Chest wall arteriovenous fistula: an unusual complication after chest tube placement

Successful embolization of an anterior chest wall arteriovenous malformation using combined transfemoral and transradial approaches with onyx

We present a case of successful embolization of an anterior chest wall arteriovenous malformation (AVM) in a 24-year-old male patient. This report aims to highlight the efficacy and safety of using the liquid embolic agent (onyx) as well as the combined approaches (trans-femoral and trans-radial) in managing rare complex chest wall AVMs.

"Please mind the gap": successful use of ultrasound-assisted spinal anesthesia for urgent cesarean section in a patient with implanted spinal cord stimulation system for giant chest wall arteriovenous malformation - a case report

Background

The use of Spinal Cord Stimulation (SCS) system to treat medically refractory neuropathic pain is increasing. Severe neuropathic pain can be found in giant chest wall arteriovenous malformations (AVMs), exceedingly rare and debilitating abnormalities, rarely reported during pregnancy.

Case presentation

We present a report of a pregnant patient with implanted Spinal Cord Stimulation (SCS) system because of painful thoracic AVM scheduled for an urgent cesarean section in which we used lumbar ultrasound (US) to rule out the possibility to damage SCS electrodes and to find a safe site to perform spinal anesthesia.

Conclusions

The use of lumbar US to find a safe site for a lumbar puncture in presence of SCS system in a patient affected by painful thoracic AVM makes this case a particularly unique operative challenge and offers a new possible use of ultrasound to detect a safe space in patients with SCS implant.

Atraumatic tension hemothorax associated with ruptured aneurysm of intercostal artery-azygous fistula: a case report

Atraumatic tension hemothorax is extremely rare. We report a case of 62-year-old woman presented with obstructive and hypovolemic shock status by tension hemothorax due to ruptured aneurysm of congenital intercostal artery-azygous fistula. Contrast-enhanced computed tomography and aortography revealed an aberrant 12th intercostal artery flowing into the aneurysm with a fistula draining into the azygous vein and the rupture of aneurysm. Our experience indicates that the rupture of congenital arteriovenous fistulas (AVFs) of systemic circulation in the thoracic cavity might cause not only hypovolemic shock but also atraumatic tension hemothorax. Surgery following preoperative endovascular embolization offers a feasible treatment strategy for ruptured aneurysms associated with AVFs.

Giant Chest Wall Arteriovenous Malformation: A Case Report and Literature Review

BACKGROUND

We present an interesting case of a 55-year-old male with a large left chest mass after significant cutaneous bleeding. Computed tomography angiogram of the chest revealed arteriovenous malformation with blood supply from sub-branches of the left subclavian artery, left internal mammary artery, and left external carotid artery. Measuring 5.0 × 14.0 × 10.8 cm, the mass extended superior to the clavicle and inferior to the third rib with medial and lateral borders at the level of the clavicular head and coracoid, respectively.

METHODS

Arteriovenous malformations (AVMs) are characterized by abnormal connections between arteries and veins which bypass the capillary system. Often small and asymptomatic, large AVMs can be painful, prone to bleeding and, if large enough, interfere with activities of daily living. While described involving various parts of the body, most notably in the central nervous system, there is a paucity of literature involving chest wall AVMs.

RESULTS

Using a staged, multidisciplinary approach, treatment began with an endovascular exclusion of the arterial blood supply, which involved a combination of coil embolization and stent exclusion of feeder vessels. Two days postembolization, the patient underwent an en bloc resection of affected portion of his chest wall. Reconstruction was completed with a combination rotational flap and split-thickness skin graft. Following the procedures, the patient had an uncomplicated recovery. Three years following procedure, he has no signs of recurrence of his AV malformation.

CONCLUSION

Surgical planning and indications for giant arteriovenous malformations remains a unique and difficult problem. The complex anatomy and extreme rarity of a chest wall AVM requires a multidisciplinary staged approach but can be treated with a multistage, multidisciplinary surgical approach with satisfactory and long-lasting results.

Tube Thoracostomy: A Structured Review of Case Reports and a Standardized Format for Reporting Complications

INTRODUCTION

Although seemingly straightforward, tube thoracostomy (TT) has been associated with complication rates as high as 30 %. A lack of a standardized nomenclature for reporting TT complications makes comparison and evaluation of reports impossible. We aim to develop a classification method in order to standardize the reporting of complications of TT and identify all reported complications of TT and time course in which they occurred to validate the reporting method.

METHODS

A systematic search of MEDLINE, Scopus, EMBASE, and Cochrane Central Register of Controlled Trials and Database of Systematic Reviews from each databases inception through November 5, 2013 was conducted. Original articles written in the English language reporting TT complications were searched. This review adhered to preferred reporting items for systematic reviews and meta-analyses (PRISMA) standards. Duplicate reviewers abstracted case reports for inclusion. Cases were then sorted into one of the five complication categories by two reviewers, and in case of disagreements, settled by a third reviewer.

RESULTS

Of 751 papers reporting TT complications, 124 case reports were included for analysis. From these reports, five main categories of TT complications were identified: insertional (n = 65); positional (n = 36); removal (n = 11); infective and immunologic (n = 7); and instructional, educational, or equipment related (n = 5). Placement of TT has occurred in nearly every soft tissue and vascular structure in the thoracic cavity and intra-abdominal organs.

CONCLUSION

Our classification method provides further clarity and systematic standardization for reporting TT complications.

Complications of chest tubes: a focused clinical synopsis

PURPOSE OF REVIEW

Chest tube placement, or tube thoracostomy, is an invasive procedure designed to evacuate air and/or fluid from the thorax, whether emergent or elective. In the placement of these devices particular attention and effort must be made to understand safe and reliable anatomic techniques and device maintenance so as to avoid serious injury to the patient. This review focuses on complications of chest tube placement, with the emphasis on patient safety and error prevention.

