Bronchial artery embolization shows higher clinical efficacy and lower recurrence than pharmacotherapy for hemoptysisBronchial artery embolization shows better results for coughing up blood

Bronchial artery embolization (BAE) is widely used for hemoptysis, but the supporting evidence has mainly been derived from observational studies, and its certainty remains unclear. This study aimed to evaluate the efficacy and safety of BAE compared with other treatment modalities based exclusively on randomized controlled trials (RCTs), with evidence certainty assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. We searched seven databases from inception to December 29, 2024, without language restrictions. Two reviewers independently screened studies, extracted data, and assessed risk of bias. Random-effects meta-analyses were performed, and evidence certainty was assessed using GRADE. Comparator-specific analyses were primary for the main outcomes, while pooled analyses across different comparators were exploratory. An updated search on June 24, 2026 identified no additional eligible RCTs. The review was registered in PROSPERO. Twenty RCTs involving 1,594 patients were included. Compared with pharmacotherapy, BAE showed higher clinical efficacy (RR 1.24, 95% CI 1.18–1.31), lower recurrence (RR 0.26, 95% CI 0.13–0.54), lower mortality (RR 0.20, 95% CI 0.05–0.90), and fewer overall complications (RR 0.41, 95% CI 0.26–0.63), all supported by moderate-certainty evidence. BAE plus usual care versus usual care showed higher clinical efficacy (RR 1.27, 95% CI 1.12–1.43; very-low-certainty evidence) and lower recurrence (RR 0.28, 95% CI 0.15–0.53; moderate-certainty evidence), but no clear differences in mortality (RR 0.36, 95% CI 0.05–2.43) or overall complications (RR 1.04, 95% CI 0.45–2.39), both with low-certainty evidence. Compared with bronchoscopic balloon tamponade, BAE showed no clear difference in clinical efficacy (RR 0.91, 95% CI 0.80–1.03; low-certainty evidence), recurrence (RR 2.14, 95% CI 0.17–27.10; very-low-certainty evidence), or overall complications (RR 1.15, 95% CI 0.54–2.46; low-certainty evidence). The comparative effects of BAE varied by treatment strategy. Evidence was more consistent versus pharmacotherapy, while estimates for bronchoscopic balloon tamponade and add-on usual-care designs were less certain. Findings should therefore be interpreted by specific treatment contrast rather than as a single overall effect. Further well-designed multicenter RCTs are needed. https://www.crd.york.ac.uk/PROSPERO identifier CRD420250643812.