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• W2067088355 abstract "Editor: Acute hemomediastinum and hemothorax are usually related to chest trauma, rupture of thoracic aortic aneurysm, or aortic dissection. Causes of spontaneous mediastinal hemorrhage have been subdivided by Ellison et al (1) in four categories: (i) complication of enlarging mediastinal masses, (ii) transient increase in intrathoracic pressure, (iii) sudden sustained hypertension, and (iv) altered hemostasis (1,2). Rupture of a bronchial artery aneurysm (BAA) is rarely the etiology of mediastinal hemorrhage. We present a case of a ruptured BAA in which the diagnosis was made by thoracic computed tomography (CT) and successful treatment was achieved by embolization with n-butyl-2-cyanoacrylate. It allows occlusion of feeding and outflow vessels as reported with other embolization materials (3).Clinical manifestations, causes, and treatments of BAA will be discussed. A 72-year-old man with a clinical history of chronic obstructive pulmonary disease presented at the emergency room reporting sudden radiating epigastric pain. At arrival, his hemoglobin level was 11.5 g/L and decreased 2 g/L during the 6 first hours after admission. A thoracic plain radiograph revealed an enlarged mediastinum. Plain CT (Lightspeed; General Electric, Milwaukee, WI) showed an enlarged mediastinum. After injection, enlarged bronchial arteries (3 mm in diameter) were visible with a hemomediastinum and a nodular enhancing homogenous mass of 1.5 cm diameter just below the carina level, which was suspected to be a BAA (Fig 1a). Bronchial arteriography arteries was then performed. A large anterior bronchial common trunk was catheterized with use of a 5-F Cobra 2 catheter (Terumo, Tokyo, Japan). With use of a coaxial 3-F catheter (Terumo), the origin of the right bronchial artery was catheterized and, on angiographic opacification, we confirmed a single right bronchial artery aneurysm (1.5 cm in diameter). Catheterization of the efferent branches could not be performed because of vessel tortuosity (Fig 1b); three different microcatheters and a 0.014-inch guide wire were used without success. As a consequence, we decided to occlude the aneurysm and the efferent branches with use of embucrylate (Histoacryl, B. Braun, Melsungen, Germany) mixed with iodized oil (Lipiodol; Guerbet, Aulnay-sous-Bois, France). Injection of 0.3 mL (50% Histoacryl/50% Lipiodol) was necessary to allow a complete occlusion of the aneurysm (Fig 1c). One week later, the patient was discharged and CT performed 1 month after discharge confirmed almost total regression of the hemomediastinum and no enhancement of the aneurysm in early and delayed vascular enhancement phases (Fig 1d). Bronchial artery aneurysm is a rare entity. It can be found incidentally or be related to dramatic hemorrhagic manifestations if a rupture happens. To our knowledge, 33 cases of BAA have been reported in the literature (1–8). Of those 33, one third were asymptomatic at diagnosis and the most frequent clinical sign was hemoptysis (39%). Other symptoms are variable and are related to compression effect or rupture into adjacent organs (esophagus, superior vena cava, main bronchus). Ruptured BAA rarely presents as a spontaneous hemomediastinum as in our case (5). BAAs are usually a consequence of bronchiectasis or recurrent bronchopulmonary inflammation. It is hypothesized that increased bronchial arterial flow to the lungs during inflammation could be a mechanism of bronchial artery dilation and subsequent aneurysm formation. Mediastinal BAA can be incidentally identified or suspected on CT, but in a hemodynamically stable patient, the definite diagnosis has to be confirmed by selective bronchial artery angiography, which enables therapeutic embolization at the same time. Our case is the second to be reported of a ruptured BAA treated by embolization. The other one was described by Ishisaki et al (7) and was embolized preoperatively. Most cases described did not involve CT and were treated immediately in the operating room after the discovery of an enlarged mediastinum on a chest plain radiograph. Our case stresses the utility of CT with contrast injection. This exploration eliminates other potential causes of hemomediastinum such as aortic aneurysm or hemorrhagic mediastinal mass and even allows a suspected diagnosis of bronchial artery aneurysm. Remy-Jardin et al (8) showed that transcatheter embolization was successful in obliterating the blood flow and excluding the aneurysm if the segment between the aneurysm and aorta is judged sufficiently long on bronchial arteriography. If this segment is short, as recommended by Sakai (3), the origin of the bronchial arteries can be covered with a covered stent after the outflow vessels are occluded. In the literature, different embolic materials have been used, such as steel coils, gelatin particles, and occlusion balloons. Whatever embolic material is used, most authors put the emphasis on the necessity to occlude not only the feeding vessel but also efferent branches to avoid retrograde filling of the aneurysm. In our case, catheterization of the efferent branches was impossible because of the tortuosity of the right bronchial artery. When embucrylate is adequately diluted, it casts distally to the injection site and allows occlusion of distal vessels. In our case, no intercostal branches were present, so there was no risk of inadvertent embolization of spinal branches. If intercostal branches werepresent, Letters to the Editor" @default.
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• W2067088355 date "2001-11-01" @default.
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• W2067088355 title "Hemomediastinum Caused by Rupture of a Bronchial Artery Aneurysm: Successful Treatment by Embolization with N-Butyl-2-Cyanoacrylate" @default.
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• W2067088355 doi "https://doi.org/10.1016/s1051-0443(07)61563-2" @default.
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