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This study assesses the safety and efficacy of particle embolization during bronchial artery embolization (BAE) in patients with shunts between bronchial and non-bronchial systemic arteries and the pulmonary artery. In this retrospective, single-center study, we analyzed 312 BAE procedures performed from June 2020 to April 2023. The patient cohort had shunts between bronchial and non-bronchial systemic arteries and the pulmonary artery. We meticulously collected and examined comprehensive data, including clinical characteristics, computed tomography (CT) imaging, and embolization procedural details. Vascular shunts were identified in 49 patients. The etiologies of hemoptysis included post-TB sequelae (42.8%), bronchiectasis (26.5%), active TB (12.2%), aspergilloma (8.1%), bacterial pneumonia (4.1%), lung cancer (4.1%), and non-tuberculous mycobacterial infection (2%). The technical success rate of the procedures was 98%, with 149 out of 152 identified vessels successfully embolized. All patients experienced cessation or significant reduction of hemoptysis within 24 hours following the procedure. The clinical success rates were 97.9% at one month, 93.9% at six months, and 89.8% at one year. No shunt-related complications were detected. BAE with particle embolization is a safe and effective treatment for hemoptysis, particularly in cases with complex shunts between bronchial and non-bronchial systemic arteries and the pulmonary artery. • Chronic inflammation as a risk factor for recurrent hemoptysis. • Chronic inflammation leads to vascular shunts. • At one year, BAE achieved 89.8% clinical success in shunt patients. • BAE offers safe, effective hemoptysis treatment for patients with vascular shunts. [ABSTRACT FROM AUTHOR]

• BAE is a lifesaving treatment for pwCF with massive haemoptysis. • However, BAE carries a potential risk of neurovascular complications. • There should be a low threshold for imaging of symptomatic patients post-BAE. • BAE should be reserved for patients with acute life-threatening haemoptysis. Bronchial artery embolisation (BAE) is a treatment used to manage haemoptysis. We performed a 7-year review of BAE procedures for haemoptysis at our CF centre aiming to evaluate the incidence and outcomes of patients with neurovascular complications post-BAE. Our review suggests that whilst BAE is an effective method for controlling life-threatening haemoptysis, patients are at risk of developing neurovascular complications with long term residual symptoms, and therefore careful consideration should be given in offering BAE, especially to otherwise well patients with chronic small volume haemoptysis and managing teams should have a low threshold to image symptomatic patients. [ABSTRACT FROM AUTHOR]

To report the authors' experience of bronchial artery embolisation (BAE) in a series of patients to control haemoptysis associated with infected pulmonary artery pseudoaneurysms (PAPs). All patients who underwent BAE based on computed tomography angiography (CTA) findings indicative of haemoptysis between February 2019 and September 2022 at Xiangyang Central Hospital were identified. Charts of patients with haemoptysis and infectious PAPs were reviewed retrospectively. Data were collected data on age, sex, underlying pathology, source pulmonary artery of the PAP, association with cavitary lesions or consolidation, systemic angiography findings, technical and clinical success, and follow-up. Seventeen PAPs were treated in 16 patients, with a mean age of 60.3 years (range: 37–82 years). The most common underlying cause was tuberculosis (15/16, 93.8%). Imaging by CTA did not identify the source pulmonary artery for 15 (88.2%) PAPs; all were associated with cavitary lesions or consolidation. All PAPs were visualised on systemic angiography. The technical and clinical success rates were both 87.5%. Two patients who experienced a recurrence of haemoptysis during follow-up underwent repeat CTA, which confirmed the elimination of the previous PAP. BAE may be a valuable technique to control haemoptysis associated with infectious PAPs that are visualised on systemic angiography. A possible contributing factor is PAPs arising from very small pulmonary arteries. [ABSTRACT FROM AUTHOR]

To explore the feasibility of a "triple-low" dose (low tube voltage, low tube current, and low contrast agent volume) bronchial artery computed tomography (CT) angiography (CTA) to replace routine dose bronchial artery CTA before bronchial artery embolisation (BAE). CTA was obtained from 60 patients with body mass index (BMI) < 30 kg/m2 using a 256 multi-section iCT system, and they were divided into two groups: (1) group A: 100 kVp, 100 mAs, 50 ml contrast medium (CM); (2) group B: 120 kVp, automatic tube current modulation (ACTM), 80 ml CM. CT attenuation of the thoracic aorta, image noise, signal-to-noise ratio (SNR) and contrast-to-noise ratio (CNR) were calculated, and subjective image quality scores and traceability scores assessed. The effective radiation dose was calculated. The radiation dose was reduced by 79.7% in group A compared to group B (p< 0.05). The CT attenuation of the thoracic aorta was increased by approximately 13% in group A compared to group B (p< 0.05). Higher image noise, lower SNR, and CNR were obtained in group A compared to group B (all p< 0.05). Both subjective image quality scores and traceability scores did not differ between groups A and B (both p >0.05). It is feasible to use the "triple-low" dose CTA protocol for patients with a body mass index (BMI) < 30 kg/m2. The radiation dose was reduced by 79.7%, and the dose of contrast medium was reduced by 37.5% to ensure the diagnostic value. • Lower tube voltage and tube current were used. • Reduced amount of contrast agent. • Reduced radiation dose while maintaining diagnostic value. [ABSTRACT FROM AUTHOR]

