Intercostal artery pseudoaneurysm due to stab wound

[Intervention for Chest Trauma and Large Vessel Injury]

Trauma is an injury to the body that involves multiple anatomical and pathophysiological changes caused by forces acting from outside the body. The number of patients with trauma is increasing as our society becomes more sophisticated. The importance and demand of traumatology are growing due to the development and spread of treatment and diagnostic technologies. In particular, damage to the large blood vessels of the chest can be life-threatening, and the sequelae are often severe; therefore, diagnostic and therapeutic methods are becoming increasingly important. Trauma to non-aortic vessels of the thorax and aorta results in varying degrees of physical damage depending on the mechanism of the accident and anatomical damage involved. The main damage is hemorrhage from non-aortic vessels of the thorax and aorta, accompanied by hemodynamic instability and coagulation disorders, which can be life-threatening. Immediate diagnosis and rapid therapeutic access can often improve the prognosis. The treatment of trauma can be surgical or interventional, depending on the patient's condition. Among them, interventional procedures are increasingly gaining popularity owing to their convenience, rapidity, and high therapeutic effectiveness, with increasing use in more trauma centers worldwide. Typical interventional procedures for patients with thoracic trauma include embolization for non-aortic injuries and thoracic endovascular aortic repair for aortic injuries. These procedures have many advantages over surgical treatments, such as fewer internal or surgical side effects, and can be performed more quickly than surgical procedures, contributing to improved outcomes for patients with trauma.

Isolated giant true intercostal artery aneurysm with arteriovenous fistula: A case report

OBJECTIVES

Intercostal artery aneurysm (IAA) is a very rare condition. Interestingly, only one study reported a case of intercostal aneurysm caused by an arteriovenous fistula (AVF). Here, we report the case of a patient with non-ruptured isolated giant true IAA caused by an AVF (size, 28 × 41 mm).

METHODS

Treatment options for IAA include open surgery and endovascular treatment (EVT). We chose EVT, as it is minimally invasive. The right 11th intercostal artery and aneurysm diverged from the aorta. Two outflow arteries, one inflow artery, and an AVF from the aneurysm were confirmed, and coil embolization was performed. The artery of Adamkiewicz did not communicate with the right 11th intercostal artery. We performed angiography and confirmed occlusion of IAA with endoleak.

RESULTS

There were no clinical findings indicative of spinal cord infarction after treatment. The patient did not develop complications and was discharged the day after treatment. Endoleak was not observed on computed tomography angiography findings at 1 month after treatment.

CONCLUSIONS

In our patient, an AVF might have caused IAA. Endovascular treatment for non-ruptured isolated giant IAA is a safe and minimally-invasive treatment. We found that performing EVT is beneficial when the size of the IAA exceeds 30 mm.

Massive hemothorax caused by intercostal artery pseudoaneurysm:a case report

BACKGROUND

Intercostal artery pseudoaneurysm is rare and at the risk of rupture. The aetiology is always reported to be iatrogenic and traumatic injury. Embolisation is the most common therapeutic method. Here, we report a case of spontaneous intercostal artery pseudoaneurysm and cured by combining covered stent grafting and surgical management.

CASE PRESENTATION

A 60-year-old man complained of acute right back pain for 5 h. Computed tomography showed right massive hemothorax and a giant mass with distinct feeding vessel originated from the thoracic aorta within the right hemithorax. Thoracocentesis was performed, and then a covered stent was positioned across the origin of the feeding vessel. The patient was diagnosed with intercostal artery pseudoaneurysm. Finally, we successfully resected the pseudoaneurysm and ligated the proximal part of the artery. Histologic examination have proved the diagnosis. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. There is no recurrence reported during follow-up.

CONCLUSIONS

Spontaneous intercostal artery pseudoaneurysm is extremly rare. Delayed hemothorax due to rupture of the pseudoaneurysm may occur years after the formation. Early diagnosis is important and a combined treatment of endovascular intervention and surgical management is feasible, especially for the case of ruptured large tumour-like mass presentation of the pseudoaneurysm.

Role of Intercostal Artery Embolization in Management of Traumatic Hemothorax

Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.

