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:

• acute aortic syndrome
• thoracic aortic injury from blunt or penetrating aortic trauma
• esophageal perforation (including Boerhaave syndrome)
• iatrogenic causes
  • post cardiac or thoracic surgery
  • intravascular procedures including catheter placement
  • EBUS-guided biopsy
• spontaneous cervicomediastinal hematoma
• hemorrhage from a cervical, mediastinal or retroperitoneal mass

Case prepared with the help of Dr Yves Provost and Dr Jean-Nicolas Racicot.