Mediastinal hematoma secondary to bronchial artery laceration following endobronchial ultrasound-guided (EBUS) biopsy

Case contributed by Dr Francis Fortin

Presentation

Acute chest pain irradiating from posterior to anterior during hospitalisation for unrelated reason. Prior lung cancer with right superior wedge resection and radiotherapy. Suspected new left lung cancer. Known severe descending thoracic aortic atherosclerosis.

Patient Data

Age: 75 years
Gender: Female

Prior right superior surgery with staple line. Suspicious left upper lobe linear opacity.

Increased density of the inferior mediastinum superimposed over the heart. New veiled opacity projecting over the inferior third of the right lung which could represent, amongst other possibilities, a pneumonia or a pleural effusion (patient is sitting, partially reclined).

Focal irregularity of an atheromatous plaque of the anterior wall of the descending thoracic aorta at the level of the left main bronchus. Left upper lobe spiculated lesion suspicious for lung cancer. Prior right upper lobe wedge resection.

There is focal hypermetabolism in the region of the previously described irregular descending aortic atheromatous plaque, probably due to inflammatory reaction. The left upper lobe lesion is suspicious for lung cancer because of its hypermetabolism. No suspicious lymph node activity or evidence of distant metastasis.

New onset large mediastinal hematoma with compression of the left atrium and inferior pulmonary veins, right hemothorax and mild hemopericardium. Because of the known severe descending aortic atherosclerosis, an aortic false aneurysm (penetrating atherosclerotic ulcer) with intra-mural hematoma and aortic rupture was initially considered, despite the appearance of the irregular atheromatous plaque itself being unchanged.

Further questioning of the clinical team revealed that the patient had endobronchial ultrasound-guided (EBUS) biopsy of mediastinal lymph nodes 4 days prior. She had slight central chest pain since then, but following an intense cough, her pain intensified to 10/10.

Upon revising the images, an arterial pooling of contrast is seen in the immediate subcarinal area, with bronchial arteries coursing nearby. Delayed images were not available to confirm if there was blushing which would help differentiate between active extravasation and a pseudoaneurysm, although the morphology of the contrast pooling suggests the former hypothesis.

Ultrasound

EBUS-guided biopsy of a station 7 (subcarinal) lymph node 4 days prior.

EBUS-guided biopsy of a station 7 (subcarinal) lymph node 4 days prior.

The patient was subsequently taken to angiography for treatment of a suspected bronchial artery laceration.

DSA (angiography)

Diagnostic and therapeutic bronchial artery angiography

Bronchial arteries show considerable anatomical variation 4. In this patient, catheterization of the right superior (first image) and left (second image) bronchial arteries showed no bleeding. Subsequent catheterization of a right inferior (third stack) bronchial artery shows subcarinal contrast extravasation. This artery was embolized with glue (fourth image) resulting in successful complete obliteration of the artery and cessation of bleeding. The "shadow image" of the contrast pool on the last image is due to imperfect image subtraction because of patient respiration and the glue being mixed with radio-opaque Lipiodol.

Annotated maximum intensity projection (MIP) images reformatted from the CT angiography above after conventional angiography demonstrate the right bronchial arterial anatomy with the right superior (blue) and right inferior (yellow) bronchial arteries originating from the thoracic aorta. Contrast pooling in the subcarinal area (red) is highlighted.

Case Discussion

Although reported in <1% of EBUS-guided mediastinal lymph node biopsies, hemorrhage remains the most common complication of this procedure 3. Massive hemorrhage, defined as more than 300 mL of bleeding, or transfusion requirements, was reported in only 1 case out of 7345 cases in a Japanese series 3. Other isolated case reports have been published 1.

The patient, in this case, presented with delayed massive hemorrhage because of iatrogenic laceration of a variant right inferior bronchial artery coursing in a subcarinal location after EBUS biopsy. After embolization and monitoring in the intensive care unit, the patient recovered uneventfully.

When faced with mediastinal hematoma, one should consider several diagnostic possibilities, with patient history often being the key to diagnosis. Of note, aortic rupture will generally cause a left hemothorax, which is the opposite of that seen in this case. Differential diagnoses for mediastinal hematoma include 2:

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Case information

rID: 59717
Published: 22nd Apr 2018
Last edited: 14th Aug 2019
System: Vascular, Chest
Inclusion in quiz mode: Included

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