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Ohtaka K, Ohtake S, Ishii Y, Kaku S, Takeuchi Y, Mizota T, Yamamura Y, Ichinokawa M, Yoshioka T, Tamoto E, Murakawa K, Ono K, Kato T. Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report. J Med Case Rep 2024; 18:280. [PMID: 38879573 PMCID: PMC11180386 DOI: 10.1186/s13256-024-04602-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 05/29/2024] [Indexed: 06/19/2024] Open
Abstract
BACKGROUND Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage. CASE PRESENTATION A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful. CONCLUSION We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.
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Affiliation(s)
- Kazuto Ohtaka
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan.
- Department of Thoracic Surgery, Hokkaido University Hospital, West 5 North 14, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan.
| | - Setsuyuki Ohtake
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Yu Ishii
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Saya Kaku
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Yuta Takeuchi
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Tomoko Mizota
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Yoshiyuki Yamamura
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Masaomi Ichinokawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Tatsuya Yoshioka
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Eiji Tamoto
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Katsuhiko Murakawa
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Koichi Ono
- Department of Surgery, Obihiro Kosei General Hospital, West 14 South 10, Obihiro, Hokkaido, 080-0024, Japan
| | - Tatsuya Kato
- Department of Thoracic Surgery, Hokkaido University Hospital, West 5 North 14, Kita-Ku, Sapporo, Hokkaido, 060-8648, Japan
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Rösch RM. From diagnosis to therapy: the acute traumatic hemothorax - an orientation for young surgeons. Innov Surg Sci 2023; 8:221-226. [PMID: 38510367 PMCID: PMC10949117 DOI: 10.1515/iss-2023-0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/17/2024] [Indexed: 03/22/2024] Open
Abstract
Introduction This review aims to provide an overview of diagnosing and managing traumatic haemothorax for young surgeons. Content Of 27,333 polytrauma patients in Germany in 2021, 35 % were admitted with thoracic trauma. In polytrauma patients, chest injuries are an independent negative predictor of 30-day mortality. These patients should be treated in an evidence-based and standardized manner to reduce mortality and morbidity. There are several methods of immediate diagnosis that should be used depending on hemodynamic stability. In addition to physical examination and chest X-ray, more specific techniques such as the eFAST protocol and Computed tomography (CT) of the chest are available. Once the source of bleeding has been identified, acute treatment is given depending on hemodynamic stability. Thoracic drainage remains the gold standard in the initial management of hemothorax. If surgery is required because of an active source of bleeding, a hemothorax that has not been completely relieved, or associated injuries, either a minimally invasive or open approach can be used. The main focus is to stabilize the patient and avoid early and late complications. Summary and Outlook Rapid and prompt diagnosis and management of traumatic hemothorax is essential for patient outcome and should be taught to all young surgeons who are in direct contact with these patients.
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Affiliation(s)
- Romina M. Rösch
- Department of Thoracic Surgery, University Hospital Heidelberg, Heidelberg, Germany
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Friedman A, Ulrich M. Case report: Spontaneous hemothorax following anticoagulation for microthrombi in severe COVID pneumonia. Respir Med Case Rep 2023; 44:101864. [PMID: 37332847 PMCID: PMC10272501 DOI: 10.1016/j.rmcr.2023.101864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/18/2023] [Accepted: 05/10/2023] [Indexed: 06/20/2023] Open
Abstract
Background Anticoagulant therapy has become a hallmark of treatment for critically ill COVID patients. Gastrointestinal and intracranial hemorrhage are known major complications of anticoagulation, but spontaneous hemothorax is a rare event, particularly in the absence of pre-existing structural lung disease, vascular malformations, or genetic bleeding diatheses. Herein is a case of spontaneous hemothorax following anticoagulation for microthrombi in a patient with acute hypoxic respiratory failure due to Covid pneumonia. Case presentation A 49 year old male with hypertension, asthma, and obesity was admitted for acute hypoxic respiratory failure due to Covid pneumonia. He was treated with dexamethasone, baricitinib, and therapeutic enoxaparin as empiric therapy for severe COVID disease. He subsequently developed a massive right hemothorax with associated hemorrhagic shock, which required initiation of massive transfusion protocol, vasopressor support and mechanical ventilation. No clear etiology for the hemothorax was determined upon investigations. The patient eventually improved and was discharged to a skilled nursing facility on chronic oxygen therapy. Conclusions Various mechanisms have been proposed for the development of non-traumatic hemothoraces, including tearing of adhesions and rupture of vascularized bullae. Such explanations find support in radiologic and pathologic studies of pleural changes in Covid pneumonia, and likely played a role in the hemorrhage experienced by our patient.
