Systemic artery-to-pulmonary artery fistulas and recurrence of noncancer-related hemoptysis after bronchial artery embolization: a retrospective study

To investigate the clinical and angiographic characteristics of systemic artery-to-pulmonary artery fistulas (SA-PAFs) in patients with noncancer-related hemoptysis undergoing bronchial artery embolization (BAE), and to assess their associations with procedural outcomes and recurrent hemoptysis. We retrospectively analyzed consecutive patients with noncancer-related hemoptysis treated with BAE between January 2020 and December 2024. Patients were categorized as having non-SA-PAF, mild SA-PAF, or massive SA-PAF on angiography. Clinical features, angiographic findings, embolization outcomes, and recurrence-free survival were compared. Cox regression analyses were used to identify factors associated with recurrence. Among 276 included patients, SA-PAFs were identified in 216 (78.3%), including 134 (48.6%) with mild SA-PAF and 82 (29.7%) with massive SA-PAF. Massive SA-PAF was associated with greater vascular complexity, including more culprit arteries and more frequent ectopic bronchial artery and non-bronchial systemic artery involvement. The overall clinical success rate was 98.2%, but complete cessation of hemoptysis was less frequent in the massive SA-PAF group (79.3%) than in the mild SA-PAF (91.0%) and non-SA-PAF (95.0%) groups. Among 271 patients with clinical success and follow-up, recurrence occurred in 54 (19.9%) and was most frequent in the massive SA-PAF group (32.9%). Recurrence-free survival was significantly worse in patients with massive SA-PAF. In the primary multivariable model, TB-related disease was independently associated with recurrence, whereas SA-PAF classification was not. In exploratory models, ectopic bronchial artery was independently associated with recurrence. SA-PAFs are common angiographic findings in noncancer-related hemoptysis treated with BAE. Massive SA-PAF is associated with greater vascular complexity and poorer unadjusted outcomes, whereas TB-related disease remained the most robust independent predictor of recurrence and ectopic bronchial artery may represent an additional exploratory angiographic marker.