Hemomediastinum and hemothorax after dissecting bronchial artery aneurysm: the limit of the surgical option

We read with great interest the article by Quero-Valenzuela et al. [1] describing an unusual case of hemomediastinum and hemothorax after dissecting bronchial artery aneurysm. Mediastinal bronchial artery aneurysm is a rare condition which can lead to potentially fatal hemorrhage. The clinical presentation usually consists of respiratory and/or cardiovascular symptoms (mimicking an aortic dissection), even if atypical clinical pictures (hemoptysis, hemomediastinum and hematemesis) have been previously reported [2]. We completely concur with the statement that endovascular treatment should be planned only in patients with ‘sustained hemodynamical stability’; otherwise urgent surgical procedure seems to be mandatory to assess and treat mediastinal compression and/or life-threatening bleeding [3]. Nonetheless, we should point out the limits of surgery in the treatment of posterior mediastinal hemorrhage. The most frequent surgical options include thoracotomy or sternotomy, while videothoracoscopy is not recommended considering the emergent clinical scenario. In particular, posterolateral thoracotomy probably represents the best surgical solution to control a posterior mediastinal bleeding [4]. However, surgical treatment sometimes is ineffective with high rates of intraoperative mortality, especially when a massive hemorrhage occurred but also because of the technical difficulties of having an ‘emergency bleeding control’ in this region. On the basis of these considerations, we warmly recommend the use of mini-invasive angiographic procedures as long as is clinically feasible.

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