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Affiliation(s)
- Alexander Friedman
- Corresponding author. Department of Internal Medicine, Riverside University Health Systems Medical Center, 26520 Cactus Ave, Moreno Valley, CA, 92555, USA.
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Aramaki H, Fukaguchi K, Yamagami H, Maeda Y, Tsunoda S, Akazawa K, Koyama H. Obstructive shock due to a spontaneous haemothorax caused by primary lung cancer. Respirol Case Rep 2023; 11:e01082. [PMID: 36605537 PMCID: PMC9808146 DOI: 10.1002/rcr2.1082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 12/19/2022] [Indexed: 01/05/2023] Open
Abstract
We describe the case of a 67-year-old man with shock and hypoxemia. Chest X-ray showed bilateral lung mass shadows and left pleural effusion with a mediastinal shift, suggesting malignancy. Physical examination and point-of-care ultrasound findings did not suggest obstructive or cardiac shock, but the patient had prolonged shock refractory to fluid and blood transfusion therapy. We inserted a drain into the left thoracic cavity, which enabled the patient to recover from shock. We diagnosed the patient with obstructive and hypovolemic shock due to spontaneous haemothorax caused by primary lung cancer. Tension haemothorax due to malignancy is rare, and when obstructive shock is combined with haemorrhagic shock, it can be very difficult to determine the cause of shock.
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Affiliation(s)
- Hiroe Aramaki
- Department of General Internal MedicineShonan Kamakura General HospitalKamakuraJapan,Division of Critical CareShonan Kamakura General HospitalKamakuraJapan
| | - Kiyomitsu Fukaguchi
- Division of Critical CareShonan Kamakura General HospitalKamakuraJapan,Department of Emergency MedicineShonan Kamakura General HospitalKamakuraJapan
| | - Hiroshi Yamagami
- Department of Emergency MedicineShonan Kamakura General HospitalKamakuraJapan
| | - Yuki Maeda
- Department of Emergency MedicineShonan Kamakura General HospitalKamakuraJapan
| | - Shun Tsunoda
- Department of HaematologyShonan Kamakura General HospitalKamakuraJapan
| | - Kenichiro Akazawa
- Department of General Internal MedicineShonan Kamakura General HospitalKamakuraJapan
| | - Hiroshi Koyama
- Division of Critical CareShonan Kamakura General HospitalKamakuraJapan
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Spontaneous hemothorax in a 48-year-old man with COVID-19 acute respiratory distress syndrome. Respir Med Case Rep 2023; 42:101806. [PMID: 36620726 PMCID: PMC9811899 DOI: 10.1016/j.rmcr.2023.101806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 12/18/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
A 48-year-old man presented with gradually worsening dyspnea three days after testing positive for COVID-19. He was admitted to the intensive care unit on maximum high flow nasal cannula settings and subsequently intubated for hypoxic respiratory failure due to COVID-19 pneumonia. Two weeks into the patient's hospital course, he unexpectedly developed worsening hypotension with multiple vasopressor requirements. Labs revealed an unexpected hemoglobin drop from 12.5 to 7.9 g/dL. Chest radiograph showed near complete opacification of the right hemithorax concerning for hemothorax. This case presentation describes a rare phenomenon of spontaneous hemothorax in a patient with COVID-19.
