MSCT
AJR 2006; 186:649–6550361–803X/06/1863–649
? American Roentgen Ray Society
M N T U R E D I C A L I M A
G I N G
A C E Y O F
C h e s t I m a g i n g ?P i c t o r i a l E s s ay
Bronchial and Nonbronchial Systemic Arteries in Patients with Hemoptysis: Depiction on MDCT Angiography
Myung Jin Chung
1Ju Hyun Lee 1Kyung Soo Lee 1Young Cheol Yoon 1O Jung Kwon 2Tae Sung Kim 1
Keywords: bronchial arteries, CT technique, hemoptysis, lung, lung disease, MDCT angiography DOI:10.2214/AJR.04.1961
Received December 24, 2004; accepted after revision February 10, 2005.
Supported by grant R11-2002-103 from the Korea Science and Engineering Foundation.
1Department of Radiology, Samsung Medical Center, 50,
Ilwon-Dong, Kangnam-Ku, Seoul 135-710, Korea. Address correspondence to K. S. Lee (kyungs.lee@https://www.wendangku.net/doc/3a17376034.html,).
2Division of Pulmonary and Critical Care Medicine,
Department of Medicine, Sungkyunkwan University School of Medicine, Seoul 135-710, Korea.OBJECTIVE.In this pictorial essay, we show the usefulness of MDCT angiography for vi-sualization 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 conven-tional 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.
ronchial artery embolization is regarded as the therapeutic method of choice for the manage-ment of massive hemoptysis [1],and rapid identification of the site and the cause of bleeding using noninvasive imaging techniques is an essential aspect of embolo-therapy [2, 3]. Thus, CT depiction of the
B
A B
Fig.1—Enlarged right intercostobronchial trunk in 38-year-old man with multi-drug-resistant pulmonary tuberculosis.
A, Lung window coronal reconstruction image (2.0-mm thickness) shows multiple thin-walled cavities in right lung and bronchiectasis (arrows ) in right upper lobe.
B, Selective right bronchial angiogram shows enlarged right intercostobrachial trunk. Hypertrophied inferior branch (arrows , right bronchial artery) supplies right bronchial tree.(Fig.1 continues on next page)
Chung et al.
bronchial and nonbronchial systemic arter-ies responsible for hemoptysis, before inter-ventional 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 non-bronchial systemic feeder vessels responsi-
ble for hemoptysis.
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, branch-
ing patterns, and courses. The right intercosto-
bronchial trunk (Fig.1), which usually arises
from the right posterolateral aspect of the tho-
racic aorta, is the most constant vessel [3, 4, 6].
C
D
E Fig.1(continued)—Enlarged right intercostobronchial trunk in 38-year-old man with multi-drug-resistant pulmonary tuberculosis.
C, 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.
D, Mediastinal window oblique coronal image (2.0-mm collimation) shows right intercostobronchial trunk (arrow) and intercostal artery (arrowhead) arising from aorta.
E, Volume-rendering image clearly shows right intercostobronchial trunk (arrow) and intercostal arteries (arrowheads) arising from aorta.
MDCT Angiography of Systemic Arteries
The left bronchial arteries usually originate from the anterior surface of the thoracic aorta or from the concavity of the aortic arch, pass for-ward 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] (Fig.2). When a bronchial artery origi-nates 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] (Fig.3).
Four kinds of classic bronchial artery
branching patterns have been described: one
right intercostobronchial trunk and two left
bronchial arteries (40%); one right intercosto-
bronchial trunk and one left bronchial artery
(21%); one intercostobronchial trunk, a right
bronchial artery, and two left bronchial arter-
ies (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.2 and 4).
Causes of Massive Hemoptysis and
Causes of Bronchial Artery Aneurysm
Pulmonary tuberculosis (Fig.1), bron-
chogenic carcinoma, bronchiectasis (Figs.2
and 3), cystic fibrosis, and aspergillosis are the
Fig.2—Double left bronchial arteries in 51-year-old
man with bronchiectasis.
A, 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).
B and C, 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.
D, Volume-rendering image shows clearly
hypertrophied upper (arrows) and lower (arrowheads)
left bronchial arteries.
A
B C D
Chung et al.
A B
C D Fig.3—Hypertrophied ectopic right bronchial artery in 51-year-old woman with bronchiectasis in both lungs.
A, 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.
B, Selective right bronchial arteriography image shows enlarged and tortuous right bronchial artery (arrows).
C, 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.
D, Volume-rendering image shows right bronchial artery (arrowheads) arising from right internal mammary artery (arrows).
