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Objective: Toreportamysteriousevolutionprocessofazygosveinaneurysms(AVA)andmanagementoutcome. Methods: Thepatientsclinicaldataandimagingdatawereretrospectivelyanalyzed,andshewasfollowedupfor12months. Results: A45-year-oldfemalewithoutanyremarkablepastmedicalhistoryexceptforthyroiddiseasewasadmittedtoour hospitalbecauseofanabnormalshadowdetectedbychestreontgenogram.Nosignificanttraumawasrecorded.Subsequent dynamiccontrast-enhancedCTrevealedaslowlyenhancedposteriormediastinalmassmeasuring7.9cm×3.5cm,which connectedtheazygosarchwithnormalappearanceofothermediastinalvasculature.Therewasnolaboratoryorimagingdatato suggestportalhypertension.AconfidentialdiagnosisofanidiopathicAVAwasmade.Plannedvideo-assistedthoracoscopic surgerywascancelledfromthepatientsopposition.RuptureofAVAoccurredjustafterherleftthyroidloberesectiononthe secondweekoffirstcare.Meanwhile,thepatientonlypresentedwithslightshortnessofbreathandchestCTrevealedanilldefined masswithinhomogenousopacityintheanterioraspectoftherightuppermediastinumthatwasnotpresentonCT performed2weeksearlier,whilepreviousAVAintheposteriormediastinumvanished.Becausethepatientremained haemodynamicallystableandwasasymptomatic,sheagainrefusedfurtherintervention.Thepatientfortunatelysurvivedthis catastrophiceventandherhematomaslowlyresolvedonserialimagingfollow-up. Conclusion:AVAisaveryrarecauseofmediastinalmassandcanbeidiopathicorresultfromincreasingpressureintheazygos veincausedbyportalhypertension,inferiorvenacavaocclusionorheartfailure.Mostreportedcaseshavedemonstratedno specificsymptoms.Dynamiccontrast-enhancedCTisextremelyusefultomakeapreoperativediagnosisofthisabnormalityin thosepatientswithprominentlyenhancedmassdirectlyconnectingazygos.AlthoughAVAmaytheoreticallyrupture,nostudies ofAVAregardingruptureandhemorrhagehavebeenreportedintheliterature.Inourpatient,thepresenceofcontained intrathoracichematomaandabsenceofpreviousAVAwerepossiblytheoutcomeofAVArupturefromunnoticedrapidincrease inintrathoracicpressure.RespiratorymotionfacilitatedbloodwithinAVAtoevacuateanddisappear.Meanwhile,Contained hematomacreatedatamponadeforrupturedmouthtostophematomaprogression,asthepatientremainedhaemodynamically stableandrequiredneitherurgentsurgicalinterventionnorbloodtransfusion. IdiopathicAVAcanspontaneouslyruptureandyieldtointrathoracichematomaaccompanyingthelesionchangeofinitial location.Conservativetreatmentisfeasibleforthosepatientswithstablehaemodynamicsbutregularimagingfollowupneedto bewarranted.