Emergency surgery for a ruptured bronchial artery aneurysm: a case report

Background: A mediastinal bronchial artery aneurysm is a rare disease, and its rupture causes mediastinal hematoma and/or hemothorax, which results in hemorrhagic shock. Radiological intervention is considered as a first-line treatment for both ruptured or unruptured mediastinal bronchial artery aneurysms because it is less invasive than surgical interventions. However, a hemodynamically unstable patient might require an emergency surgery. We herein report a case of an 86-year-old female patient who had a ruptured mediastinal bronchial artery aneurysm, which led to cardiac arrest, and who survived after an emergency thoracotomy carried out to achieve hemostasis. Case Description: The patient presented with sudden-onset, severe back pain. A chest computed tomographic scan with contrast revealed a massive left hemothorax and mediastinal hematomas with extravasation. A three-dimensional reconstruction showed a saccular aneurism in the aorto-pulmonary window area, which was connected to the bronchial artery. The patient was urgently transferred to our hospital for transarterial embolization. However, due to the hemodynamic instability, we decided to perform an emergency thoracotomy to achieve hemostasis. Despite continuous volume replacement with blood transfusion and fluid with vasopressor infusion, she went into cardiac arrest during the induction of general anesthesia and was provided cardiac resuscitation. Under the guidance of three-dimensional imaging, an anterolateral incision was made on the left side of the chest just lateral to the level of the ruptured aneurysm based on the imaging, and the third intercostal space was opened. A saccular aneurism with arterial bleeding was identified in a mediastinal hematoma in the aortopulmonary window area just below the incision. The afferent and efferent arteries of the aneurysm were ligated to achieve hemostasis. Conclusions: An important practice point is that although radiological interventions were not able to be performed due to patient's hemodynamic instability, emergency hemostasis was successfully achieved, with guidance from three-dimensional computed tomographic imaging despite massive hemothorax and hematoma.