Chest
Volume 149, Issue 3, March 2016, Pages 869-881
Journal home page for Chest

Special Features
Vessels of the Central Airways: A Bronchoscopic Perspective

https://doi.org/10.1016/j.chest.2015.12.003Get rights and content

Blood supply of the tracheobronchial tree is derived from a dual system involving pulmonary and bronchial circulation. Various primary and secondary abnormalities of central airway vasculature can present with patterns that are distinct during bronchoscopy. These patterns maybe visualized during bronchoscopic evaluation of a patient with hemoptysis or as an incidental finding during an airway examination for other indications. Thorough knowledge of airway vasculature abnormalities and recognition of possible underlying pathophysiology is vital for the bronchoscopist. This review is a comprehensive description of vascular anatomy of the airway and the different vascular abnormalities that can be encountered during bronchoscopy.

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.

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