Management of Hemoptysis Post Coronary Angiography
Immediately assess severity and stabilize the airway—if massive hemoptysis (>200 mL/24h or causing respiratory compromise), proceed directly to bronchial artery embolization without delay, as this achieves 73-99% immediate hemostasis and delaying intervention significantly increases mortality. 1, 2
Initial Assessment and Stabilization
Determine bleeding severity first: Massive hemoptysis is defined as bleeding placing the patient at high risk for asphyxiation or exsanguination (traditionally ≥200 mL in 24 hours), though the rate of bleeding correlates more closely with mortality than total volume 1. Post-angiography hemoptysis can occur from aberrant bronchial arteries arising from the internal mammary artery used for bypass grafts 3.
For Massive Hemoptysis (Clinically Unstable):
- Intubate immediately with a single-lumen cuffed endotracheal tube (NOT double-lumen) to allow bronchoscopic suctioning and clot removal 1
- Avoid BiPAP entirely—positive pressure ventilation worsens bleeding 1, 2
- Establish large-bore IV access (ideally 8-Fr central line) for volume resuscitation 1
- Stop all anticoagulants and NSAIDs immediately—these worsen bleeding, which is critical post-angiography when patients are typically on dual antiplatelet therapy 1, 2
- Proceed directly to bronchial artery embolization (BAE) without bronchoscopy or other diagnostic delays, as over 90% of massive hemoptysis originates from bronchial arteries 1, 2
For Mild-to-Moderate Hemoptysis (Clinically Stable):
- Obtain CT chest with IV contrast as the preferred initial diagnostic test—this identifies the cause and location in 77% of cases versus only 8% with bronchoscopy alone 1, 2
- Stop NSAIDs and hold anticoagulation until bleeding resolves 1, 2
- Admit to hospital for monitoring if hemoptysis ≥5 mL 1
- Consider bronchoscopy to identify the bleeding source and perform therapeutic interventions if needed 1
Specific Post-Angiography Considerations
Critical pitfall: Aberrant bronchial arteries can arise from the internal mammary artery (IMA) used in coronary bypass grafting, causing delayed hemoptysis years after the procedure 3. This requires:
- Selective angiography of the IMA if standard bronchial artery evaluation is negative 3
- Embolization of aberrant bronchial branches arising from the IMA graft 3
Bronchoscopic Management (If Performed)
Use these techniques for visible central airway bleeding 1:
- Tamponade by wedging the bronchoscope into the bleeding bronchus 1
- Iced saline instillation to constrict blood vessels 1
- Bronchial blockade balloons for temporary control 1
- Topical hemostatic tamponade with oxidized regenerated cellulose mesh (98% success rate) 1
- Thermal ablation (argon plasma coagulation, Nd:YAG laser, or electrocautery) for visible lesions 1
Definitive Management
Bronchial artery embolization is first-line therapy with 73-99% immediate success rates 1, 2. CT angiography should precede BAE for arterial mapping 1, 2.
Important caveat: Recurrence occurs in 10-55% of cases after BAE, requiring close follow-up 1, 2. Recurrence within 3 months suggests incomplete embolization; after 3 months suggests vascular collateralization 1.
Post-Intervention Management
- Admit to ICU for monitoring of coagulation parameters, hemoglobin, and ongoing bleeding 1
- Actively warm the patient and all transfused fluids to prevent hypothermia-induced coagulopathy 1
- Resume anticoagulation only after complete resolution of hemoptysis (typically 12-24 hours after last episode) 2
- Start venous thromboprophylaxis as soon as bleeding is controlled 1
When Surgery Is Indicated
Surgery is reserved as a final option when BAE fails, carrying 16% mortality associated with blood aspiration into the contralateral lung and pneumonectomy 1. This is rarely needed post-angiography but may be considered if bleeding is from a surgically accessible source and the patient is stable 1.