Non-massive versus massive hemoptysis and the impact of preoperative embolization in patients with destroyed lung parenchyma: a single-center experience

Introduction

Pulmonary parenchymal destruction frequently occurs due to chronic pulmonary infections, such as pulmonary tuberculosis. This condition often creates a favorable environment for opportunistic infections, most notably those caused by fungal agents like Aspergillus species (1).

Beyond direct destruction of the pulmonary arterial wall, hemoptysis can also result from direct invasion of adjacent blood vessels by infectious lesions, as well as from bronchial artery dilation and the formation of vascular aneurysms (1,2).

Recurrent hemoptysis in the setting of pulmonary parenchymal destruction represents a major clinical challenge and has attracted growing attention. Studies report mortality rates exceeding 50% in cases of massive hemoptysis, highlighting the need for prompt emergency intervention. For patients with persistent or refractory hemoptysis, surgical resection of the affected pulmonary segment may serve as definitive treatment or as an adjunct to medical therapy. Surgical resections for inflammatory/infectious diseases are frequently challenging operations with higher morbidity than lung resection for oncological diseases. In addition, massive hemoptysis is also associated with significant morbidity and adverse impacts on surgical outcomes, as demonstrated in prior research (3,4).

The definition of massive hemoptysis in this study followed clinically based criteria rather than the absolute volume of expectorated blood, consistent with prior studies emphasizing life-threatening physiological compromise as a determinant of severity (3-5).

However, despite the demonstrated relationship of hemoptysis and poor outcomes after surgical intervention, there is limited research evaluating the perioperative impact and management strategies for recurrent hemoptysis in patients undergoing pulmonary resection due to parenchymal destruction. This study aims to address this gap by analyzing the differences between patients with non-massive versus massive hemoptysis, and the effect of preoperative embolization on those who were at patients with structural lung changes who received surgical intervention for hemoptysis during the perioperative period (5-9). We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1707/rc).

Methods

Study population

We retrospectively collected data from both outpatient and emergency patients presenting with hemoptysis secondary to pulmonary parenchymal destruction who underwent surgical treatment between January 2019 and January 2024 at Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (No. 7.436.548; CAAE 17362819.2.0000.0068). The requirement for informed consent was waived due to the retrospective nature of the study.

Diagnostic definition

All patients underwent chest computed tomography (CT) using multidetector scanners. Pulmonary parenchymal destruction was defined based on specific radiological criteria, including extensive bronchiectasis, cavitary disease, volume loss of the affected lobe or lung, architectural distortion of the pulmonary parenchyma, and thoracic cage asymmetry.

Massive hemoptysis was defined as any amount of bleeding that could result in a life-threatening condition, such as impaired oxygenation, hemodynamic instability, or respiratory failure, regardless of the absolute volume of blood ˜expectorated.

Inclusion and exclusion criteria

We included all patients with radiologically confirmed pulmonary parenchymal destruction and hemoptysis who underwent pulmonary resection during the same hospital admission. Patients were excluded if their medical records were incomplete or if they did not attend outpatient follow-up during the 12-month observation period. Figure 1 demonstrates a general sample of the population.

Figure 1 General sample of the population.

Statistical analysis

Statistical analysis was performed using SPSS version 26.0 (SPSS Inc., Chicago, IL, USA). Data were presented using descriptive statistics, including mean, standard deviation, median [interquartile range (IQR)] for quantitative variables, and absolute numbers with corresponding percentages for categorical variables. For categorical variables, we used Fisher’s exact test and Pearson’s Chi-squared test where appropriate (according to application conditions). For non-parametric quantitative variables, we used the Mann-Whitney U test (which is equivalent to the Wilcoxon rank sum test for two independent groups). All analyses were conducted using the R programming environment (R version 4.5.1), with a statistical significance threshold set at P<0.05.

Results

Following a comprehensive review of all medical records, using predefined inclusion and exclusion criteria, a total of 51 patients were included in this study for data analysis.