Intercostal artery pseudoaneurysm following thoracentesis: multi-modal imaging and treatment

Background

A pseudoaneurysm occurs as the result of a contained rupture of an arterial wall, yielding a perfused sac that communicates with the arterial lumen. Pseudoaneurysm of an intercostal artery is an extremely rare event but it carries with it a significant risk of rupture and subsequent hemothorax. It must be considered as a potential complication of thoracentesis.

Case presentation

Here, we report a rare case of an intercostal artery pseudoaneurysm following thoracentesis in an 82-year old male. The patient presented with respiratory distress 1 day after a therapeutic thoracentesis had been performed. Computed tomography (CT) with contrast revealed a left intercostal pseudoaneurysm with hemothorax and adjacent compressive atelectasis. Doppler ultrasound revealed bidirectional blood flow in the pseudoaneurysm sac. An intercostal arteriogram and thoracic aortogram aided in confirmation of the pseudoaneurysm and successful treatment with coil embolization.

Conclusions

An intercostal pseudoaneurysm complication following thoracentesis is very rare but important to rule out as a possible cause of hemothorax after the procedure. Capturing this finding with the aid of multiple imaging modalities allowed for diagnostic certainty and rapid treatment with coil embolization, leading to a successful patient recovery.

A Unique Case of Esophageal Bleeding: Arterioenteric Fistula Secondary to Intercostal-Bronchial Trunk Pseudoaneurysm Rupture

Esophageal bleeding has a broad differential. One rare cause of esophageal bleeding is an intercostal artery pseudoaneurysm, which usually presents as hemothorax secondary to trauma or an iatrogenic cause; we identified only 9 reported cases in the English literature. Rarer still is pseudoaneurysm of the intercostal-bronchial trunk, which has not been reported in the literature. We report a 61-year-old man with an intercostal-bronchial trunk pseudoaneurysm who presented with hematemesis and signs of upper gastrointestinal bleeding without previous history of trauma. This case report serves to broaden the differential for esophageal bleeding.

Buttock wounds: beware what lies beneath

A 25-year-old man presented to a major trauma centre with multiple stab wounds, most significantly to the right buttock. Triple-phase CT revealed no acute bleeding and his wounds were closed. In the month following injury, he re-presented seven times to the emergency department (ED) complaining of bleeding and wound breakdown. After his seventh ED attendance, he was examined under general anaesthesia. Intraoperatively, profuse arterial bleeding was encountered and the local major haemorrhage protocol was activated. The on-call consultant vascular surgeon attended and definitive control was achieved. A large haematoma had acted to tamponade ongoing arterial bleeding and an underlying pseudoaneurysm: a finding not reported, but present, on the initial CT angiogram. Following 24 hours in the intensive care unit, he was transferred to the surgical ward and discharged 4 days later. Regular review in the outpatient department over the following 9 weeks monitored successful wound healing.

Transcatheter arterial embolization for intercostal arterio-esophageal fistula in esophageal cancer

Background

While esophageal fistula formation in the adjacent organs is associated with high rates of morbidity and mortality, the management of non-aortic arterio-esophageal fistula has not been frequently reported.

Case presentation

A 69-year-old Japanese man who had undergone definitive chemoradiotherapy for esophageal cancer was admitted to our hospital with hematemesis. He was diagnosed with mediastinal abscess caused by esophageal perforation, and esophageal bypass surgery was performed. After 3 days, he presented with fatal hemoptysis. As angiography revealed an intercostal artery pseudoaneurysm, transcatheter arterial embolization was performed.

Conclusions

When patients with esophageal cancer, especially those with a history of radiotherapy and/or mediastinitis, present with hematemesis and/or hemoptysis, the possibility of non-aortic arterio-esophageal fistula should be considered. Transcatheter arterial embolization is an effective treatment for non-aortic arterio-esophageal fistula.

Angiographic analysis of the lateral intercostal artery perforator of the posterior intercostal artery: anatomic variation and clinical significance

PURPOSE

Knowledge of the anatomic variations of the posterior intercostal artery (PICA) and its major branches is important during transthoracic procedures and surgery. We aimed to identify the anatomic features and variations of the lateral intercostal artery perforator (LICAP) of the PICA with selective PICA arteriography.

