Chest
Special FeaturesVessels of the Central Airways: A Bronchoscopic Perspective
Section snippets
Pulmonary Circulation
The lung is a unique organ with a dual blood supply. It receives blood from the pulmonary as well as the bronchial circulation. The pulmonary circulation is composed of the pulmonary arteries (PAs), which originate from the right ventricle and rapidly subdivide over a short distance to form approximately 280 billion pulmonary capillaries.2 The pulmonary capillaries completely envelop the alveoli and are the main site of gas exchange. The resulting surface area, which is capable of gas exchange,
Abnormalities of Bronchial Venous Plexus and Bronchopulmonary Venous Connections
The tracheal veins also empty into the inferior thyroid venous plexus, whereas the bronchial drainage depends on bronchial veins for the proximal and pulmonary veins for the distal bronchi, respectively.6 Several areas of anatomic connections between the bronchial and pulmonary veins are collectively referred to as the bronchopulmonary circulation. This anastomosis could occur at the hilum and subpleural regions and is not usually clinically relevant.7 However, anything causing an impediment to
Bronchial Artery Malformation
Bronchial artery malformations can result from aneurysmal dilatation of the bronchial artery or an arteriovenous malformation (AVM) that connects the tortuous bronchial artery to the PA or pulmonary vein. These malformations may occur as a congenital anomaly or as a result of infection, trauma, or lung tumors.22 Most patients with these anomalies are asymptomatic but they may also present with massive hemoptysis. Bronchial artery malformations may appear during bronchoscopy as a submucosal
Pulmonary Artery Aneurysm and Pseudoaneurysm
Aneurysms and pseudoaneurysms are rare anomalies of the PA that are difficult to distinguish clinically and bronchoscopically. The cause of these abnormalities of the PA can be congenital (associated with cardiac defects such as patent ductus arteriosus) or acquired as a result of conditions such as tuberculosis, syphilis, and collagen vascular disease including Marfan syndrome and Behcet disease.26, 27, 28 PA pseudoaneurysm has been described in the setting of trauma (Swan-Ganz catheterization
Neoplasms
Neoplasms of the central airways that originate primarily from the vasculature are rare. Several neoplasms, primary and metastatic, have a characteristic bronchoscopic appearance but are not of primary vascular origin and hence are not discussed in detail here.
Bronchiectasis
Bronchiectasis is the leading cause of hemoptysis worldwide.37 Bronchial arterial enlargement and increased pulmonary vascular anastomosis in bronchiectasis was described for the first time by Liebow et al.38 Recent studies have conclusively demonstrated that bronchial arteries are hypertrophic owing to thickening of the vessel walls in patients with bronchiectasis.37 Kosar et al37 also demonstrated that as the severity of bronchiectasis increased, the diameter of the bronchial artery also
Dieulafoy Lesion of the Bronchus
A Dieulafoy lesion (DL) of the bronchus is a rare occurrence accounting for about 6% of all cases of hemoptysis.42, 43 In a prospective study by Savale et al,42 Dieulafoy disease of bronchus was identified in approximately 50% of patients who had undergone surgery for high-volume hemoptysis. It seems to have a strong association with heavy smoking, although causality has yet to be proven conclusively. DL causes massive and recurrent hemoptysis in patients with otherwise normal lung architecture
Conclusions
Blood supply of the tracheobronchial tree is derived from a complex dual system with contributions from the low-resistance pulmonary arteries and the high-resistance bronchial arteries. Several conditions, both primary and secondary, affect the central airway vasculature and may have a distinct appearance during bronchoscopy (Table 1). A bronchoscopist is typically involved in the care of these patients when they present with hemoptysis. However, some of the vascular patterns may be seen as
Acknowledgments
Author contributions: A. K., A. D., S. K. R., and A. M. contributed to the content of the manuscript and to approval of the final version to be published.
Financial/nonfinancial disclosures: None declared.
References (54)
- et al.
Endobronchial changes in chronic pulmonary venous hypertension
Chest
(1988) - et al.
Gross and microscopical blood supply of the trachea
Ann Thorac Surg
(1977) - et al.