In the initial analysis, participants were categorized into two groups based on the clinical presentation of hemoptysis—massive hemoptysis (n=19) and non-massive hemoptysis (n=32). Among the 11 patients with massive hemoptysis who did not undergo preoperative BAE, the procedure was not performed due to the unavailability of interventional radiology (n=6) or inability to identify the bleeding artery during angiography (n=5). None of these patients had pulmonary artery bleeding.

The median interval from hospital admission to surgery was 3 days (IQR, 1–5 days). In two patients, emergency surgery was required due to uncontrolled bleeding or respiratory compromise.

Patients who died within 12 months were included in the analysis; only those lost to follow-up were excluded.

Group characteristics according to hemoptysis type

The overall mean age of participants was 42 years (range, 35–58 years), with no statistically significant difference between the groups (P=0.69). Considering the general study population and the non-massive hemoptysis group, females were more prevalent. However, in the massive hemoptysis group, males represented the majority of participants (11 patients; 58.0%), although this difference was not statistically significant.

Regarding the duration of symptoms from the first episode of hemoptysis to the current presentation, the mean duration was similar between the two groups, approximately 24 months.

Pulmonary tuberculosis is the most common cause of both massive (94.7%) and non-massive (87.5%) hemoptysis. Regarding other causes, we had 3 patients with recurrent infection and 2 participants with congenital pulmonary malformation.

Lobectomy is the most frequently performed procedure in both groups, with no statistically significant difference in the frequencies between massive (57.9%) and non-massive (65.6%) hemoptysis, and the upper lobes were the most prevalent, with 41 patients in total.

Regarding comorbidities, seven patients had hypertension, and three patients had diabetes mellitus. Most of the participants (37 patients) did not have any comorbidities. Table 1 shows general characteristics of the population

Kaplan-Meier analysis demonstrated no significant survival difference between massive and non-massive hemoptysis groups (P=0.42) or between BAE and non-BAE subgroups (P=0.45)

Perioperative outcomes of the initial analysis

Several perioperative parameters of patients undergoing pulmonary resection were analyzed.

Eighteen participants required a blood component red blood cell (RBC) transfusion. Patients in the massive hemoptysis group demonstrated a higher prevalence of transfusion need [8 (25%) vs. 10 (53%)], reaching statistical significance (P=0.046).

In addition to the difference in the number of patients requiring transfusion, the length of ICU stay differed significantly between groups (P=0.02). Participants in the massive hemoptysis group had a median ICU stay of 4.0 days (IQR, 1.0–5.0 days), whereas those in the non-massive group stayed a median of 1.0 day (IQR, 0.0–4.0 days).

Seven participants required surgical reintervention due to complications (hemothorax, empyema), five of whom belonged to the massive hemoptysis group, although this difference did not reach statistical significance (P=0.09).

Operative time and duration of chest tube drainage were also longer on average in the massive hemoptysis group, but these differences were not statistically significant (P=0.44 and 0.37, respectively). Table 2 demonstrates perioperative outcomes.

General characteristics of the massive hemoptysis group

Regarding general characteristics, participants were subdivided into two groups: those who underwent preoperative bronchial artery embolization (BAE) (n=8) and those who did not (n=11). All patients presenting with massive hemoptysis underwent surgery during the same hospitalization. Patients who did not receive embolization were either unable to identify the arterial branch supplying the destroyed pulmonary area anatomically or had the unavailability of the procedure at the required time.

In the overall analysis of patients with massive hemoptysis, males and white participants were more prevalent. The mean age of participants was 43 years (IQR, 38.0–56.0 years), with a slightly higher mean age in the non-embolization group (47 vs. 41 years), although this difference was not statistically significant (P=0.49).

Ten participants required blood component transfusion. Although not statistically significant (P=0.07), eight of these patients had not undergone preoperative embolization. Table 3 presents the characteristics of the massive hemoptysis group.