METHODS

We retrospectively evaluated 353 PICAs in 75 patients with selective PICA arteriography for the following characteristics: incidence, length (as number of traversed intercostal spaces), distribution at the hemithorax (medial half vs. lateral half), and size as compared to the collateral intercostal artery of the PICA.

RESULTS

The incidence of LICAPs was 35.9% (127/353). LICAPs were most commonly observed in the right 8th-11th intercostal spaces (33%, 42/127) and in the medial half of the hemithorax (85%, 108/127). Most LICAPs were as long as two (35.4%, 45/127) or three intercostal spaces (60.6%, 77/127). Compared to the collateral intercostal artery, 42.5% of LICAPs were larger (54/127), with most of these observed in the right 4th-7th intercostal spaces (48.8%, 22/54).

CONCLUSION

We propose the clinical significance of the LICAP as a potential risk factor for iatrogenic injury during posterior transthoracic intervention and thoracic surgery. For example, skin incisions must be as superficial as possible and directed vertically at the right 4th-7th intercostal spaces and the medial half of the thorax. Awareness of the anatomical variations of the LICAPs of the PICA will allow surgeons and interventional radiologists to avoid iatrogenic arterial injuries during posterior transthoracic procedures and surgery.

Ruptured intercostal artery pseudoaneurysm: a rare cause of acute back pain

A 63-year-old man with no relevant medical history presented with acute non-traumatic back pain and was found to have a T8 intercostal artery pseudoaneurysm associated with haemomediastinum on CT of the chest. He was taken to angiography with interventional radiology and the aneurysm was coiled without complication.

Intercostal artery pseudoaneurysm after ultrasound-guided liver biopsy: a case report and review of the literature

We present a 58-year-old woman with a right intercostal artery pseudoaneurysm after percutaneous ultrasound (US)-guided liver biopsy. The patient presented 6 days after liver biopsy with a painful, pulsatile right-sided chest wall mass at the site of biopsy needle insertion. Intercostal artery pseudoaneurysm was diagnosed with color Doppler US. Successful treatment with percutaneous US-guided injection of thrombin resulted in complete thrombosis and closure of the pseudoaneurysm. Only 12 previous cases of intercostal artery pseudoaneurysm have been reported in the English-language literature, and this is the first reported case resulting from percutaneous liver biopsy. Given how frequently percutaneous liver biopsies are performed, it is important to raise awareness of this potentially serious complication.

Intercostal artery pseudoaneurysm complicating corrosive acid poisoning: Diagnosis with CT and treatment with transarterial embolisation

Pseudoaneurysms of intercostal artery are very rare. All the published cases have been caused by trauma, either iatrogenic or otherwise. They can cause hemothorax, retroperitoneal hemorrhage or can present as pulsatile chest mass. Doppler ultrasound, contrast-enhanced CT and conventional angiogram can accurately diagnose this condition. All the reported cases have been treated by embolisation, stenting or surgery. We report an unusual case of intercostal artery pseudoaneurysm arising as a complication of corrosive poisoning presenting with hematemesis and treated by glue embolisation. The authors believe this to be the first case of intercostal artery pseudoaneurysm that is non-traumatic, complicating corrosive poisoning and presenting with hematemesis.

Ruptured intercostal artery pseudoaneurysm in a patient with blunt thoracic trauma: diagnosis and management

Intercostal artery pseudoaneurysm is an extremely unusual condition, with less than 10 reported cases to our knowledge. Most of them have been associated with surgical interventions or blunt thoracic trauma. The bleeding risk in this kind of lesions is considerable, the majority of them presenting as haemothorax. We present a case of an intercostal artery pseudoaneurysm detected after a blunt thoracic trauma in a patient with signs of acute bleeding. The identification of a small artery pseudoaneurysm as the cause of haemothorax requires knowledge of this possible aetiology as well as detailed attention to the CT technique. Embolisation is considered to be the first therapeutic method in the management of a ruptured pseudoaneurysm. To reduce the risk of failure, the anatomic features and adjacent vessels providing collateral branches must be studied and embolised if needed, with important attention to collateral blood supply arising from the musculophrenic and anterior intercostal arteries.

