to be part of the pathogenesis of haemop-
tysis in CF. The use of small embolisation particles in the
presence of shunting may cause severe complications
such as microembolisms to lung tissue, spine and brain
with dysphagia, bronchial necrosis, bowel ischaemia,
paraplegia, myocardial infarction and cerebral stroke
with complication rates up to 6.6% in m- BAE.6 23 36–39 In
our study group, no severe complications were reported
despite the presence of shunts in all patients. Broncho-
pulmonary anastomoses are approximately 325 µm in
size,28 why several authors advise the use of particles
not smaller than 500 µm or even 2 mm in case of visible
shunting.6 8 20 Inadvertent embolisation of pulmonary
arteries with microspheres might therefore be discussed
as explanation for deterioration of FEV1% pred. in
m- BAE but not in ssBACE. Perhaps the use of larger
microspheres 900–1200 µm in size should be considered.
Adverse events with ischaemia of different organ systems
seem to be a major risk worth taking into consideration
when carrying out BAE. Coils are at least 2 mm in size,
ruling out direct inadvertent embolisation and embolisa-
tion through shunts. The prevention of severe complica-
tions due to the large size of coils and at the same time
only flow reduction and not complete flow cessation in
the affected lung territory might be valuable arguments
for the use of coils.
Chronic hypercapnic respiratory failure is a common
finding in advanced CF. Arterial blood is delivered to
alveolar capillaries through these bronchopulmonary
anastomoses transporting arterial hypercapnic blood.
In animal models, 30% of CO2 elimination is through a
hypertrophied bronchial circulation.40 Henig et al postu-
late that in abnormal ventilation/perfusion distribution
in CF, increased bronchial flow delivers arterial blood
with high PaCO2 providing a second opportunity for
gas exchange. This effective recirculation of blood with
increased PaCO2 augments the elimination of carbon
dioxide.32 At the same time, oxygen exchange might be
impaired as arterial blood is shunting into pulmonary
vessels. The role of bronchial artery- to- pulmonary artery
shunting and its contribution to pathogenesis and gas
exchange is not yet well understood.
Microbiology
Chronic infection with Pseudomonas aeruginosa and B.
cepacia is associated with more rapid decline in lung func-
tion but with reduced association with massive haemopt-
ysis.5 In our cohort, record of P. aeruginosa and B. cepacia
was as well associated with reduced lung function as 92%
of patients with FEV <40% pred. showed positive sputum
cultures. However, we cannot confirm a reduced associ-
ation with haemoptysis as 79% of patients had positive
sputum cultures for P. aeruginosa compared with 58%
normal prevalence in this age group.41 The prevalence
of 44% of Staphylococcus aureus is lower than the normal
prevalence of 68% at this age.41 Chronic infection with
Aspergillus fumigatus was higher with 47.1% in our cohort
compared with 35% normal prevalence at this age. The
role of fungi in the CF lung is still not well elucidated,
but evidence of a harmful and complex role is getting
stronger.42
Nine per cent of patients presented with liver cirrhosis
as opposed to 4.2% in the American CF population, and
17.6% of patients had concomitant diabetes mellitus
compared with 30.6%.41
SUMMARY
In adult patients with CF and massive haemoptysis,
ssBACE has good short- term and excellent long- term
outcomes in our cohort. ssBACE might bear important
advantages as embolisation is less radical, leaving smaller
vessels to not only supply the lung tissue to remain
vital but possibly also antibiotic therapy to better access
inflamed territories. Since the primary aim of the embo-
lisation is to achieve short- term haemostasis, long- term
survival and non- recurrence, our data support the use of
coils and a prudent restricted protocol.
Author afliations
1Pediatric Radiology, Hannover Medical School, Hannover, Germany
2Radiology, Hannover Medical School, Hannover, Germany
3Department of Pediatric Pulmonology and Sleep Medicine, University
Hospital Essen, Essen, Germany
4Department of Pediatrics I, University Hospital Essen, Essen, Germany
5Ruhrlandklinik Pneumology, University Hospital Essen, Essen, Germany
6Robert- Bosch- Krankenhaus Klinik Schillerhohe, Gerlingen, Germany
7Department of Respiratory Medicine, University Hospital Leipzig, Leipzig,
Germany
8Department of Pneumology, Hospital of the Goethe University Frankfurt,
Frankfurt am Main, Germany
9Department of General Pediatrics, University Hospital Munster, Munster,
Germany
10Pediatrics, HELIOS Klinikum Erfurt, Erfurt, Germany
11Pediatrics, Stadtisches Klinikum Solingen, Solingen, Germany
12Pediatrics, Johannes Gutenberg University Hospital Mainz, Mainz, Germany
13Department of Clinical Radiology, University Hospital Munster, Munster,
Germany
Contributors MD: conception and design of the study, acquisition, analysis and
interpretation of data, and writing of the original draft. DMR: revision and editing of
the original draft. CD- S: formal analysis/statistics, revision and editing and gures.
FS: revision and editing, data acquisition. SS, CN, PK, HW, OE, JG- O, AS, VS and KP:
data acquisition. FW: revision and editing, ensuring accuracy and integrity of the
study. MJM: supervision, revision and editing.
Funding The authors have not declared a specic grant for this research from any
funding agency in the public, commercial or not- for- prot sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in
the design, conduct, reporting or dissemination plans of this research.
Patient consent for publication Not required.
copyright. on August 12, 2021 by guest. Protected byhttp://bmjopenrespres.bmj.com/BMJ Open Resp Res: first published as 10.1136/bmjresp-2021-000985 on 12 August 2021. Downloaded from
DohnaM, etal. BMJ Open Resp Res 2021;8:e000985. doi:10.1136/bmjresp-2021-000985 7
Open access
Ethics approval This study complies with the guidelines for human studies and was
conducted ethically in accordance with the World Medical Association Declaration of
Helsinki. It was approved by the ethical committee related to the institution (AEKNO
approval le number 2016/181).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement All data relevant to the study are included in the
article or uploaded as supplemental information.
Open access This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non- commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the
use is non- commercial. See:http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.
ORCID iD
MarthaDohna http:// orcid. org/ 0000- 0002- 2471- 8530
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