To investigate whether pre-procedure Computed Tomography Angiography (CTA) improves radiation exposure, procedure complexity, and symptom recurrence after bronchial embolization for massive hemoptysis. A single-center retrospective review of bronchial artery embolization (BAE) for massive hemoptysis was performed for procedures between 2008 and 2019. Multi-variate analysis was performed to determine the significance of pre-procedure CTA and etiology of hemoptysis on patient radiation exposure (reference point air kerma, RPAK) and rate of recurrent hemoptysis. There were 61 patients (mean age 52.5 years; SD = 19.2 years, and 57.3% male) and CTA was obtained for 42.6% (26/61). Number of vessels selected was a mean of 7.2 (SD = 3.4) in those without CTA and 7.4 (SD = 3.4) in those with CTA (p = 0.923). Mean procedure duration was 1.8 h (SD = 1.6 h) in those without CTA and 1.3 h (SD = 1.0 h) in those with CTA (p = 0.466). Mean fluoroscopy time and RPAK per procedure were 34.9 min (SD = 21.5 min) and 1091.7 mGy (SD = 1316.6 mGy) for those without a CTA and 30.7 min (SD = 30.7 min) and 771.5 mGy (SD = 590.0 mGy) for those with a CTA (p = 0.523, and p = 0.879, respectively). Mean total iodine given was 49.2 g (SD = 31.9 g) for those without a CTA and 70.6 g (SD = 24.9 g) for those with a CTA (p = 0.001). Ongoing hemoptysis at last clinical follow up was 13/35 (37.1%) in those without CTA and 9/26 (34.6%) in those with CTA (p = 0.794). Pre-procedure CTA did not improve radiation effective dose and symptom recurrence after BAE and is associated with significant increases in total iodine dose. • Bronchial artery embolization can be performed without pre-procedure cross-sectional imaging. • Computed tomography angiography does not add significant radiation effective dose. • Cases with an otherwise suspected bleeding site should proceed directly to interventional treatment. [ABSTRACT FROM AUTHOR]

Haemoptysis occurs in up to 25 % of young people with Cystic fibrosis (CF) [1]. We undertook a literature review and described the management approach to haemoptysis in CF between 2010 and 2020 at an Australian tertiary paediatric centre, The Children's Hospital Westmead, Sydney, New South Wales, using a retrospective review of the medical records which identified 67 episodes. Sixty episodes met inclusion criteria, including 31 patients. Using the US CF Foundation guidelines, episodes were classified as scant (53.3 %), moderate (38.3 %) or massive (8.3 %). Fifty-two percent of patients were female, mean age at presentation was 15.4 years (SD+/- 2.4) and 58 % were homozygous for the Fdel508 genotype. Twelve episodes (9 patients) required bronchial artery embolization (BAE). BAE was used in all cases of massive haemoptysis 5/5 (100 %), 6/23 (22 %) episodes of moderate and 1/32 (3 %) episode of scant haemoptysis as an elective procedure for recurrent haemoptysis. Our literature review and institutional experience highlights the need for up-to-date management guidelines in the management of haemoptysis in Cystic Fibrosis. Based on our experience, we provide a proposed algorithm to help guide the management of haemoptysis in CF. [ABSTRACT FROM AUTHOR]

• ETI therapy revolutionizes CF care with improved lung function and quality of life. • CF patients on ETI may show unusual symptoms during respiratory exacerbations. • Recognizing subtle symptoms is crucial for timely intervention. • Vigilance is essential in managing CF patients on ETI. • New diagnostic methods are needed to enhance care. The introduction of CFTR modulator drugs like elexacaftor-tezacaftor-ivacaftor (ETI) has transformed the management of cystic fibrosis (CF), significantly improving symptoms, lung function, and quality of life, while reducing reliance on intravenous antibiotics. However, respiratory exacerbations in the CFTR modulators era remain poorly understood from both pathophysiological and clinical perspectives. We present the case of a 20-year-old Caucasian woman with CF (F508del/L1077P) who, after three years of ETI treatment, experienced a severe episode of hemoptysis, despite being almost asymptomatic in the weeks leading up to admission, requiring bronchial artery embolization. Following ETI treatment, auscultatory findings and FEV 1 changes may be less significant, making the detection of respiratory exacerbation more challenging. This highlights the need for heightened vigilance in managing such cases and underscores the challenge of diagnosing and managing exacerbations in the era of modulators. Long term real-world studies are essential to comprehend the evolving course of the disease during ETI treatment. [ABSTRACT FROM AUTHOR]

• During embolisation embolic microspheres could migrate from bronchial to pulmonary arteries • In advanced disease, anastomoses between bronchial and pulmonary artery could reach 800µm • Nontarget pulmonary embolisation might explain complications such as chest pain Haemoptysis is a life-threatening complication of cystic fibrosis (CF). One treatment is bronchial artery embolisation (BAE) using embolic-microspheres (EMs). During BAE, pulmonary arteries can be seen on digital subtracted angiography while iodine containing contrast material injection is performed in the bronchial artery. This suggests that EMs could go from bronchial to nontarget pulmonary arteries. The aim was to evaluate if EMs could be found inside pulmonary arteries on lung explants after BAE in transplanted CF patients. Retrospective observational study including patients with CF who underwent lung transplantation and had previously needed BAE. Clinical, chest CT angiography, and angiographic data were reviewed from medical records. Pathology examination of lung explants was performed to analyze the EMs anatomical localisation. Eight patients were included between 2013 and 2015, four males with a mean age of 29 (19-45) years. All patients had bronchial artery hypertrophy on CT and bronchial-to-pulmonary artery shunting during BAE. On pathology examination, EM ≤800 µm were found in the pulmonary arteries in all patients and were responsible for distal branch occlusions. Two pulmonary infarcts were observed on CT angiography after BAE and confirmed histopathologically. EM migration from the bronchial to pulmonary arteries is a common occurrence after BAE in patients with advanced stage CF. Although BAE is a highly effective means of controlling haemoptysis in CF, studies on the optimal particle size are needed to preserve pulmonary artery circulation, because these results suggest that low size EMs could lead to nontarget embolisation. [ABSTRACT FROM AUTHOR]

Although COVID-19 coagulopathy typically manifests with thrombotic complications, hemorrhagic complications also occur and must be considered when making decisions about anticoagulation in these patients. Here, we report a case of massive hemoptysis occurring in a recently post-partum woman via Cesarean section with COVID-19 who was managed via bronchial artery embolization while on extracorporeal membrane oxygenation. • Although COVID-19 coagulopathy typically manifests with thrombotic complications, hemorrhagic complications can occur and must be considered when making decisions about anticoagulation • Pulmonary hemorrhage is an uncommon manifestation of COVID-19 infection, occurring in 0.9-3% of cases • Bronchial artery embolization for pulmonary hemorrhage seems safe and effective in the setting of COVID-19 infection [ABSTRACT FROM AUTHOR]