The radiographic findings of fibrosing mediastinitis
Chest
(1994) - et al.
A mycotic pulmonary artery aneurysm presenting as an endobronchial mass
Chest
(2003) - et al.
Endobronchial lesions in HIV-infected individuals
Chest
(1994) - et al.
Endobronchial metastasis: an epidemiologic and clinicopathologic study of 174 consecutive cases
Lung Cancer
(2014) - et al.
Airway involvement in sarcoidosis
Chest
(2009) - et al.
Endobronchial ultrasound-guided transbronchial needle aspiration vs conventional transbronchial needle aspiration in the diagnosis of sarcoidosis
Chest
(2014) - et al.
Dieulafoy’s disease: a cause of massive hemoptysis that is probably underdiagnosed
Ann Thorac Surg
(2005) Lethal hemoptysis caused by biopsy injury of an abnormal bronchial artery
Chest
(2001)
Isolated bronchial telangiectasia
Chest
Pulmonary telangiectasia without hypoxemia
Chest
Endobronchial telangiectasias and hemoptysis in scleroderma
Am J Med
American College of Chest Physicians. Interventional pulmonary procedures: guidelines from the American College of Chest Physicians
Chest
Influence of pulmonary arterial and left atrial pressures on pulmonary vascular resistance
Circ Res
The bronchial circulation: small, but a vital attribute of the lung
Am Rev Respir Dis
The contribution of the bronchial circulation to the venous admixture in pulmonary venous blood
J Physiol
The airway vasculature: recent advances and clinical implications
Thorax
Bronchial varices in congenital unilateral pulmonary vein atresia
Am J Respir Crit Care Med
Bronchoscopic findings in congenital isolated unilateral pulmonary vein atresia in an adult
J Bronchology Interv Pulmonol
A case of tracheal varices in an adolescent patient with cyanotic heart disease
Ann Am Thorac Soc
A case of bronchial varices due to extrahepatic portal hypertension
Respiration
Caput medusae in the mediastinum
Am J Respir Crit Care Med
Bronchial venous plexus in left ventricular dysfunction
J Bronchology Interv Pulmonol
Mediastinal fibrosis complicating healed primary histoplasmosis and tuberculosis
Medicine (Baltimore)
External-beam radiotherapy for massive hemoptysis complicating mediastinal fibrosis
South Med J
Tuberculous fibrosing mediastinitis: CT and MRI findings
J Thorac Imaging
Cited by (15)
Rasmussen aneurysm: Case series of a rare complication of Pulmonary Tuberculosis
2023, Respiratory Medicine Case ReportsReply to “Bronchial Artery Aneurysm and Pseudoaneurysm: Which Endovascular Treatment?”
2021, Archivos de BronconeumologiaAirways flat angioma misdiagnosed as difficult asthma in an adolescent
2021, Respiratory Medicine Case ReportsCitation Excerpt :As reported, flat bronchial angiomas represent a rare cause of congenital malformations and have to be considered in the differential diagnosis of pediatric asthma [1]. Airways angiomas are usually diagnosed through bronchoscopy performed for persistent cough, stridor or other respiratory symptoms [3]. The diagnosis of airway flat angioma is often made during childhood [3].
Nonthrombotic Pulmonary Embolism From Inorganic Particulate Matter and Foreign Bodies
2018, ChestCitation Excerpt :The “feeding vessel sign” on contrast-enhanced CT scans is useful for identifying PAVMs.120 Contrast-enhanced CT scanning allows for an accurate examination of the architecture of the PAVM, which consists of a feeding artery, the aneurysmal bulb, and a draining vein.121 They also allow for the visualization of potential complications such as thrombosis of feeding vessels.113
Rasmussen's pseudoaneurysm- case report
2018, Respiratory Medicine Case ReportsCitation Excerpt :Moreover, bronchoscopy could localize the bleeding or diagnose its cause when chest x-ray and/or CT fail to do so [15,16]. In the other hand, bronchoscopic examination of the airways does not have specific findings in many important causes of hemoptysis such as bronchiectasis as an example [17]. In our case, bronchoscopic examination was not informative, it merely confirmed the present of AFB in the airways.