Multidisciplinary collaborative treatment of a rare case of chronic hemoptysis: diagnostic and therapeutic insights from a 7-year clinical course.

A middle-aged woman who had undergone a right upper and middle lobectomy 7 years earlier presented with recurrent intermittent hemoptysis. Evaluation at our institution revealed that the main right pulmonary artery supplying the remaining lung had previously been transected and ligated. She also had pulmonary aspergillosis, tuberculosis, and bronchiectasis. Sequential interventions, including bronchoscopy and bronchial artery embolization (BAE) with gelatin sponge particles (350-560 μm), failed to achieve durable hemostasis. Double-lumen endotracheal intubation was performed to prevent blood spillover into the contralateral lung and avoid asphyxia. Definitive surgical treatment was therefore performed. To the best of our knowledge, this is the first reported case to combine iatrogenic main pulmonary artery transection during lobectomy, 7-year survival of the residual lung sustained by multi-source systemic collateral perfusion, coexisting pulmonary aspergillosis and tuberculosis, and COVID-19-triggered life-threatening hemoptysis. This case illustrates a complex, multifactorial mechanism underlying massive hemoptysis. Following right pulmonary artery interruption, the residual lung became dependent on systemic collateral circulation, including hypertrophied bronchial arteries and non-bronchial systemic arteries (NBSAs). These high-pressure, fragile vessels-together with chronic infection and structural lung disease, particularly Aspergillus colonization and post-tuberculous changes-promote vascular remodeling, erosion, and rupture. Superimposed viral infection (e.g., COVID-19) may further exacerbate inflammation and vascular instability, triggering life-threatening bleeding. Given its rarity and complexity, this case provides important insights into the mechanisms and management challenges of refractory hemoptysis driven by multi-source systemic collaterals.