• A large variation of dose values per procedure and department were found. • DRLs were defined for PTBD, BAE, TACE, IEAE, TIPS e ETFPA, in terms of P KA in Gy.cm2, K a,r in mGy and Fluoro time (FT) in minutes. • The results revealed a relevant potential for optimisation and harmonisation of dose values. • Standardisation of data collection methods to set national DRLs in order to facilitate comparisons. To establish Portuguese Diagnostic Reference Levels (DRLs), for six body fluoroscopy guided interventional procedures (FGIP). A retrospective study was conducted in five interventional departments most representative of Interventional Radiology (IR) practice. Dose values, in terms of air kerma area product (P KA in Gy.cm2), air kerma at the patient entrance reference point (K a,r in mGy), and exposure parameters (fluoroscopy time (FT) and number of cine runs) were collected. Examinations were selected per procedure (at least 20), according to the antero-posterior and lateral diameter mean value (±5 cm), measured on previous Computed Tomography (CT) examinations. Data of 489 body FGIP show a large variation on dose values per procedure and per department. National DRLs in terms of P KA were 20.2 Gy.cm2 for Percutaneous transhepatic biliary drainage (PTBD), 98.2 Gy.cm2 for Bronchial artery embolisation (BAE), 247.7 Gy.cm2 for Transarterial chemoembolisation (TACE), 331.6 Gy.cm2 for Inferior epigastric arteries embolisation (IEAE), 312.0 Gy.cm2 for Transjugular intrahepatic portosystemic shunt (TIPS) and 19.3 Gy.cm2 for Endovascular treatment of femoral popliteal arteries (ETFPA). This is the first study reporting Interventional Radiology DRLs in Portugal and we propose preliminary national estimates for the six more common body FGIP. The results of this study will be presented and discussed with all Portuguese IR departments, to promote procedures optimisation. [ABSTRACT FROM AUTHOR]

Pulmonary infarction results from occlusion of the distal pulmonary arteries leading to ischemia, hemorrhage and ultimately necrosis of the lung parenchyma. It is most commonly caused by acute pulmonary embolism (PE), with a reported incidence of around 30%. Following an occlusion of the pulmonary artery, the bronchial arteries are recruited as primary source of perfusion of the pulmonary capillaries. The relatively higher blood pressure in the bronchial circulation causes an increase in the capillary blood flow, leading to extravasation of erythrocytes (i.e. alveolar hemorrhage). If this hemorrhage cannot be resorbed, it results in tissue necrosis and infarction. Different definitions of pulmonary infarction are used in literature (clinical, radiological and histological), although the diagnosis is nowadays mostly based on radiological characteristics. Notably, the infarcted area is only replaced by a fibrotic scar over a period of months. Hence and formally, the diagnosis of pulmonary infarction cannot be confirmed upon diagnosis of acute PE. Little is known of the impact and relevance of pulmonary infarction in acute PE, and whether specific management strategies should be applied to prevent and/or treat complications such as pain, pneumonia or post-PE syndrome. In this review we will summarize current knowledge on the pathophysiology, epidemiology, diagnosis and prognosis of pulmonary infarction in the setting of acute PE. We highlight the need for dedicated studies to overcome the current knowledge gaps. • Nearly 30% of acute pulmonary embolism patients show signs of pulmonary infarction. • Various pulmonary infarction definitions are used (clinical/radiological/histological). • Whether pulmonary infarction requires specific treatment is unknown. • Future research should focus on long-term clinical outcomes of pulmonary infarction. [ABSTRACT FROM AUTHOR]

Acute, major pulmonary haemorrhage in children, is rare, may be life-threatening and at times presents atypically. Dieulafoy's disease of the bronchus presenting with recurrent or massive hemoptysis was first described in adults. Prior to reviewing the literature, we report an illustrative case of bronchial Dieulafoy's disease (BDD) in a child presenting unusually with massive apparent hematemesis. The source of bleeding is a bronchial artery that fails to taper as it terminates within the bronchial submucosa. A high index of suspicion is required to identify such lesions via radiological imaging and the role of bronchial artery embolisation is highlighted with video images of angiography included. [ABSTRACT FROM AUTHOR]

• Locally advanced NSCLC failed first-line CCRT is a treatment challenge. • Combined iodine-125 brachytherapy and BACE can achieve a good local tumor control for NSCLC after CCRT failed. • Combined iodine-125 brachytherapy and BACE is effective and safe for NSCLC after CCRT failed. To evaluate the efficacy and safety of the combination of computed tomography (CT)-guided iodine-125 brachytherapy and bronchial arterial chemoembolization (BACE) for locally advanced stage III non-small cell lung cancer (NSCLC) after failure of concurrent chemoradiotherapy. We retrospectively evaluated 28 patients with locally advanced stage III NSCLC in whom concurrent chemoradiotherapy had failed and were consequently, treated with radioactive iodine-125 seed implantation followed by BACE. The prescribed radiation dose was 140 Gy, with a median radioactivity of 0.60 mCi. The tumor-feeding arteries were detected on angiography, and chemotherapeutic agents (gemcitabine 1000 mg/m2 + lobaplatin 30 mg/m2) were then administered via arterial infusion. The tumor-feeding arteries were embolized using 300–500 μm embosphere microspheres. The endpoints were treatment response rate, progression-free survival (PFS), and toxicity. The median number of implanted iodine-125 seeds was 58 pellets (range, 44–114 pellets). The median post-operative dose covering 90 % of the target volume (D90) was 143.4 Gy (range, 123.6–159.9 Gy). A total of 73 cycles of BACE were conducted (2.61 cycles per case). The bronchial arteries were the main tumor-feeding arteries. In total, 11 patients had hemoptysis, and it was significantly alleviated within 24 h after BACE. There was no serious procedure-related complication. The 6-month objective response and disease control rates were 71.42 % and 92.86 %, respectively. No severe complications occurred during the follow-up. Local control duration ranged from 5–12 months, and the median PFS was 8 months (95 % confidence interval: 7.3–8.8 months). The combination of CT-guided iodine-125 brachytherapy and BACE is an effective and safe approach for the treatment of NSCLC after failure of concurrent chemoradiotherapy and is worthy of clinical application. [ABSTRACT FROM AUTHOR]

