Massive hemothorax due to inferior phrenic artery injury after blunt trauma

Following a collision with a car while walking at the traffic intersection, an 81 year-old female was transferred to the emergency department by helicopter. The patient had medication for hypertension and wasn’t on antiplatelet or anticoagulant medications. On hospital arrival (50 min after injury) the patient was alert, with a systolic/diastolic blood pressure (SBP/DBP) of 126/86 mmHg, a heart rate of 110 beats/min. Physical examination revealed tenderness in the pelvic region and contusion in the left knee joint. Initial laboratory studies revealed the following values; hemoglobin, 12.0 g/dl; white blood cell (WBC) count, 11,500/μl; platelet count, 16.9 × 10⁴/μl; creatinine (Cr), 0.45 mg/dl; prothrombin time international ratio, 1.00; activated partial thromboplastin time, 26.5 s; Arterial blood gas analysis measured on arrival revealed the following values; pH, 7.430; PCO₂, 30.6 mmHg; PO₂, 69.0 mmHg; HCO₃ ⁻, 21.8 mmol/l; base excess, −3.6 mmol/l; lactate, 2.4 mmol/l.

Computed tomography (CT) scanning with contrast medium (80 min after injury) demonstrated that active extravasations were detected in the retrocrural space (Fig. 1a) and from branches of the internal iliac artery (Fig. 1b) with fractures to the pubic and ischial bones. In addition, No other injuries were observed in the abdominal solid organs, and obvious lung injury, rib fracture and diaphragm rupture were not found. In primary management intravenous lines were secured and a rapid infusion with normal saline was started, however, approximately 60 min after arrival, the patient’s vital signs became unstable (98/58 mmHg and 111 beats/min for SBP/DBP and heart rate, respectively). Immediately blood transfusion was started. To control the continuous bleeding from the pelvic fractures, angiography was performed. The right and left iliac arteries were cannulated with a 5-Fr cobra catheter (Medikit Co. Ltd., Tokyo, Japan). Digital subtraction angiography (DSA) of the internal iliac artery did not demonstrate obvious bleeding from both the internal and the external iliac artery, however, the patient situation was impending and embolization of the bilateral internal iliac arteries was empirically performed with gelatin sponge particles (Serescue; Nippon Kayaku Co. Ltd., Tokyo, Japan) based on the CT scans performed at arrival. CT scans performed during angiography demonstrated that the hematoma extended into the retrocrural space. Injury of the aorta and aortic branches was suspected. Each branch of aorta, comprising the left gastric artery, the celiac artery (including the left inferior phrenic artery) and superior mesenteric artery, was cannulated with a 5-Fr shepherd’s hook catheter (Terumo Clinical Supply Co. Ltd., Gifu, Japan) and a 5-Fr Michelson catheter (Medikit Co. Ltd., Tokyo, Japan). However, obvious extravasation was not confirmed. The patient recovered from shock and was transferred to the intensive care unit (ICU), but shock occurred again at 3 h post-ICU admission. Enhanced CT scans were perfomed again and revealed the hematoma extending from within the retrocrural space to the right pleural space, and extravasation within the retrocrural space (Fig. 2). Therefore, angiography was immediately repeated. The left inferior phrenic artery was cannulated with a 5-Fr Michelson catheter, and DSA of the left inferior phrenic artery showed extravasation (Fig. 3a). NBCA was mixed with iodized oil (Lipiodol; Andre Guerbet, Aulnay-sous-Bois, France) at a ratio of 1:3, and the mixture was injected. Post-embolization angiography was performed to confirm the absence of extravasation, and completion of TAE (Fig. 3b). Massive hemothorax in the right pleural space was demonstrated on post-embolization chest CT. A thoracostomy tube was inserted, and approximately 1000 ml of bloody fluid was collected. After TAE, the increase of hemothorax was not confirmed. The patient needed 14 units of red blood cells and 8 units of fresh frozen plasma within 24 h from injury. The post-treatment course was uneventful and clinical symptoms revealing a diaphragmatic injury were not seen. The patient was enrolled in orthopediac department for the operation of left knee joint on the 17^th day and transferred to another hospital for rehabilitation without complications on the 39^th day.