Unexpected Bronchial Anatomy Lesson

A 73-year-old woman presented with hemoptysis. Significant past medical history included paroxysmal atrial fibrillation, deep vein thrombosis of lower extremities, and recently diagnosed segmental pulmonary embolism on right upper lobe. The patient was being treated with warfarin. Her initial physical examination was unremarkable. Admission laboratory data showed an international normalized ratio of 3.9, which rapidly decreased to 1.5 after fresh frozen plasma administration. Chest radiograph showed no lung infiltrates or mass. Bronchoscopy was performed, and surprisingly, a large organized blood clot was visualized completely occluding the right main stem bronchi. No active bleed was noted. The blood clot was removed with a cryotherapy probe in a single attempt, providing us with an unexpected bronchial anatomy lesson (Figure 1). Further airway exam immediately after the clot removal Figure 1. (A) Blood clot removed in one piece from patient’s right bronchial tree. (B) Some form of tracheobronchial tree variation or anomaly has been reported to be found in 1 to 12% of patients (up to 70% in four more recent series) (1, 2). Therefore, the anatomy seen in these pictures cannot be generalized to all patients.