An anomalous coronary artery is reported in 2% to 23% of patients with tetralogy of Fallot (TOF). Knowledge of coronary anatomy prior to corrective surgery is vital to avoid damage to vessels crossing the right ventricular outflow tract (RVOT). A meta-analysis on the prevalence of anomalous coronary arteries in TOF is lacking to date. Here, an overview of coronary anomalies in TOF is provided and implications for patient management are discussed. PubMed, Embase and Web of Science were searched. Analysis was done using Revman 5.3 (Cochrane Community, London). The primary analysis focused on the origin and proximal course of the right and left coronary arteries. In addition, the prevalence of large conus arteries and coronary arteriovenous fistulas (CAVF) was calculated. Twenty-eight studies, encompassing 6956 patients, were included; 6% of TOF patients have an anomalous coronary artery. Hereof, 72% cross the RVOT; the majority of the remaining 28% courses behind the aorta. Six percent of patients have a large conus artery and 4% a CAVF. Other coronary anomalies include a left or right coronary artery from the pulmonary trunk or left or right pulmonary artery, coronary tree hypoplasia and anastomoses between coronary and bronchial arteries. The prevalence of coronary anomalies in TOF is 4–6%. In patients with an anomalous coronary artery, 72% cross the RVOT. The combined risk of encountering an anomalous coronary artery or a large conus artery crossing the RVOT is 10.3%. Coronary anatomy should be defined before surgery and the surgical approach adapted accordingly. Unlabelled Image • The prevalence of coronary anomalies in TOF is 4–6%. • In patients with an ACA, 72% of the anomalous arteries cross the RVOT. • The risk of encountering an ACA or large conus artery crossing the RVOT is 10.3%. • Before surgery, define the coronary anatomy to avoid damage of anomalous vessel. • Surgical approach should be adapted to the course of an anomalous coronary artery. [ABSTRACT FROM AUTHOR]

Pulmonary arteriovenous malformations (PAVM) present with a variety of clinical manifestations, including hemoptysis. The usual management strategy relies upon interventional techniques, with surgery reserved for cases which are recalcitrant to less invasive measures. A 14-year-old female presented with massive and refractory hemoptysis. CTA and bronchoscopy did not identify a targetable lesion, but given her clinical instability she underwent percutaneous angiography which identified a right-sided PAVM with bronchial artery to pulmonary artery communication coursing near the right mainstem bronchus. Embolization procedures were initially successful to control bleeding, but recurrences of hemoptysis prompted surgical evaluation. Approximately two years after initial presentation, we performed robotic ligation of her PAVM which resulted in definitive control of the lesion with no additional bleeding episodes. She recovered well from surgery with a one-night hospital stay, and has experienced no surgical complications or recurrent bleeding to date. Rarely, pediatric PAVMs may require surgical intervention if interventional methods do not achieve definitive therapy. A variety of surgical techniques may be employed as dictated by the lesion's characteristics. Robotic approaches, including ligation, should be considered for patients with failure of conservative measures as it provides minimally invasive, precise technical management of PAVM. • What is currently known about this topic? • Pulmonary arteriovenous malformations (PAVM) are rare lesions that cause bleeding, embolism, and pathologic shunting. Interventional techniques are the mainstay of therapy, but surgery is required complex or recurrent cases; the role of robotic approaches to PAVM management is relatively unexplored. • What new information is contained in this article? • We report a robotic surgical technique to manage recrruent bleeding due to a PAVM. This technique can be used when other interventional measures fail. [ABSTRACT FROM AUTHOR]

The impact of cystic fibrosis (CF) on male reproductive health is profound. The vast majority of men with CF are infertile due to obstructive azoospermia. Multiple factors associated with CF contribute to an increased prevalence of testosterone deficiency, which adversely affects muscle mass, bone density, and quality of life. This article reviews the pathophysiology, diagnosis, and management of infertility and testosterone deficiency that occur in men with CF. With improving survival of CF patients, these topics are becoming more significant in their clinical care. • Infertility affects nearly all men with CF and is from anatomical obstruction. • They still produce sperm and can potentially father children by harvesting sperm. • Male hypogonadism is seen in CF and is diagnosed based on morning serum testosterone. • Measurement of FSH and LH can distinguish between primary and secondary hypogonadism. • A variety of different testosterone preparations are available for replacement. [ABSTRACT FROM AUTHOR]

Bone disease is a frequent complication in adolescents and adults with cystic fibrosis (CF). Early detection and monitoring of bone mineral density and multidisciplinary preventive care are necessary from childhood through adolescence to minimize CF-related bone disease (CFBD) in adult CF patients. Approaches to optimizing bone health include ensuring adequate nutrition, particularly intake of calcium and vitamins D and K, addressing other secondary causes of low bone density such as hypogonadism, encouraging weight bearing exercise, and avoiding bone toxic medications. Of the currently available anti-resorptive or anabolic osteoporosis medications, only bisphosphonates have been studied in individuals with CF. Future studies are needed to better understand the optimal approach for managing CFBD. • Optimizing bone health includes adequate nutrition, intake of calcium and vitamins D and K, and weight bearing exercise. • Bone density should be monitored regularly in patients with CF. • The decision to start pharmacologic therapy and choice of medication should be made on a case-by-case basis. • Only bisphosphonates have been studied specifically in patients with CF. • CFTR modulators offer promise for improving CF bone disease by enhancing overall targeting CFTR dysfunction in bone cells. [ABSTRACT FROM AUTHOR]