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Suzuki T, Takada T. Spontaneous Tension Hemothorax in a Patient with Asbestosis. Clin Pract Cases Emerg Med 2022; 6:330-332. [PMID: 36427035 PMCID: PMC9697885 DOI: 10.5811/cpcem.2022.6.57031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/03/2022] [Indexed: 11/19/2022] Open
Abstract
CASE PRESENTATION A 75-year-old man with a history of asbestosis presented to the emergency department with sudden-onset dyspnea and hemoptysis, triggered by coughing. The patient was hemodynamically unstable and in respiratory distress. Computed tomography revealed a massive hemothorax on the left side and compression of the descending thoracic aorta. He underwent emergency surgical exploration after decompression by chest tube insertion. The hemothorax was caused by tears in the pleural adhesions due to asbestosis and induced by coughing. DISCUSSION Spontaneous hemothorax is a rare subtype of hemothorax. There have been only a few case reports of spontaneous tension hemothorax. In addition to its typical findings, compression of the thoracic descending aorta was observed in our patient. We hypothesize that severely diminished pulmonary compliance contributed to the extremely high intrathoracic pressure, which led to this unusual finding.
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Affiliation(s)
- Toshinao Suzuki
- Teikyo University Chiba Medical Center, Interventional Radiology Center, Chiba, Japan
| | - Toshihiko Takada
- Fukushima Medical University, Department of General Medicine, Shirakawa Satellite for Teaching And Research (STAR), Fukushima, Japan
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Hu K, Chopra A, Kurman J, Huggins JT. Management of complex pleural disease in the critically ill patient. J Thorac Dis 2021; 13:5205-5222. [PMID: 34527360 PMCID: PMC8411157 DOI: 10.21037/jtd-2021-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 06/21/2021] [Indexed: 11/08/2022]
Abstract
Disorders of the pleural space are quite common in the critically ill patient. They are generally associated with the underlying illness. It is sometimes difficult to assess for pleural space disorders in the ICU given the instability of some patients. Although the portable chest X-ray remains the primary modality of diagnosis for pleural disorders in the ICU. It can be nonspecific and may miss subtle findings. Ultrasound has become a useful tool to the bedside clinician to aid in diagnosis and management of pleural disease. The majority of pleural space disorders resolve as the patient’s illness improves. There remain a few pleural processes that need specific therapies. While uncomplicated parapneumonic effusions do not have their own treatments. Those that progress to become a complex infected pleural space can have its individual complexity in therapy. Chest tube drainage remains the cornerstone in therapy. The use of intrapleural fibrinolytics has decreased the need for surgical referral. A large hemothorax or pneumothorax in patients admitted to the ICU represent medical emergencies and require emergent action. In this review we focus on the management of commonly encountered complex pleural space disorders in critically ill patients such as complicated pleural space infections, hemothoraces and pneumothoraces.
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Affiliation(s)
- Kurt Hu
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Amit Chopra
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY, USA
| | - Jonathan Kurman
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Terrill Huggins
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical University of South Carolina, Charleston, SC, USA
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Tanaka Y, Haratake N, Kinoshita F, Takenaka T, Tagawa T, Mori M. Spontaneous hemopneumothorax with a ruptured aneurysm in the second intercostal artery: report of a case. Gen Thorac Cardiovasc Surg 2021; 69:1133-1136. [PMID: 34043127 DOI: 10.1007/s11748-021-01620-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 03/06/2021] [Indexed: 12/01/2022]
Abstract
Ruptured intercostal aneurysm is a rare cause of spontaneous hemopneumothorax (SHP). A 29-year-old woman presented to our hospital with left neck pain and, in the emergency room, suddenly lost consciousness. Chest radiography showed massive pleural effusion and the moderate collapse of the left lung. A chest drain was placed and 800 mL of bloody pleural effusion was collected. Contrast-enhanced computed tomography showed a ruptured aneurysm near the left pulmonary apex. Emergency angiography further revealed the ruptured aneurysm in the second intercostal artery. Transcatheter angiographic embolization (TAE) was performed, which resulted in hemostasis. On hospitalization day 2, the hematoma was removed via video-assisted thoracic surgery. A bulla was also identified in the lower lobe and removed. She was discharged from the hospital on a postoperative day 6 without complications. Thus, TAE might be effective to control bleeding during the initial treatment of SHP due to a ruptured aneurysm.
