Recurrent Massive Bleeding from an Intercostal Artery Aneurysm Through an Empyema Chest Tube

doi:10.1378/chest.104.2.637

Chest

Volume 104, Issue 2, August 1993, Pages 637-639

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Intercostal artery aneurysms can be of congenital, post-traumatic, or mycotic type. Intercostal arterial aneurysmal bleeding can be brisk enough to lead into shock or sudden death. Bleeding through chest tubes has been reported due to various causes; it is commonly due to injury to intercostal or pulmonary vessels and is occasionally due to leaking aortic aneurysms. We describe a patient who had development of repeated episodes of brisk bleeding through an empyema chest tube leading to shock episodes requiring resuscitations. After extensive search, the bleeding source was found to be an intercostal artery aneurysm. Transcatheter embolization of that intercostal artery with absorbable gelatin sponge (Gelfoam) was successful in obliterating the blood flow to the aneurysm and in preventing further bleeding.

Section snippets

Case Report

A 37-year-old white alcoholic man was treated in the ICU for respiratory failure secondary to community-acquired pneumonia. On the third day of mechanical ventilation, a left-sided tension hydropneumothorax developed, which was drained via tube thoracostomy. The fluid grew Pseudomonas aeruginosa. He received intravenous ceftazidime and amikacin. On the 20th day of hospitalization, a right-sided P aeruginosa empyema developed, which was drained via tube thoracostomy. Both chest tubes continued

Discussion

Intercostal arterial aneurysms are reported to occur as isolated anomalies, in association with about 10 percent of cases of aortic coarctation,¹ as a complication of thoracentesis or rib fractures. Partial ligation of an intercostal artery at thoracotomy led to the development of a poststenotic aneurysm.² Intercostal arteriovenous fistula occurred following percutaneous pleural biopsy.³ Intrathoracic bleeding from Aspergillus fumigatus mycotic aneurysms of intercostal arteries was the cause of

References (9)

LupetinAR et al.
Coarctation of the aorta associated with intercostal artery aneurysms: computed tomography diagnosis
J Comput Tomogr
(1985)
LifschultzBD et al.
Multiple mycotic aneurysms and transverse myelopathy complicating repair of aortic coarctation
Ann Thorac Surg
(1982)
RydellJR.
Emergency thoracotomy for massive spontaneous hemopneumothorax
J Thorac Surg
(1959)
SchwarzmanPS.
Spontaneous hemothorax
J Am Coll Emerg Physicians
(1979)

There are more references available in the full text version of this article.

Cited by (24)

Avoiding the Intercostal Arteries in Percutaneous Thoracic Interventions
2022, Journal of Vascular and Interventional Radiology
The purpose of this study was to define relevant intercostal artery (ICA) anatomy potentially impacting the safety of thoracic percutaneous interventional procedures. An ICA abutting the upper rib and running in the subcostal groove was defined as the lowest risk zone for interventions requiring a supracostal needle puncture. A theoretical high-risk zone was defined by the ICA coursing in the lower half of the intercostal space (ICS), and a theoretical moderate-risk zone was defined by the ICA coursing below the subcostal groove but in the upper half of the ICS. Arterial phase computed tomography data from 250 patients were analyzed, revealing demographic variability, with high-risk zones extending more laterally with advancing age and with more cranial ribs. Overall, within the 97.5th percentile, an ICS puncture >7-cm lateral to the spinous process incurs moderate risk and >10-cm lateral incurs the lowest risk.
Intercostal artery aneurysmosis
2013, Annals of Thoracic Surgery
Citation Excerpt :
There is a single case report in the literature of a mycotic intercostal artery pseudoaneurysm, but in our patient the fungal culture results were negative and she did not have any evidence of a systemic infection [12]. Endovascular management of these aneurysms has shown success in the small number of patients reported in the literature [2, 6, 8, 13–15]. We also had success using endovascular embolization to occlude flow into several of the aneurysms in our patient.
Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries
2009, Journal of Vascular Surgery
Citation Excerpt :
Carrillo at al stated that the morbidity associated with a thoracotomy, coupled with the frustratingly low yield of finding the source of the hemorrhage in some patients, makes selective angiography and transcatheter embolization (SATE) a less invasive, more accurate, and reliable method to treat these patients.12 The advantages of TAE for the management of ICA hemorrhage have been documented by several reports, which were summarized in Table III.1-7,9-12,14 However, only the series by Carrillo et al from 1998 included a larger patient population (five patients with ICA and three with internal mammary artery injuries).12
The purpose of this retrospective study was to evaluate transcatheter arterial embolization (TAE) for the management of iatrogenic and blunt traumatic intercostal artery (ICA) injuries associated with hemothorax and clinical deterioration.
From May 1999 through April 2007, 24 consecutive patients (17 men, 7 women; mean age 53 years) presenting with active ICA hemorrhage underwent TAE mainly by means of coils combined with polyvinyl alcohol (PVA) particles. Eleven of them had blunt traumatic injuries (group A, n = 11) and 13 had iatrogenic injuries (group B, n = 13). In all patients, ICA injuries resulted in acute bleeding with clinical deterioration and hemothorax. Before discharge, all patients underwent clinical examination, laboratory tests, and chest x-ray. After discharge, no specific follow-up protocol was required, and the patients were questioned on their state of health at regular intervals and underwent CT or chest x-ray as needed.
Primary technical success (PTS) was achieved in 21 of 24 patients (87.5%). In group A, it was achieved in all but one patient (90.9%) and in group B in 11 of 13 patients (84.6%). A total of three patients needed secondary interventions, which failed in one of them, amounting to a secondary technical success rate (STS) of 8.3%. The total cumulative mortality rate was 37.5% (n = 9). In group A, it was 9.1% (n = 1) and in group B, it was 61.5% (n = 8). 30-day-mortality was 9.1% in group A, where one patient died due to multiple severe associated injuries, and 30.8% (n = 4) in group B, where one patient died due to treatment failure and three patients due to severe comorbidities. During follow-up, no more deaths occurred in group A, while in group B, four more patients died due to severe comorbidities, amounting to a late mortality rate of 30.8%.
No technical complications and no complications such as chest wall or spinal cord ischemia were observed. The mean observation period was 44.6 months in group A and 23.8 months in group B.
TAE of ICAs is a minimally invasive, safe, and reliable treatment option to control massive intrathoracic hemorrhage, especially in patients with serious comorbidities and/or multiple injuries. However, it should be performed only by experienced interventionalists and exact knowledge of the anatomic features of the affected artery and of collateral pathways is mandatory to avoid complications.
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Isolated giant true intercostal artery aneurysm with arteriovenous fistula: A case report
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Intercostal artery pseudoaneurysm in pulmonary tuberculosis - A rare cause of hemoptysis: A case report with review of the literature
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Chest

Selected ReportsRecurrent Massive Bleeding from an Intercostal Artery Aneurysm Through an Empyema Chest Tube

Section snippets

Case Report

Discussion

J Comput Tomogr

Ann Thorac Surg

J Thorac Surg

J Am Coll Emerg Physicians

Selected Reports
Recurrent Massive Bleeding from an Intercostal Artery Aneurysm Through an Empyema Chest Tube