To depict imaging anatomy of bronchial artery (BA) using multidetector CT-angiography (MDCTA) and evaluate the value of MDCTA for management of hemoptysis patients requiring admission to emergency room. We retrospectively studied the clinical and radiological data of patients with severe hemoptysis (≥ 100 ml of expectorated blood in a 24-hour period) requiring admission to emergency room from Jan 1, 2013 to Dec 31, 2015. Patients' images of MDCTA, treatment modalities, and outcome were discussed. A total of 108 patients underwent MDCTA scans. Etiology of hemoptysis was mainly bronchiectasis (44%), tuberculosis sequelae (26%) and tumor (18%). MDCTA visualized 197 traceable BAs and also suggested the involvement of 35 nonbronchial systemic arteries. The mean diameter of BAs, measured at the level of the bronchial bifurcation in the mediastinum, was 2.8±1.2 mm. The mean diameter of BAs, for 52 patients who only received conservative treatment, was 2.9±1.1 mm, and was not significantly larger than that of BAs for 56 patients who underwent bronchial artery embolization (BAE) for continued bleeding which did not resolve after conservative treatment (2.7±1.1 mm, P = 0.94). The technical success rate of embolization was 95% (53/56). Clinical success rate during follow-up was achieved in 50 (94%) of 53 patients who had undergone embolization. MDCTA provides useful information for identifying the anatomical characteristics of bleeding-related BAs and nonbronchial systemic arteries for the management of patients with severe hemoptysis. However, MDCTA could not determine the individuals who need BAE through measuring diameter of BAs. [ABSTRACT FROM AUTHOR]

Chronic thromboembolic pulmonary hypertension (CTEPH) is often diagnosed after a long delay, even though signs may already be present on the computed tomography pulmonary angiogram (CTPA) used to diagnose a preceding acute pulmonary embolism (PE). In this setting of suspected acute PE, we evaluated the diagnostic accuracy of dedicated CTPA reading for the diagnosis of already existing CTEPH. Three blinded expert radiologists scored radiologic signs of CTEPH on initial CTPA scans with confirmed acute PE in 50 patients who were subsequently diagnosed with CTEPH during follow-up (cases), and in 50 patients in whom sequential echocardiograms performed >2 years after the acute PE diagnosis did not show any signs of pulmonary hypertension (controls). All 50 control index CTPA scans had signs of right ventricular (RV) overload. Sensitivity and specificity of expert CTPA reading was calculated, and best-predicting radiologic parameters were identified. The overall expert reading yielded a sensitivity of 72% (95% confidence interval [CI] 58%–84%) and a specificity of 94% (95% CI 83%–99%) for CTEPH diagnosis. Multivariate analysis identified 6 radiologic parameters as independent predictors: intravascular webs; pulmonary artery retraction or dilatation; bronchial artery dilatation; right ventricular (RV) hypertrophy; and interventricular septum flattening. The presence of 3 or more these parameters was associated with a sensitivity of 70% (95% CI 55%–82%), a specificity of 96% (95% CI 86%–100%), and a c-statistic of 0.92. Standardized reading of CTPA scans performed for acute PE can be useful for the diagnosis of CTEPH when structured identification of 6 characteristics is employed during interpretation. The use of this strategy may help reduce diagnostic delay of CTEPH. [ABSTRACT FROM AUTHOR]

Polyarteritis nodosa is characterized by presence of aneurysms in the renal, hepatic and mesenteric vasculature, and less often by vascular abnormalities in the intracranial compartment. Spinal subarachnoid hemorrhage is a rare phenomenon that can be associated with inflammatory vasculopathies such as polyarteritis nodosa, but the link between aneurysm formation and spinal subarachnoid hemorrhage in polyarteritis nodosa is unclear. We describe a case of a patient with polyarteritis nodosa and spinal subarachnoid hemorrhage following rupture of an aneurysm of the anterior spinal artery. Following operative washout and decompression of the subarachnoid hemorrhage, spinal digital subtraction angiography was performed and revealed intimal contour irregularities, stenotic changes, and multiple small aneurysms in renal, hepatic, and bronchial arteries and some proximal spinal arteries, and, most notably, a pseudoaneurysm of the anterior spinal artery supplied directly by the artery of Adamkiewicz. Polyarteritis nodosa was subsequently diagnosed in light of these findings. Though previous cases have noted spinal subarachnoid hemorrhage in of the context of polyarteritis nodosa, we found no previously documented case of a definitive aneurysm of the anterior spinal artery in a case of polyarteritis nodosa documented on angiography. This case highlights the potential importance of monitoring for aneurysms of the spinal vasculature in cases of polyarteritis nodosa and in screening for vasculitides in cases of spinal subarachnoid hemorrhage. Future studies are needed to describe patterns of the specific anatomic localization and incidence of spinal artery aneurysms in polyarteritis nodosa. • Spinal subarachnoid hemorrhage and intradural spinal aneurysm are rare. • Intradural spinal aneurysm and subarachnoid hemorrhage have not been definitively documented radiologically in PAN • We present a patient with spinal subarachnoid hemorrhage originating from a spinal aneurysm who was later found to have PAN. [ABSTRACT FROM AUTHOR]

Abstract Background Hemoptysis is one of the most alarming condition to both the patients suffering from it and the treating physicians. It is caused due to varied etiologies. One of the emergent and at times life-saving treatment option is by minimally invasive interventional radiological technique of Bronchial Atery Embolization (BAE). The authors aimed to carry out a retrospective analysis of short term efficacy and safety of all patients treated by this technique at a tertiary care thoracic centre. Methods A total of 52 patients were included in the study who had a median follow up of 35 days. All these patients were referred for hemoptysis, intractable hemoptysis not controlled by conservative management or massive hemoptysis. An analysis of the underlying etiology, immediate and short term outcomes and complications was made. Results The study showed Tuberculosis and its sequel (bronchiectasis and chronic fibrotic changes) as the commonest etiology (65%). The BAE showed high short term efficacy (92%) in stopping the hemoptysis with a relatively low complication rate especially of major complications such as spinal cord ischemia (1.9%). The study strengthens the limited Indian data available on the subject and based on its outcome, BAE should be tried in all patients presenting with uncontrollable or massive hemoptysis not getting relief by conservative management alone. Conclusion BAE is a very effective procedure with very less complications for management of massive or uncontrollable hemoptysis. [ABSTRACT FROM AUTHOR]