Perioperative outcomes in the massive hemoptysis group

Participants who did not undergo preoperative embolization had a longer mean duration of pleural drainage (9.0 vs. 4.0 days), which was statistically significant (P=0.01). Additionally, the mean length of stay in the intensive care unit (ICU) was longer in the non-embolization group (5.0 vs. 1.0 days), also reaching statistical significance (P=0.02).

Regarding intraoperative bleeding, patients without embolization experienced more than twice the average blood loss compared to those in the embolization group (570.0 vs. 225.0 mL), with statistical significance (P=0.050). Consequently, the number of blood component transfusions was higher in the non-embolized group (median 1.0 vs. 0.0 U; P=0.03).

Although not statistically significant, operative time (345.0 vs. 270.0 min; P=0.14), total hospital length of stay (9.0 vs. 6.0 days; P=0.09), and the need for surgical reintervention (4 vs. 1 patient; P=0.34) were also greater in the group not undergoing preoperative BAE. Table 4 shows perioperative outcomes of massive hemoptysis population.

We analyzed the variation in hemoglobin levels pre- and postoperatively between patients in both groups. There was a slight, more pronounced reduction in the non-embolization group, without statistical significance (1.9 vs. 1.8 g/dL, P=0.96). Figure 2 demonstrates pre- and postoperative hemoglobin levels (g/dL) in the massive hemoptysis group.

Figure 2 Pre- and postoperative hemoglobin levels (g/dL) in the massive hemoptysis group.

Discussion

Mortality rates in massive hemoptysis cases can exceed 50%. In this study, the analysis of 51 patients undergoing pulmonary resection due to hemoptysis revealed clinically and perioperatively relevant findings, especially when comparing subgroups with and without hemodynamic compromise (1,2,10).

Consistent with current literature, patients with massive hemoptysis exhibited worse perioperative outcomes, with a higher need for blood component transfusion (52.6% vs. 25%, P=0.046), longer ICU stays (mean 4.0 vs. 1.0 days, P=0.02), and a higher rate of surgical reintervention. However, the latter did not reach statistical significance. These findings support the data reported by Lordan et al., Sakr et al., and Kiral et al., who described massive hemoptysis as an independent predictor of increased intraoperative complexity and prolonged postoperative recovery (3,9,11,12).

Additionally, this study highlights the role of BAE as an effective adjunct tool in the surgical management of massive hemoptysis. Patients undergoing BAE showed reduced intraoperative blood loss (225 vs. 570 mL, P=0.050), shorter duration of pleural drainage (4.0 vs. 9.0 days, P=0.01), and decreased ICU length of stay (1.0 vs. 5.0 days, P=0.02). These data reinforce the hemostatic benefits previously described in retrospective series, such as the multicenter study conducted by Panda et al. and studies by Haponik et al. Although embolization was not feasible in all cases due to anatomical or structural limitations, its implementation, when possible, appears to have a positive impact on bleeding control and perioperative parameters (3-5).

It is noteworthy that, despite no statistically significant differences in operative time or total hospital length of stay, both parameters tended to be longer in the non-BAE group, possibly reflecting greater hemodynamic instability and technical complexity associated with the lack of prior arterial bleeding control. These observations align with findings from Jean-Baptiste et al., who describe embolization as a therapeutic bridge for clinical stabilization prior to definitive pulmonary resection (8,13).

Another point to consider is that most patients with massive hemoptysis were male, although this difference was not statistically significant compared to the non-massive hemoptysis group. This finding is consistent with studies indicating a higher prevalence of destructive pulmonary diseases—such as bronchiectasis and tuberculosis sequelae—among men, especially in endemic regions (7,14).

Strengths and limitations

Despite the robustness of the perioperative data, this study has inherent limitations related to its retrospective design and relatively small sample size, which may compromise the statistical significance of some clinically relevant variables, such as the rate of surgical reintervention. Nevertheless, the results provide important evidence regarding the utility of BAE in the context of massive hemoptysis and reinforce the need for institutional protocols to ensure timely access to the procedure when indicated.

