Bronchial bleeding caused by recurrent pneumonia after radical esophagectomy for esophageal cancer

Figure 1 Unenhanced computed tomography after esophagectomy. A: Computed tomography (CT) revealed consolidation in the right middle lobe; B: CT simultaneously demonstrated consolidation in the right lower lobe (A and B); C: Although there was no evidence of newly developed pneumonia, consolidation remained in the right middle lobe 14 mo after esophagectomy (arrow).

Figure 2 Imaging findings before bronchial arterial embolization. A: Bronchoscopy revealed hemosputum in the entrance of the right middle lobe bronchus (yellow arrow) extending down to the lower lobe bronchus (green arrow); B, C: Computed tomography and chest radiography revealed a massive infiltrative shadow in the right middle lobe with atelectasis in the right lower lobe.

Figure 3 Computed tomography arteriography. A: Computed tomography (CT) arteriography revealed a tortuous artery ascending from the right inferior phrenic artery that arose directly from the aorta (arrows); B: CT arteriography demonstrated several tortuous arteries arising from the left subclavian artery that descended obliquely along the right main bronchus (arrows); C: A collateral right bronchial artery (BA) arising from the inferior phrenic artery. Right inferior phrenic arteriography showed an abnormal tortuous artery (arrows); D: Ectopic BAs arising from the left subclavian artery. Left subclavian arteriography showed abnormal tortuous arteries arising from a root of the left subclavian artery (arrows).

Figure 4 Intraoperative findings. A: The presence of a collateral bronchial artery (BA) arising from the right inferior phrenic artery running along the phrenic nerve (green arrowheads) was confirmed; the tissue was black in color due to the first bronchial arterial embolization procedure (yellow arrowheads). B: Engorged right BAs streaming into the right middle lobe were dissected at the level of bifurcation of the middle lobe bronchus (arrows). UL: Upper lobe; ML: Middle lobe; LL: Lower lobe; Br: Middle lobe bronchus; PA: Pulmonary artery; PV: Pulmonary vein.

Figure 5 Gross and histopathological findings of the resected specimen. A: An ill-demarcated whitish area with a brownish tint was noted on the cut surface of the resected lung (arrows). Macroscopically, the bleeding origin was not detected; B: Organizing pneumonia with the accumulation of hemosiderin-laden macrophages was observed [Elastica van Gieson stain (EVG), magnification × 24]; C: The bronchus was enlarged, and engorged bronchial artery with medial hypertrophy and overgrowth of small branches were identified near the bronchus (arrows) (EVG, magnification × 24). Br: Bronchus; PA: Pulmonary artery.