Purpose: Comparison of radiation doses in patients undergoing angiographic bronchial artery embolization (BAE) before and after a noise reduction imaging technology upgrade.Methods: We performed a retrospective study of 70 patients undergoing BAE. Procedures were performed before (n=32) and after (n=38) the technology upgrade containing additional filters and improved image-processing. Cumulative air kerma (AK), cumulative dose area product (DAP), number of exposure frames, total fluoroscopy time and amount of contrast agent were recorded. Mean values were calculated and compared using two-tailed t-tests. DSA image quality was assessed independently by two blinded readers and compared using the Wilcoxon signed-rank test.Results: Using the new technology resulted in a significant reduction of 59% in DAP (149.2 (103.1-279.1) vs. 54.8 (38.2-100.7) Gy*cm2, p<0.001) and a significant reduction of 60% for AK (1.3 (0.6-1.9) vs. 0.5 (0.3-0.9) Gy, p<0.001) in comparison to procedures before the upgrade. There was no significant difference between the number of exposure frames in both groups (251±181 vs. 254±133 frames, p=0.07), time of fluoroscopy (28.8 (18.5-50.4) vs. 28.1 (23.3-38.7) min, p=0.73), or the amount of contrast agent used (139.5±70.8 vs. 163.1±63.1ml, p=0.11). No significant difference regarding image quality could be detected (3 (2,3) vs. 3 (2-4), p=0.64).Conclusions: The new angiographic noise reduction technology significantly decreases the radiation dose during bronchial artery embolization without compromising image quality or increasing time of fluoroscopy or contrast volume. [ABSTRACT FROM AUTHOR]

It has long been recognized that the pattern of particle deposition in the respiratory tree affects how far aerosols penetrate into the deeper zones of the arterial tree, and hence contribute to either their pathogenic potential or therapeutic benefit. In this paper, we introduce an anatomically-inspired model of the human respiratory tree featuring the generations 0–7 in the Weibel model of respiratory tree (i.e., the conducting zone). This model is used to study experimentally the dynamics of inhaled aerosol particles (0.5–20 µm aerodynamic diameter), in terms of the penetration fraction of particles (i.e., the fraction of inflowing particles that leave the flow system) during typical breathing patterns. Our study underline important modifications in the penetration patterns for coarse particles compared to fine particles. Our experiments suggest a significant decrease of particle penetration for large-sized particles and higher respiratory frequencies. Dimensionless numbers are also introduced to further understand the particle penetration into the respiratory tree. A decline is seen in the penetration fraction with decreasing Reynolds number and increasing Stokes number. A simple conceptual framework is presented to provide additional insights into the findings obtained. [ABSTRACT FROM AUTHOR]

Endobronchial ultrasonography (EBUS) is an adequate tool to analyze the bronchial structure, visualize the tracheobronchial wall invasion by intrathoracic malignancies, and measure the regional perfusion. The purpose of this study was to investigate the potential of EBUS to quantitatively assess structures and perfusion characteristics of bronchial anastomosis in lung transplant recipients. EBUS was performed with a regular 5-MHz ultrasonic videobronchoscope (BF-UC180F, Olympus) in lung transplant recipients undergoing surveillance bronchoscopies. Sequential pictures were taken of the bronchial anastomosis, including color flow Doppler and pulsed wave Doppler measurements. In addition to the comparison of bilateral lung transplant recipients, single lung transplant recipients were used as an internal control. The follow up was 10 months and surveillance bronchoscopies were performed routinely every 4 to 6 weeks. All patients received an immunosuppression of tacrolimus, MMF, and prednisone. None of the patients developed a rejection episode during the observation period. 64 EBUS examinations were performed in 6 bilateral lung transplant recipients and 2 single lung transplant recipients. Three layers were measured as major components of the bronchial wall. The absolute thickness of the native bronchial wall in single lung transplant recipients varied from 2.4 to 2.9 mm. The thickness of the bronchial wall of bronchial anastomosis varied from 2.0 to 2.2 mm in uneventful cases. Small bronchial arteries were identified by color flow Doppler and pulsed wave Doppler measurements revealed a velocity of 3 to 17 cm/s of the total cohort. Patients with complications of the bronchial anastomosis (e.g. stenosis and/or insufficiencies) had a velocity of less than 8 cm/s and less perfusion resulted in smaller bronchial wall structures with a thickness of less than 1.8 mm. EBUS enables to evaluate wall structures of the bronchial anastomosis in lung transplant recipients and to measure the thickness as well as the perfusion in a reproducible fashion. Thus, EBUS may be a useful tool for routine follow up after lung transplantation to detect possible complications at an early stage. [ABSTRACT FROM AUTHOR]

• The treatment of advanced squamous cell lung cancer after failure of system therapy is challenging • Intravascular interventional therapy has drawn increasing attention as an important method for advanced lung cancer Bronchial artery chemoembolization(BACE) or bronchial artery infusion(BAI) is considered an alternative treatment • Drug-eluting beads BACE maybe a better choice which could prolong OS and PFS and improve short-term tumor response To analyze the efficacy and safety of bronchial arterial embolization (BACE) with drug-eluting beads (DEB) versus bronchial artery infusion (BAI) followed by polyvinyl alcohol (PVA) particle embolization for the treatment of advanced squamous cell lung cancer after the failure of systemic therapy. Thirty-six patients with advanced squamous cell lung cancer who underwent bronchial arterial interventional therapy were included in this retrospective study. The DEB group (n = 20) was treated with nedaplatin and DEB loaded with gemcitabine, and the PVA group (n = 16) BAI with nedaplatin and gemcitabine followed by embolization with PVA particles. The treatment efficacy and complications were analyzed. The technical success rate was 100 %. The two groups were followed up for a median period of 8.9 months. The mean overall survival (OS) in the DEB group was 12.6 months (95 % CI:9.99–15.21), which was significantly longer than 8.14 months (95 % CI:6.07–10.2) in the PVA group (p = 0.007). The median progression-free survival (PFS) in the DEB group was 4.3 months (95 % CI:2.33–6.27), significantly longer than 3.2 months (95 % CI:2.55–3.85) in the PVA group (p = 0.030). The objective response rate (ORR) six months after the procedure was 50 % in the DEB group and 12.5 % in the PVA group. In the univariate and multivariate analyses, DEB-BACE was an independent prognostic factor for survival. Only grade 1 adverse events like fever, chest pain, and cough were seen. DEB-BACE may be a good choice for patients with advanced lung squamous cell carcinoma, as it could prolong OS and PFS without increasing adverse events. [ABSTRACT FROM AUTHOR]

