• CORRESPONDENCE 327 FIGURE 1. Intraoperative picture. An aberrant artery connecting the left subclavian artery and apex of the lung was found by thoracoscopy. The arrow designates bleeding from that artery after cutting it intentionally. aberrant artery, connecting the left subclavian artery and apex of a lung, was found by chance in a 30-year-old man with spontaneous pneumothorax, which seemed to have originated congenitally and to have enough flow to cause massive bleeding when cut inten- tionally. In this report, we discuss the possibility of an aberrant artery being a mechanism of bleeding in spontaneous hemopneu- mothorax. A 30-year-old man was admitted to our emergency department because of left spontaneous pneumothorax. A chest radiograph showed free air space in the upper area of the left pleural cavity. A thoracotomy tube was inserted anteriorly and connected to an underwater seal and controlled suction apparatus (-15 cm of water) to achieve full expansion of the lung. However, air leakage had been observed through the tube for 1 week. We decided to perform a video-assisted bullectomy. During the operation, thora- coscopy showed a resfiform structure connecting the left subcla- vian artery and apex of the lung without any adhesion and inflam- mation around the apex of the lung and pleural cupola. Before bullectomy, this structure was recognized as an aberrant artery by observing pulsatile bleeding when it was cut intentionally (Fig 1). It took 5 minites to hemostate by clipping the artery. The amount of bleeding increased to about 300 mL. After complete clipping, bullectomy was performed using endoscopic linear staplers. The patient was discharged on the fifth day after surgery and has been doing well without any complication. Although spontaneous pneumothorax has a high incidence, spontaneous hemopneumothorax is very rare, the reported inci- dence being only 1% to 2% of that of spontaneous pneumothorax.1 There are 2 possible mechanisms of bleeding in hemopneumotho- rax. One is that bleeding occurs as a result of a tear caused by collapse of the lung in cases of adhesion between the parietal and visceral pleurae in which small and noncontractible vessels have developed, e The other is that bleeding rarely originates from a well-vascularized ruptured bulla. 3 In our case, there was no adhe- sion or inflammatory changes on the pleural surface around the rentiform structure. These findings suggested that this vessel might have originated congenitally rather than secondarily. Considering the amount of hemorrhage observed in our case, this aberrant artery could have caused critical hemothorax if collapse of the lung had caused it to tear at the onset of spontaneous pneumothorax. Even though several cases of spontaneous hemopneumothorax have been reported to have been successfully treated conserva- tively, bleeding in those cases must have been caused by different sources, such as those mentioned earlier. However, some cases show a rapidly worsening time course after onset of spontaneous hemopneumothorax, which may be caused by tearing of an aber- rant artery. Emergency surgery should be considered when con- tinuous uncontrollable bleeding from a thoracostomy tube is ob- served. 5 Moreover, video-assisted thoracic surgery has recently come to be used in many hospitals. With this less invasive method, it would be reasonable to consider performing surgery in an earlier stage to reduce the amount of blood transfusion and the risk of hemor- rhagic shock. 6 In summary, we found an aberrant artery in a case of sponta- neous pneumothorax, which indicated the possibility of an aberrant artery being a source of life-threatening bleeding in spontaneous hemopneumothorax. Surgical treatment for pneumothorax should be considered if a rentiform structure in the upper pleurai cavity is seen on chest X-ray film or computed tomographic images. In such cases, video-assisted thoracic surgery is the treatment of choice. YOSI-IIHIKO KUR1MOTO, MD KEISUKE HATAMOTO, MD MAMORU HASE, MD EICttl NARIMATSU, MD YASUFUMI ASAI,MD Department of Traumatology and Critical Care Medicine TOMIO ABE, MD Department of Thoracic and Cardiovascular Surge~ Sapporo Medical University Sapporo. Japan References 1. O'Neill S: Spontaneous pneumothorax; aetiology, manage- ment and complications. Ir Med J 1987;80:306-311 2. EastridgeCE: Spontaneoushemopneumothorax requiring tho- racotomy. South Med J 1985;78:1392-1393 3. Rowell NR: Spontaneous haemopneumothorax. Br J Tuberc 1956;50:214-220 4. Tateloe S, Kanazawa H, Yamazaki Y, et al: Spontaneous he- mopneumothorax. Ann Thorac Surg 1996;62:1011-1015 5. Hsu NY, Hsieh M J, Liu HP, et al: Video-assistedthoracoscopic surgery for spontaneous hemopneumothorax.World J Surg 1998; 22:23-27 OUT-OF-HOSPITAL THROMBOLYSIS IN CARDIAC ARREST AFTER UNSUCCESSFULRESUSCITATION To the Editor:--Survival after sudden out-of-hospital cardiac arrest remains low. 1 As suggested by Spaulding et al, acute myo- cardial infarction (AMI) is frequent in patients with cardiac ar- rest. e Acute myocardial infarction therapies associated with ad- vanced cardiac life support (ACLS) could improve survival. We report the case of a patient who presented sudden out-of-hospital cardiac arrest in which ACLS was unsuccessful. After a thrombo- lyric bolus infusion, return to spontaneous circulation suggested that thrombolytic therapy could facilitate recovery during out of hospital cardiopulmonary resuscitation as recently discussed. 3 The patient was a 41-year-old man with a past history significant for cigarette smoking and familial coronary artery disease. He saw a cardiologist because he had been suffering for several hours from persisting retrosternal chest pain. At the beginning of the exami- nation, he suddenly collapsed and the cardiologist diagnosed a ventricular fibrillation (VF). Defibrillation was performed without success. Then, cardiac arrest with asystole rhythm occured. Basic cardiac life support (BCLS) was started by the cardiologist and, 10 Copyright © 2001 by W.B. Saunders Company 0735-6757/01/1904-0028535.00/0 doi:l 0.1053/ajem.2001.24504