massive hemoptysis is a life - threatening pulmonary emergency and has a variety of underlying conditions . transcatheter bronchial artery embolization ( bae ) is a well - established and effective non - surgical procedure for the management of massive hemoptysis ( 1 ) . recently , non - bronchial systemic arteries have been reported as an important source of bleeding with massive hemoptysis . computed tomography ( ct ) and computed tomography angiography ( cta ) we herein report a rare case of massive hemoptysis in a patient with focal bronchiectasis and right inferior phrenic artery - to - right pulmonary artery fistula diagnosed by ct and cta . an 82-year - old woman was transferred to our hospital because of dyspnea and massive hemoptysis . the patient had a history of bronchial asthma that was well - controlled with bronchodilator medications . she suffered from severe hypoxemia ( ph 7.362 , pco2 35.1 mmhg , po2 61.0 mmhg , hco3 20.1 mmhg , be -5.5 mmhg , spo2 90.5% , under 10 l o2/min , reservoir mask ) . a chest ct further demonstrated multiple consolidations and ground glass opacity and focal bronchiectasis in right segment 4 ( s4 ) ( fig . since there was no active hemorrhaging from the tracheal tube , she was then extubated . computed tomography showed multiple consolidation and ground glass opacities . to determine the origin of bleeding , she underwent contrast - enhanced ct , which showed bronchiectasis in right s4 and regression of the infiltration . cta revealed an abnormal vascular anastomosis between the right inferior phrenic artery and right pulmonary artery beside the focal bronchiectasis at the right middle lobe ( fig . 3 ) , which led us to suspect it as the possible source of the massive hemoptysis . three weeks after the embolization , she was successfully discharged and has been free from recurrent hemoptysis for three years . a : a high - resolution computed tomography ( ct ) image showing focal bronchiectasis in the right middle lung ( s4 ) . b : ct angiography showing a vessel entering the bronchiectasis lesion arising from the right inferior phrenic artery . c : three - dimensional ct depicting the right inferior phrenic artery - to - right pulmonary artery fistula . right inferior phrenic artery angiogram confirmed the right inferior phrenic artery - to - right pulmonary artery fistula ( arrow ) in an intrapulmonary portion . the present case report describes an elderly woman who had right inferior phrenic artery - to - pulmonary artery fistula with focal bronchiectasis leading to life - threatening hemoptysis . however , recurrent hemoptysis after successful bae is not rare , and non - bronchial arteries can function as sources of bleeding in some cases ( 3 ) . in the present case , we planned bae to prevent recurrent hemoptysis and performed high - resolution ct and cta before bae . cta revealed the right inferior phrenic artery - to - pulmonary artery fistula , not the bronchial arteries , as the source of the bleeding . the bronchial arteries are responsible for bleeding in more than 90% of cases with massive hemoptysis . in the remaining 10% of cases , the internal mammary , intercostal , and inferior phrenic artery are typically involved in hemoptysis ( 3,4 ) . in most of the reported cases of inferior phrenic artery origin , the lower lobe of the lung was affected with chronic inflammation and found to be the site of bleeding ( 5 - 8 ) . transpleural systemic - pulmonary artery anastomoses may develop in patients with bronchiectasis , cystic fibrosis , tuberculosis , or chronic pneumonia ( 5 ) . in the present case , a right inferior phrenic artery - to - right pulmonary artery fistula was the origin of bleeding in the right middle lobe , instead of the lower lobe . the present paper demonstrates that , for effective bae in patients with massive hemoptysis , ct and cta should be performed beforehand to precisely identify the culprit lesion for bleeding .
massive hemoptysis is a medical emergency and needs immediate treatment . 
 it occurs in a wide variety of pulmonary diseases and typically originates from the bronchial arteries . 
 we herein report a very rare case of a patient bleeding from a right phrenic artery - to - pulmonary artery fistula accompanied with focal bronchiectasis in the right middle lobe of the lung . in this case , 
 multi - detector computed tomography was useful for clarifying the etiology and the abnormal anastomosis and facilitated effective angiographic embolization .