Polycyclic aromatic hydrocarbons (PAH) are produced by incomplete combustion of organic material. In the Mexico City atmosphere, the most abundant PAH is benzo[ ghi ]perylene (B ghi P), a gasoline combustion marker. At present, there are no reports of the effects of B ghi P on human bronchial cells, so the aim of the study was to evaluate the effects in vitro of B ghi P on the NL-20 cell line. Results showed that B ghi P induced the formation of small vesicles throughout the cytoplasm, with absence of nuclear fragmentation. At 48 h exposition, damage in cell membrane increased significantly at 1.24 μg/mL of B ghi P (p < 0.05). Immunocytochemistry revealed that B ghi P provokes nuclear translocation of AhR receptor, which indicates that this compound can induce transcription of genes via receptor binding (AhR pathway activation). B ghi P induced a two-fold increase (p < 0.05) in the expression of AhR and CYP4B1 (a lung-specific pathway effector). In the presence of the receptor antagonist CH-223191, the loss of viability, the nuclear translocation and the overexpression of genes decreased, though this did not prevent the formation of vesicles. B ghi P induced oxidative stress and in presence of the receptor antagonist this increased significantly. In conclusion, B ghi P can activate the overexpression of AhR and CYP4B1, and the effects are abated by the AhR receptor antagonist. This is the first report to prove that B ghi P utilizes the AhR pathway to exert its toxic effects on the NL-20 human bronchial cell line . [ABSTRACT FROM AUTHOR]

Background and objective The human lungs exchange air with the external environment via the conducting airways. The application of an anatomically accurate model of the conducting airways can be helpful for simulating gas exchange and fluid distribution throughout the bronchial tree in the lung. Methods In the current study, Lindenmayer system (L-system) has been formulated to generate the bronchial tree structure in a human lung. It has been considered that the structure of the bronchial tree is divided into two main segments: 1) The central airways (from the trachea to segmental bronchi) and 2) the dichotomous structure (from segmental bronchi to terminal bronchioles). Two sets of parametric rewriting rules which can be used to develop central and peripheral airways have been proposed; the first set used to develop central airways consists of seven rules, while the second rule set contains four rules. Results The proposed model is capable of generating bronchial tree inside the volume of the host lung; and comparison of the resulting model with those reported in the literature shows that the morphometric characteristics of L-system structure are in good agreement with their corresponding experimental data. Conclusion The resulting model can be used to obtain a mathematical model required for the study of transport phenomena occurring in the lung during respiration. [ABSTRACT FROM AUTHOR]

Background and purpose Asthma is a disease of high prevalence and morbidity that generates high costs in hospitalization and treatment. Although the airway is involved in the physiopathology of asthma, there is also evidence of the importance of vascular and lung parenchyma inflammation and remodeling, which can contribute to the functional pulmonary alterations observed in asthmatic patients. Our aim was to evaluate treatment using sakuranetin, a flavone isolated from the twigs of Baccharis retusa (Asteraceae), on vascular and lung parenchyma alterations in an experimental murine model of asthma. Methods Male BALB/c mice were subjected to a sensitization protocol with ovalbumin for 30 days and were treated with or without sakuranetin (20 mg/kg/mice) or dexamethasone (5 mg/kg/mice); then, the lungs were collected for histopathological analysis. We evaluated extracellular matrix remodeling (collagen and elastic fibers), inflammation (eosinophils and NF-kB) and oxidative stress (8-isoprostane) in the pulmonary vessels and lung parenchyma. The thickness of the vascular wall was quantified, as well as the vascular endothelial growth factor (VEGF) levels. Results We demonstrated that sakuranetin reduced the number of eosinophils and elastic fibers in both the pulmonary vessels and the lung parenchyma, probably due to a reduction of oxidative stress and of the transcription factor NF-kB and VEGF levels in the lung. In addition, it reduced the thickness of the pulmonary vascular wall. The treatment had no effect on the collagen fibers. In most of the parameters, the effect of sakuranetin was similar to the dexamethasone effect. Conclusions and implications Sakuranetin had anti-inflammatory and antioxidant effects, preventing vascular and distal parenchyma changes in this experimental model of asthma. [ABSTRACT FROM AUTHOR]

This study aimed to explore the value of a real-time comparative observation method using contrast-enhanced ultrasound (CEUS) for discriminating between bronchial and pulmonary arterial phases in diagnosing lung diseases. Forty-nine patients with 50 pulmonary lesions (45 peripheral lesions and five central lesions with obstructive atelectasis, including 36 malignant tumors, five tuberculomas, four inflammatory pseudotumors and five pneumonia lesions) detected via computed tomography and visible on ultrasonography were enrolled in this study. The arterial phases were determined by comparing contrast agent arrival time (AT) in the peripheral lung lesion with that in adjacent lung tissue, referred to as a real-time comparative observation method. Detection rates of this observation method were 100% (50/50) for pulmonary arterial phase and 88% (44/50) for bronchial arterial phase. Using the instrument's built-in graphing and analysis software, a time-intensity curve was constructed based on a chosen region of interest within the lesion where enhancement was the most obvious. Commonly used perfusion indicators in CEUS, such as AT, time-to-peak and peak intensity, were obtained from the time-intensity curve. Percutaneous puncture biopsies were performed under ultrasound guidance, and specimens of all 50 lesions were examined pathologically. AT was significantly shorter in patients with pneumonia than in those with malignant tumors or chronic inflammation (p < 0.05), whereas no difference was seen between those with malignant tumors and those with chronic inflammation. No significant differences in time-to-peak or peak intensity were seen among those with various lung diseases (p > 0.05). This is the first description of a real-time comparative observation method using CEUS for determining the arterial phases in the lungs. This method is accurate, simple to perform and provides a direct display. It is expected to become a practical and feasible tool for diagnosing lung diseases. [ABSTRACT FROM AUTHOR]