RECENT FINDINGS

There is a paucity of high-quality recent literature on tube thoracostomy complications. With the advent of value-driven healthcare, increasing emphasis is being placed on appropriate procedural indications, procedural safety, and patient satisfaction. Good clinical outcomes are critical to achieve and maintain in this context.

SUMMARY

Given the high volume of tube thoracostomies globally, greater awareness of potential complications and preventive strategies is needed. The authors attempt to bridge this important gap.

Thoracostomy tubes: A comprehensive review of complications and related topics

Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.

Tube thoracostomy: complications and its management

Background. Tube thoracostomy is widely used throughout the medical, surgical, and critical care specialities. It is generally used to drain pleural collections either as elective or emergency. Complications resulting from tube thoracostomy can occasionally be life threatening. Aim. To present an update on the complications and management of complications of tube thoracostomy. Methods. A review of the publications obtained from Medline search, medical libraries, and Google on tube thoracostomy and its complications was done. Results. Tube thoracostomy is a common surgical procedure which can be performed by either the blunt dissection technique or the trocar technique. Complication rates are increased by the trocar technique. These complications have been broadly classified as either technical or infective. Technical causes include tube malposition, blocked drain, chest drain dislodgement, reexpansion pulmonary edema, subcutaneous emphysema, nerve injuries, cardiac and vascular injuries, oesophageal injuries, residual/postextubation pneumothorax, fistulae, tumor recurrence at insertion site, herniation through the site of thoracostomy, chylothorax, and cardiac dysrhythmias. Infective complications include empyema and surgical site infection. Conclusion. Tube thoracostomy, though commonly performed is not without risk. Blunt dissection technique has lower risk of complications and is hence recommended.

Targeted wire-guided chest tube placement: a cadaver study

OBJECTIVE

Chest tube thoracostomy is a standard procedure for pleural fluid and air drainage. The aim of this study is to compare the success rate of the targeted tube thoracostomy using two different techniques: a targeted wire-guided (TWG) technique and a classical surgical (CS) technique.

METHODS

The study was performed on 153 human cadavers without documented pleural pathology, mechanically ventilated during the procedure. They were divided into two groups and to each cadaver a software generated random number was assigned. The TWG technique was applied on 76 and the CS technique on 77 cadavers. The TWG and CS groups were divided into four subgroups according to the four intended positions of the chest tube tip (target position in the pleural cavity): back-down-right, front-up-right, front-up-left and back-down-left. The precise position of the chest tube tip after thoracostomy was determined by autopsy. The placement of the thoracostomy tube was marked successful if the chest tube tip was located at an intended position.

RESULTS

The success rate with the TWG technique was 79%, whereas with the CS technique it was 30%.

CONCLUSION

A higher success rate was achieved with the TWG than with the CS thoracostomy technique.

Giant arteriovenous malformation located on the chest wall - diagnosis and endovascular treatment: report of a case

Congenital arteriovenous malformations are usually found in the lower extremities, but a chest wall location is extremely rare. Extensive vascular malformations present difficulties for patients because of severe unsightliness and life-threatening bleeding. Surgical planning and therapeutic indications in vascular malformations are still a difficult problem. This report describes the case of a 27-year-old woman with a congenital giant arteriovenous malformation of the left chest wall. Preoperative embolization was planned prior to surgical intervention because of the increased risk of massive bleeding, and the malformation was completely embolized with absolute alcohol.

Sectional Neuroanatomy of the Middle Thoracic Spine (T5-T8) and Chest

This is the third in a series of articles on the spine. The first reviewed the anatomy of the neck. The second reviewed the upper thoracic spine and chest (T1-T4). A fourth article is planned for the lower thoracic spine. Procedures in the midthoracic spine include chest tube placement, trigger point injections, chemodenervation with botulinum toxin, video-assisted thoroscopic surgery, and spinal injections. Complications include pneumothorax, hemothorax, diaphragmatic irritation, sympathetic trunk irritation, postthoracotomy pain, and intradural abscesses. This article provides anatomically accurate schematics of innervations of the middle thoracic chest and spine (T5-T8) that can be used to interpret magnetic resonance images of the muscles and nerves. Cross-sectional schematics of the middle thoracic chest and spine were drawn as they appear on imaging projections. The relevant nerves were color coded. The muscles and skin surfaces were labeled and assigned the color of the appropriate nerves. An organized comprehensive map of the motor innervation of the middle thoracic chest and spine allows the physician to increase the accuracy and efficacy of interventional procedures. This could also assist the electromyographer in correlating the clinical and electrophysiologic findings with magnetic resonance images.

A Rare Case of Pulmonary Hypertension As a Result of Arteriovenous Fistula After Cardiac Surgery

A 19 year-old woman who underwent corrective surgery for an atrial septal defect (ASD) and ventricular septal defect (VSD) 12 years previously presented with pulmonary hypertension. Cardiac catheterization showed a fistula between the right subclavian artery and vena jugularis interna. In this case, a rare example of secondary pulmonary hypertension due to acquired arteriovenous fistula after cardiac surgery is presented.

Acquired systemic-to-pulmonary arteriovenous malformation secondary to Mycobacterium tuberculosis empyema

Pulmonary arteriovenous malformations (AVMs) with systemic arterial collateralization related to a prior tuberculosis empyema are extremely rare. We report the case of a 15-year-old boy who developed a pulmonary AVM with massive systemic arterial collateralization 5 years after being treated for a Mycobacterium tuberculosis empyema necessitans. The AVM was successfully managed with combined intraarterial embolization and surgical resection.