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a single episode of hemoptysis and sudden pain in the right hemithorax&#46; The patient had diabetes&#44; hypertension&#44; COPD and reported triple coronary by-pass in 2009&#46; The chest X-ray showed right pleural effusion and the origin of the bleeding was determined with thoracentesis&#46; The patient was hemodynamically stable &#40;hemoglobin 10<span class="elsevierStyleHsp" style=""></span>g&#47;dl&#44; blood pressure 110&#47;70<span class="elsevierStyleHsp" style=""></span>mmHg&#41; but displayed slight hyperventilation with normal blood gases &#40;SO<span class="elsevierStyleInf">2</span> 95&#46;2&#37;&#44; PO<span class="elsevierStyleInf">2</span> 90&#46;8<span class="elsevierStyleHsp" style=""></span>mmHg&#44; and PCO<span class="elsevierStyleInf">2</span> 24&#46;1<span class="elsevierStyleHsp" style=""></span>mmHg&#41; and sinus tachycardia &#40;115&#8211;120<span class="elsevierStyleHsp" style=""></span>beats per minute&#41; on ECG&#46; Video-assisted thoracoscopy &#40;VAT&#41; was performed and 2000<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of blood removed&#44; although there was no evidence of any source of bleeding in the pleura&#44; diaphragm or lung&#46; The mediastinum appeared swollen&#44; convex&#44; congested and contained blood&#44; as demonstrated by needle aspiration&#46; Within 24<span class="elsevierStyleHsp" style=""></span>h of this minimally invasive method&#44; three-dimensional thin-section computerized tomography &#40;3D-TSCT&#41; of the thorax showed a conspicuous hematoma in the posterior mediastinum&#44; pulmonary artery ectasia&#44; predominantly on the left &#40;4&#46;6<span class="elsevierStyleHsp" style=""></span>cm&#41;&#44; and a right BAA &#40;6<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5<span class="elsevierStyleHsp" style=""></span>mm in diameter&#41; in the area of the hematoma&#44; that was most probably the site of the previous bleeding&#46; On the basis of radiological assessment&#44; we decided to avoid the surgical approach and opted for conservative treatment&#46; Pleural drainage was discontinued on postoperative day 4 and the patient was discharged on day 6&#44; following a repeat chest 3D-TSCT&#44; which showed a drastic reduction of mediastinal hematoma&#46; The follow-up with 3D-TSCT at 4 months and 1 and 2 years revealed resolution of the BAA and total resolution of hemomediastinum&#46; Etiology of BAA can be attributed to increased blood flow&#44; high pressure in the pulmonary artery or various lung diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Several factors intervened in our choice of a conservative approach&#58; &#40;a&#41; control of bleeding due to the obliteration of the vessel by mediastinal hematoma&#59; &#40;b&#41; the resolution of blood effusion in the pleural cavity after VAT&#59; &#40;c&#41; previous myocardial revascularization &#40;using the left internal mammary artery&#41; with mediastinal fibrosis&#44; making open BAA access difficult&#59; &#40;d&#41; good hemodynamic status&#46; In view of the patient&#39;s stable condition&#44; we used VAT as a first-line approach&#46; Moreover&#44; sinus tachycardia and hyperventilation could be symptoms of a worsening general status&#44; requiring an urgent non-targeted approach&#46; Video-assisted thoracoscopy has proved to be ideal for emptying and cleaning the pleural cavity and allowed us to determine that the bleeding originated in the mediastinum &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span>"
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Letter to the Editor
Conservative Approach in Bronchial Artery Aneurysm Rupture: A Therapeutic Option
El abordaje conservador para la rotura de un aneurisma en la arteria bronquial: una opción terapéutica
Duilio Divisi
Corresponding author
duilio.divisi@aslteramo.it

Corresponding author.
, Andrea de Vico, Roberto Crisci
Department of Thoracic Surgery, University of L’Aquila, “G. Mazzini” Hospital, Teramo, Italy

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