Endovascular Treatment of Hemoptysis: Does Bronchial Artery Embolization Fit All?

Hemoptysis is usually attributed to bleeding from bronchial or non-bronchial systemic arterial circulation. Venous airway bleeding is rarely considered, although it requires a different diagnostic and therapeutic approach. A 64-year-old man with a large retrosternal multinodular goiter was admitted for recurrent hemoptysis. Computed tomography showed left lower lobe consolidation and marked compression of the superior vena cava and brachiocephalic veins, with extensive mediastinal and chest-wall collateralization. Initial bronchoscopy suggested bleeding from the left lower lobe, and left bronchial artery embolization achieved only transient hemostasis. Recurrent bleeding within 24 h prompted repeat bronchoscopy, which demonstrated multiple submucosal tracheal varices; narrow-band imaging further delineated their vascular architecture. Integration of bronchoscopic and radiological findings established the diagnosis of venous hemoptysis secondary to benign central venous obstruction. Bilateral brachiocephalic vein stenting restored venous drainage and produced immediate and sustained resolution of hemoptysis. Subsequent thyroidectomy was performed without complications. Tracheal varices should be considered when hemoptysis recurs despite technically adequate bronchial artery embolization, particularly in the presence of central venous obstruction and collateral circulation. Definitive treatment should target the underlying venous hypertension by restoring central venous outflow.