Repeated embolization of intercostal arteries after blunt chest injury

To deal with an arterial bleeding from the chest wall after a blunt chest injury, embolization of the bleeding arteries can be a valuable therapeutic option, which is less invasive than a thoracotomy. However, its results are variable, being highly operator-dependent. In the present case, we performed successful emergency embolization of the 4th and 5th intercostal arteries for persistent hemorrhage following blunt trauma to the chest. Several days after the first embolization, secondary embolization was required for treating a pseudoaneurysm that was formed in the 5th intercostal artery. Although the mechanisms underlying pseudoaneurysm formation are not clearly understood, its rupture is potentially fatal. Therefore, it is essential to carefully follow-up patients who experience blunt chest injury to avoid this serious complication.

Intercostal artery pseudoaneurysm formation after irinotecan transarterial chemoembolization of a spinal metastasis from colorectal cancer

Over the past decade, irinotecan has become one of the first-line chemotherapeutic agents used in the treatment of metastatic colorectal cancer. Recently, irinotecan has been administered transarterially in order to perform chemoembolization in the liver. In the limited number of reports available to date using this approach, serious adverse effects have not yet been reported. In this paper, we describe the formation of an intercostal artery pseudoaneurysm after transarterial chemoembolization with irinotecan-eluting beads in a patient with spinal metastasis from colorectal cancer.

Intercostal artery pseudoaneurysm after computed tomography-guided percutaneous fine needle aspiration lung biopsy

Intercostal artery pseudoaneurysm is a rare but life-threatening complication. Herein we report an unusual case of an intercostal artery pseudoaneurysm caused by computed tomography-guided percutaneous fine needle aspiration lung biopsy and successfully treated with endovascular embolization. Radiologists performing percutaneous fine needle aspiration lung biopsies should be aware of this rare potential complication.

Intercostal artery pseudoaneurysm due to thoracentesis: diagnosis with three-dimensional computed tomographic angiography

Intercostal artery pseudoaneurysm is extremely rare, with only a few case reports in the literature. Presented in this case report is a patient who developed an intercostal artery pseudoaneurysm after thoracentesis for recurrent pleural effusion. Diagnosis traditionally required arteriography; however, as shown in this case, the resolution of current multidetector computed tomography scanners and the routine acquisition of isotropic data sets with 3-dimensional visualization enable identification and detailed characterization of small vascular lesions such as these.

Imaging appearances and endovascular management of uncommon pseudoaneurysms

Pseudoaneurysms are uncommon and their aetiology is varied. They occur in numerous anatomical locations and present with a multitude of clinical presentations sometimes life-threatening. This review describes the causes, sites, and presentations of uncommon pseudoaneurysms, as well as illustrating their diagnostic appearances and endovascular management.

Traumatic intercostal artery pseudoaneurysm following a bicycle accident

In this article we present a fatal case of a ruptured intercostal artery pseudoaneurysm that occurred a number of years after an incident in which the patient suffered a blunt-trauma injury. A long interval between blunt trauma and this type of fatality has rarely been reported. This case discusses a 49-year-old woman who was found dead at her home by her husband and was referred for autopsy because the cause of death was uncertain. Her past medical history was unknown; however, it was learned that she had a bicycle accident 4 years previously and had sustained injuries to the left side of her body. During the autopsy, healed fractures in the bones of the left lower rib cage and a large amount of blood in the left thorax were observed. Furthermore, a hematoma, containing a small rupture was found in the left tenth intercostal space adjacent to the thoracic vertebrae. Histological examinations showed that the wall of the left tenth intercostal artery was ruptured, with recent blood clots including fibrin. Additionally, in the lesion where the tunica adventitia was disrupted, the dissecting cavity was filled with blood. We concluded that the woman died of hemorrhagic shock resulting from a ruptured intercostal artery pseudoaneurysm that formed as a result of the injury incurred from the bicycle accident 4 years before.