Life-threatening haemoptysis due to tracheal varices secondary to pulmonary vein obstruction.

To cite: Morcos KHK, Roditi G, Craig S. Thorax Published Online First: [please include Day Month Year] doi:10.1136/thoraxjnl2012-202869 HISTORY A 30-year-old man with a 3 day history of increasing breathlessness and frank haemoptysis was suspected of having pulmonary embolism and anticoagulated with heparin. Haemoptysis worsened so anticoagulation was reversed and he was transferred to our institution. Pulmonary and bronchial angiography revealed a small right pulmonary artery and a prominent right intercostobronchial trunk which was embolised. However, haemoptysis recurred and a contrast enhanced ECG-gated CT scan confirmed a hypoplastic right pulmonary artery and showed thrombosed right pulmonary veins that had no communication to the left atrium, a ‘bulky’ right hilum and thickened bronchial walls with smooth mucosal indentations into the airway lumen (figures 1 and 2). Bronchoscopy confirmed carinal and right bronchial varices. Aventilation perfusion (V/Q) scan showed normal ventilation but very little perfusion of the right lung. The patient underwent a standard dissectional stapled right pneumonectomy. Intraoperatively, the right main bronchus and distal trachea were encircled by bronchial veins which were the only means by which the lung could drain as the native pulmonary veins had no discernable flow. In addition there were a number of venous collaterals to the chest wall. Postoperatively the patient had no further haemoptysis and repeat bronchoscopy showed resolution of the varices. Histopathology showed thrombosed pulmonary veins with signs of recanalisation and a dilated bronchial venous plexus involving the hilar bronchial submucosa. There was an acquired moderate degree of chronic inflammation involving the pulmonary artery wall causing stenosis.