Application of multiphase post-mortem computed tomography angiography (MPMCTA) in a case of hemoptysis due to bronchopulmonary arterial fistula

Bronchopulmonary arterial fistula (BPAF), an abnormal connection between the bronchus and the vascular tree, is a rare life-threatening condition whose clinical presentation is massive hemoptysis with high mortality rate. Here we present a case of fatal massive hemoptysis due to a BPAF in which the fistula was detected by postmortem imaging following the multiphase postmortem computed tomographic angiography (MPMCTA) protocol. A 71-year-old man presented with an episode of persistent cough associated with profuse bleeding from the respiratory orifices, then lost consciousness and died. The subject was a heavy smoker and had complained of a persistent dry cough in the days before death. MPMCTA was performed, then autopsy and histological examination were carried out. Postmortem imaging revealed the presence, at the left pulmonary hilum, of a lesion compatible with a, previously not detected, primary lung tumor, in the context of which MPMCTA documented a BPAF. Through postmortem imaging, a hepatic lesion, suggestive of a metastasis, was also observed. These findings were later confirmed by autopsy, and histologic examination allowed the diagnosis of primary lung tumor and liver metastasis. The case presented here underscores the usefulness of postmortem angiography techniques in cases where vascular injury is hypothesized as the cause of death, especially if there are no radiological images performed during life. Indeed, these techniques allow to detect prior to anatomical dissection the acute vascular damage causative of death, any additional vascular abnormalities, as well as anatomical variants affecting the region where the vascular damage occurred.