Spontaneous hemothorax following rupture of a major aorto-pulmonary collateral artery

Abstract

We report the case of a 69-year-old man with a history of 2,3diphosphoglycerate deficiency and consecutive splenectomy due to hemolytic anemia. He presented in emergency room following a sudden onset of severe pain in the right upper abdomen and mild dyspnea. One week before, he had suffered short-lasting chest pain after cycling. There was no history of congenital heart or lung disease, chest trauma or anticoagulant medication. The ECG was normal, but there were diminished breath sounds and dullness to percussion on the right side of the thorax. Ultrasound showed a right-sided pleural effusion, and surprisingly, thoracentesis revealed a bloody effusion with a hematocrit identical to the peripheral blood. Computer tomography confirmed a large right-sided hemothorax, caused by an ongoing bleeding out of a vascular malformation (Fig. 1). With incipient shock, the patient was transferred to the intensive care unit, and emergency cardiac surgery was initiated. While the pericardial and the left pleural cavity were without pathological findings, the right pleural cavity was filled with blood originating from the right lower lobe. A trial to improve the visibility using a double-lumen endotracheal tube was not tolerated hemodynamically, and cardiopulmonary bypass became necessary. A vascular malformation, a vessel connecting the descending aorta with a pulmonary vessel of the lower lobe could be demonstrated. The bleeding originated from a rupture of this major aorto-pulmonary collateral artery (MAPCA) close to the aortic branch-off. The ligation of this vessel stopped all