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The X-ray suggested right hemothorax.were as follows: Glasgow Coma Scale, E4V3M6; blood pressure, 75/- mmHg; heart rate, 140 beats per minute; respiratory rate, 30 breaths per minute and percutaneous saturation, 98% under 10 L per minute of oxygen. A physical examination revealed a head contusion and weakness of the right respi-ratory sound. The chest roentgenography showed decreased radiolucency in the right lung field (Figure 1), suggesting right hemothorax. Focus assessment of sonography for trauma also showed fluid collection, which was limited to the right thoracic cavity. Initially, he underwent immediate massive transfusion without cross-matching and tracheal intubation following right thoracostomy, which drained over 1 L of hemorrhaging. As his blood pressure did not respond to massive transfu-sion, right thoracotomy was tentatively performed by young emergency physicians in order to pack gauze and achieve hemostasis around the pulmo-nary hilus, where blood was emerging without a hilar clamp, while the patient was in the supine position. However, his unstable circulation deterio-rated. After closing the thoracotomy, he was moved to the computed tomography (CT) room and CT revealed hemorrhaging from the inferior azygos vein near a thoracic vertebral fracture (Figure 2) and right subdural hematoma. He experienced cardiac arrest after returning to the ER. A thoracic surgeon standing by at home attended the ER and explored the right thoracic cavity by opening the thoracotomy. The surgeon recognized an azygos arch injury and achieved hemostasis by gauze packing. The surgeon also performed manual Figure 1　Chest X-ray on arrivalcompression at the hemorrhaging site of the infe-rior azygos vein, and transfusion was continued. However, a return of spontaneous circulation was not obtained due to hemorrhaging associated with the trauma itself and the operative incision site due to the patient’s bleeding tendency.Review and analysis of the relevant literatureA PubMed search was undertaken to identify English articles from 1989 to 2022 using the key words “azygos”, “injury” and “blunt”. We found 28 articles about blunt azygos injury1-28). We summa-rized these cases, including the present case, in Table 1. We also added the report by Wall et al. into Table 1 as a supplement, which described the treatment of the largest series of penetrating azygos injury cases in the relevant literature29). There were 39 cases of the blunt azygos injury (average age, 41.2 years [range: 18-81 years]; male, n=20; female, n=19). The mechanisms of injury were as follows: traffic accident (n=29); fall (n=4), falling object (n=1), assault (n=1), sports (n=1), chest compression for cardiac arrest (n=1), and unknown (n=2). The other variables were as follows: right hemothorax (n=32; unknown, n=1); unstable circulation on arrival (n=32; unknown, n=1); right rib fracture, (n=20; unknown, n=5); preoperative CT examination (n=12), associated injury (n=30; unknown, n=1); surgical operation (n=36; unknown, n=2); and survival (n=19; unknown, n=2). While, a delayed appearance of Bleeding from the azygos arch was controlled (upper arrow) but hemorrhaging from the inferior azygos vein near the thoracic vertebral fracture remained (lower arrow).Figure 2　 Enhanced chest computed tomography after tentative thoracotomy399