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Affiliation(s)
- Yasushi Tanaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Naoki Haratake
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Fumihiko Kinoshita
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tomoyoshi Takenaka
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Tetsuzo Tagawa
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Masaki Mori
- Department of Surgery and Science, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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Hashimoto K, Nomata Y, Fukui T, Takada A, Narita K. Massive hemothorax in a pregnant patient with neurofibromatosis type 1. J Cardiothorac Surg 2021; 16:116. [PMID: 33931082 PMCID: PMC8086125 DOI: 10.1186/s13019-021-01504-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/22/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reports of spontaneous hemothorax in patients with neurofibromatosis type 1 are scarce despite the severe complication. We herein present the first case of hemothorax in a neurofibromatosis type 1 patient during pregnancy and discuss the difficulty associated with its diagnosis and treatment. CASE PRESENTATION A 39-year-old female at 34 weeks gestation presented with sudden left back pain and dyspnea. Chest radiography revealed massive left pleural effusion. Computed tomography showed bleeding from the intercostal artery. Although the patient appeared hemodynamically stable, the fetus was in a critical condition. Emergency caesarean section was performed within 1 hour. Subsequently, we performed endovascular coil embolization of the intercostal artery. While this intensive treatment saved the patient, her fetus could not be rescued. CONCLUSIONS Patients with neurofibromatosis type 1 may develop massive hemothorax without gross lesions. In late pregnancy, sufficient infusion and quick hemostasis are essential and can be lifesaving.
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Affiliation(s)
- Kumiko Hashimoto
- Department of Thoracic Surgery, Toyohashi Municipal Hospital, 50 Hachiken-nishi, Aotake-cho, Toyohashi, Aichi, 441-8570, Japan.
| | - Yuji Nomata
- Department of Thoracic Surgery, Toyohashi Municipal Hospital, 50 Hachiken-nishi, Aotake-cho, Toyohashi, Aichi, 441-8570, Japan
| | - Takayuki Fukui
- Department of Thoracic Surgery, Nagoya University, Nagoya, Japan
| | - Akira Takada
- Department of Radiology, Toyohashi Municipal Hospital, Toyohashi, Aichi, Japan
| | - Kunio Narita
- Department of Thoracic Surgery, Toyohashi Municipal Hospital, 50 Hachiken-nishi, Aotake-cho, Toyohashi, Aichi, 441-8570, Japan
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Real-Time Detection of Hemothorax and Monitoring its Progression in a Piglet Model by Electrical Impedance Tomography: A Feasibility Study. BIOMED RESEARCH INTERNATIONAL 2020; 2020:1357160. [PMID: 32190646 PMCID: PMC7064861 DOI: 10.1155/2020/1357160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 01/12/2020] [Accepted: 01/22/2020] [Indexed: 12/20/2022]
Abstract
Hemothorax is a serious medical condition that can be life-threatening if left untreated. Early diagnosis and timely treatment are of great importance to produce favorable outcome. Although currently available diagnostic techniques, e.g., chest radiography, ultrasonography, and CT, can accurately detect hemothorax, delayed hemothorax cannot be identified early because these examinations are often performed on patients until noticeable symptoms manifest. Therefore, for early detection of delayed hemothorax, real-time monitoring by means of a portable and noninvasive imaging technique is needed. In this study, we employed electrical impedance tomography (EIT) to detect the onset of hemothorax in real time on eight piglet hemothorax models. The models were established by injection of 60 ml fresh autologous blood into the pleural cavity, and the subsequent development of hemothorax was monitored continuously. The results showed that EIT was able to sensitively detect hemothorax as small as 10 ml in volume, as well as its location. Also, the development of hemothorax over a range of 10 ml up to 60 ml was well monitored in real time, with a favorable linear relationship between the impedance change in EIT images and the volume of blood injected. These findings demonstrated that EIT has a unique potential for early diagnosis and continuous monitoring of hemothorax in clinical practice, providing medical staff valuable information for prompt identification and treatment of delayed hemothorax.