Prospective and larger-scale studies to confirm the findings and establish more definitive guidelines on the integration of BAE into the surgical management of hemoptysis are necessary.

Conclusions

The results of this study reinforce that massive hemoptysis is associated with increased perioperative morbidity compared to non-massive hemoptysis, as evidenced by a higher need for blood transfusion, longer ICU stay, and a tendency toward increased incidence of surgical complications. Furthermore, the findings indicate that BAE performed prior to surgical intervention provides significant clinical benefits, including reduced intraoperative blood loss, decreased transfusion requirements, shorter duration of chest drainage, and reduced ICU stay.

These data support the role of embolization as a valuable adjunct tool in stabilizing patients with massive hemoptysis, which is associated with a safer surgical approach and improved outcomes. The standardization of embolization use, whenever feasible, should be considered an integral part of the multidisciplinary management of these patients.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1707/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1707/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1707/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1707/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the Hospital das Clinicas da Faculdade de Medicina da Universidade de São Paulo (No. 7.436.548; CAAE 17362819.2.0000.0068). The requirement for informed consent was waived due to the retrospective nature of the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Panda A, Bhalla AS, Goyal A. Bronchial artery embolization in hemoptysis: a systematic review. Diagn Interv Radiol 2017;23:307-17. [Crossref] [PubMed]
2. Chen G, Zhong FM, Xu XD, et al. Efficacy of regional arterial embolization before pleuropulmonary resection in 32 patients with tuberculosis-destroyed lung. BMC Pulm Med 2018;18:156. [Crossref] [PubMed]
3. Sakr L, Dutau H. Massive hemoptysis: an update on the role of bronchoscopy in diagnosis and management. Respiration 2010;80:38-58. [Crossref] [PubMed]
4. Jean-Baptiste E. Clinical assessment and management of massive hemoptysis. Crit Care Med 2000;28:1642-7. [Crossref] [PubMed]
5. Andréjak C, Parrot A, Bazelly B, et al. Surgical lung resection for severe hemoptysis. Ann Thorac Surg 2009;88:1556-65. [Crossref] [PubMed]
6. Haponik EF, Fein A, Chin R. Managing life-threatening hemoptysis: has anything really changed? Chest 2000;118:1431-5. [Crossref] [PubMed]
7. Haponik EF, Chin R. Hemoptysis: clinicians’ perspectives. Chest 1990;97:469-75. [Crossref] [PubMed]
8. Kathuria H, Hollingsworth HM, Vilvendhan R, et al. Management of life-threatening hemoptysis. J Intensive Care 2020;8:23. [Crossref] [PubMed]
9. Mal H, Rullon I, Mellot F, et al. Immediate and long-term results of bronchial artery embolization for life-threatening hemoptysis. Chest 1999;115:996-1001. [Crossref] [PubMed]
10. Fan S, Cheng X, Wang X, et al. Bronchial artery embolization versus conservative treatment for hemoptysis: a systematic review and meta-analysis. BMC Pulm Med 2024;24:428. [Crossref] [PubMed]
11. Lordan JL, Gascoigne A, Corris PA. The pulmonary physician in critical care * Illustrative case 7: Assessment and management of massive haemoptysis. Thorax 2003;58:814-9. [Crossref] [PubMed]
12. Kiral H, Evman S, Tezel C, et al. Pulmonary resection in the treatment of life-threatening hemoptysis. Ann Thorac Cardiovasc Surg 2015;21:125-31. [Crossref] [PubMed]
13. Zhou YM, Song N, Lin L, et al. Application of preoperative embolization during surgery for the destroyed lung. Ann Palliat Med 2020;9:644-7. [Crossref] [PubMed]
14. Aidé MA. Hemoptise. J Bras Pneumol 2010;36:278-80. [Crossref] [PubMed]