MDCT Angiography of Systemic Arteries
A B C Fig.4—Common trunk of lower right bronchial artery in 55-year-old woman with bronchiectasis.
A and B, 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).
C, 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).
A B C Fig.5—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.
A, 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.
B, Mediastinal window coronal reconstruction image (2.0-mm thickness) shows aneurysmal dilatation (arrow) in left bronchial artery, which arises from aortic arch (arrowhead).
C, Volume-rendering image shows aneurysm (arrow) and hypertrophied left bronchial artery (arrowheads) distal to it.
Chung et al.
common causes of massive hemoptysis. Less frequent causes include lung abscess, pneumo-nia, chronic bronchitis, interstitial pulmonary fibrosis, pulmonary artery aneurysm (Rasmus-sen aneurysm), congenital cardiac or pulmo-nary vascular anomalies, aortobronchial fistula, and ruptured bronchial artery aneurysm [1–3]. Bronchial artery aneurysm is considered to be caused by bronchiectasis, mycotic origin, or Osler-Weber-Rendu syndrome. When an-eurysmal dilatation of the bronchial artery is caused by trauma, it is called a “pseudoaneu-rysm.” 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 nonbron-chial 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 worksta-
tion, where 1.0- to 1.25-mm-thickness transaxial
images with mediastinal window settings
(width, 400 H; level, 20 H) are evaluated. Multi-
planar reconstruction images are obtained paral-
lel to the axis of the origin of the bronchial artery
to confirm the level of the origin and allow its di-
ameter to be measured. In addition, multiplanar
reconstruction images are obtained at various an-
gles to evaluate the mediastinal course and the
traceability of the bronchial arteries to the hilum.
Three-dimensional images obtained using vol-
ume-rendering and maximum-intensity-projec-
tion techniques are constructed to display the ar-
teries as a whole in a single image.
Bronchial arteries are identified in the pos-
terior mediastinum as dots or lines of in-
creased attenuation on transaxial images [7].
Transaxial and multiplanar reconstruction
images at various angles allow detailed delin-
eation of the anatomy of the bronchial arter-
ies. The origin site of the bronchial arteries is
always depicted on transaxial thin-section im-
ages. However, the mediastinal or hilar
courses of the bronchial arteries are visual-
ized more clearly on multiplanar reconstruc-
tion or volume-rendering images, which are
also superior to transaxial images in terms of
depicting the ectopic origins of bronchial ar-
teries [8, 9] (Figs.1–7).
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 Y oon 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 bron-
chial bleeding, is occasionally seen; its re-
ported prevalence is 4–11% [10].
CT Depiction of Nonbronchial
Systemic Collaterals
Nonbronchial systemic arteries enter the
lung parenchyma through the inferior pulmo-
nary ligament (Fig.6) or through the adherent
pleura (Fig.7). When enlarged vascular struc-
tures (one or several branches of the subclavian
or axillary arteries, the intercostal arteries, or
the inferior phrenic arteries) within extrapleu-
ral fat are shown in association with pleural
thickening (≥ 3 mm) and lung parenchyma ab-
normalities (Fig.7), 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 en-
largement and associated pleural thickening)
but courses to the lungs on CT images is re-
A
B
C
Fig.6—Nonbronchial systemic arterial supply in 60-year-old woman with bronchiectasis in left lower lobe.
A, Selective arteriogram shows enlarged left inferior phrenic artery (arrows) supplying bronchiectatic left lower lobes with fistulous connection to left pulmonary artery (arrowheads).
B, Mediastinal window oblique coronal reconstruction image (2.0-mm thickness) shows hypertrophied left inferior phrenic artery (arrows) heading toward left lower lobe. C, Volume-rendering image shows both hypertrophied left inferior phrenic artery (arrows) and left pulmonary artery (arrowheads) with fistulous connection.
MDCT Angiography of Systemic Arteries
Fig.7—Nonbronchial systemic arterial supply from left intercostal artery in 45-year-old woman with aspergillomas.
A, 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.
B, 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. C, Volume-rendering image shows hypertrophied left intercostal artery (arrows) arising from aorta, heading toward aspergilloma cavity (arrowheads).
A
B
C
garded as a nonbronchial systemic artery that
is not responsible for hemoptysis.
Conventional Angiography
Versus CT Angiography
By providing thin-section transaxial, mul-
tiplanar reconstruction, and 3D images, CT
angiography using MDCT allows comparable
or better images than conventional angiogra-
phy with respect to the depiction of bronchial
or nonbronchial systemic arteries. CT angiog-
raphy is particularly useful for visualizing the
ectopic origin of bronchial arteries and non-
bronchial systemic collateral arteries [8, 9].
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