Objective: To assess the influence of the lower threshold for segmentation of the volume of interest on the perfusion values in first-pass dual input volume CT-perfusion of lung lesions. Materials and Methods: Dual input maximum slope volume CT-perfusion was performed in 48 patients (mean age±standard deviation [SD], 68±10years; range, 46-87 years) who underwent subsequent CT-guided biopsy to evaluate a lung lesion. Using commercial perfusion software, a lower and upper threshold was set for determination of the CT-value range, which again determined the volume of interest for perfusion calculation. The pulmonary arterial flow (PAF), bronchial arterial flow (BAF), and perfusion index (PI; PAF/(PAF+BAF)) were calculated at following pre contrast CT value range settings: -80 to 150HU (setting 1), -200 to 150HU (setting 2), -300 to 150HU (setting 3), and -500 to 150HU (setting 4). Perfusion parameters were compared between benign (n, 15) and malignant (n, 33) lesions for each setting. Intraobserver- and interobserver reliability were calculated for setting 4. Results: Median PAF was significantly higher in malignant lesions than in benign lesions for all settings (53-96 versus 29-62mL/min/100mL, P<0.05). There was no significant difference in BAF between malignant and benign lesions. Median PAF of all lesions was significantly influenced by the CT value range setting (P<0.05), whereas the values increased from setting 1 to 4. Intraobserver analysis as well as interobserver analysis of PAF at setting 4 showed excellent reliability (Cronbach's alpha 0.98 and 0.95, respectively, P<0.01). Conclusion: PAF derived from first-pass dual-input maximum slope volume CT perfusion is statistically significantly higher in malignant than in benign lesion, whereas the measurements are influenced by the lower threshold of the CT value range setting. This has to be considered when using cutoff values provided in the literature for differentiation between benign and malignant lung lesions. [ABSTRACT FROM AUTHOR]

Organophosphate insecticides (OI) are widely used. To humans the main routes of exposure are skin and inhalation. For this, keratinocytes (HaCaT) and bronchial cells (NL-20) were used as cell culture models to evaluate the effects of OI. The aim of this study was to evaluate the effect of four OI on HaCaT and NL-20 cells: azinphos-methyl, (AM); parathion-methyl (PM); omethoate (OM); and methamidophos (MET). Cells were exposed to 0.1, 1 and 10 μg/μL of each. Results showed a decrease in cell viability in both cell lines. Viability of the NL-20 cell line decreased with the three concentrations of OM. All differences were significant (p < 0.05). Genotoxic damage, evaluated through the comet assay, was observed in both cell lines with AM. NL-20 cell line was more sensitive than HaCaT. Higher concentrations of the insecticides except MET, induced cell death. MET caused DNA damage in HaCaT cells at all concentrations. Differences were significant (p < 0.05). Both cell lines revealed the presence of single membrane vacuoles of different sizes when exposed to 1 μg/μL of each insecticide. Quantitative real time-polymerase chain reaction (RT-qPCR) showed an increase of BN1 gene in HaCaT by effect of AM and MET at 1 μg/μL. In conclusion, all the insecticides induced different levels of cyto and genotoxic effects in both cell lines. [ABSTRACT FROM AUTHOR]

Background Long-term success in pediatric lung transplantation is limited by infection and bronchiolitis obliterans syndrome (BOS). The bilateral sequential lung transplantation (BSLT) technique may result in airway ischemia leading to bronchial stenosis, dehiscence, or loss of small airways. En bloc lung transplant (EBLT) with bronchial artery revascularization (BAR) minimizes airway ischemia, thus promoting superior airway healing. BAR also allows for safe tracheal anastomosis, circumventing the need for bilateral bronchial anastomoses in small children. Methods This was a retrospective review of bilateral transplantations from 2005 to 2014. Both techniques were used in parallel. Redo and multiorgan transplants were excluded. Results There were 119 recipients comprising 88 BSLTs and 31 EBLTs. Follow-up time was 3 years (interquartile range, 1–5 years). Donor ischemic and cardiopulmonary bypass times were not different between techniques ( p = 0.48 and p = 0.18, respectively). Degree of graft dysfunction and cellular rejection scores were not different ( p = 0.83 and p = 0.93, respectively). There were 3 hospital deaths after BSLT and 2 after EBLT ( p = 0.60). Overall survival was 61% for the BSLT group and 77% for the EBLT group ( p = 0.54). Freedom from BOS was 71% in the BSLT group and 94% in the EBLT group ( p = 0.08). On routine bronchoscopy, 57% BSLT and 16% EBLT patients had 1 or more airway ischemic findings ( p < 0.0001). Multivariate analysis showed BSLT was associated with higher ischemic injury (relative risk, 2.86; 95 confidence interval, 1.3–6.5; p = 0.01) and non-airway complications (relative risk, 4.62; 95% confidence interval, 1.1–20.2; p = 0.04) but not airway reinterventions ( p = 0.07). Airway dehiscence occurred in 3 BSLT patients. Conclusions Pediatric EBLT with BAR can be safely performed without increasing operative or graft ischemic times. Airway ischemia and non-airway complications were significantly reduced when BAR was combined with tracheal anastomosis, potentially diminishing morbidity caused by anastomotic healing complications. [ABSTRACT FROM AUTHOR]