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A case of rivaroxaban associated spontaneous hemothorax. TURK GOGUS KALP DAMAR CERRAHISI DERGISI-TURKISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2020; 27:118-120. [PMID: 32082838 DOI: 10.5606/tgkdc.dergisi.2019.15090] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/18/2017] [Indexed: 11/21/2022]
Abstract
New oral anticoagulants have emerged as an alternative for warfarin for thromboembolic prevention in patients with nonvalvular atrial fibrillation. Although new oral anticoagulants have better compliance and safety margin compared to warfarin, we must be cautious with their usage. In this article, we report a case of spontaneous hemothorax related to rivaroxaban treatment. According to our research, this is the first case of spontaneous hemothorax secondary to rivaroxaban treatment.
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Abstract
Hemothorax is a collection of blood in the pleural cavity usually from traumatic injury. Chest X-ray has historically been the imaging modality of choice upon arrival to the hospital. The sensitivity and specificity of point-of-care ultrasound, specifically through the Extended Focal Assessment with Sonography in Trauma (eFAST) protocol has been significant enough to warrant inclusion in most Level 1 trauma centers as an adjunct to radiographs.1,2 If the size or severity of a hemothorax warrants intervention, tube thoracostomy has been and still remains the treatment of choice. Most cases of hemothorax will resolve with tube thoracostomy. If residual blood remains within the pleural cavity after tube thoracostomy, it is then considered to be a retained hemothorax, with significant risks for developing late complications such as empyema and fibrothorax. Once late complications occur, morbidity and mortality increase dramatically and the only definitive treatment is surgery. In order to avoid surgery, research has been focused on removing a retained hemothorax before it progresses pathologically. The most promising therapy consists of fibrinolytics which are infused into the pleural space, disrupting the hemothorax, allowing for further drainage. While significant progress has been made, additional trials are needed to further define the dosing and pharmacokinetics of fibrinolytics in this setting. If medical therapy and early procedures fail to resolve the retained hemothorax, surgery is usually indicated. Surgery historically consisted solely of thoracotomy, but has been largely replaced in non-emergent situations by video-assisted thoracoscopy (VATS), a minimally invasive technique that shows considerable improvement in the patients' recovery and pain post-operatively. Should all prior attempts to resolve the hemothorax fail, then open thoracotomy may be indicated.
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Suzuki T, Kamata S, Sato N. A case of massive hemothorax associated with an intrathoracic bronchogenic cyst. Gen Thorac Cardiovasc Surg 2019; 68:396-398. [PMID: 31134529 DOI: 10.1007/s11748-019-01145-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Accepted: 05/20/2019] [Indexed: 11/30/2022]
Abstract
A 34-year-old man presented with sudden back pain and dyspnea. Chest X-ray showed left-sided massive pleural effusion. Chest computed tomography revealed an intrathoracic mass sized 9 cm. Hemorrhagic effusion was achieved with thoracic drainage on admission. Diagnostic video-assisted surgery was indicated, and an unexpected cyst with bloody content was observed. The cyst was bluntly dissected from the pleura and removed from the diaphragm. The patient discharged uneventfully and there were no significant postoperative complications including bleeding or pneumothorax. Pathological observation of the cyst revealed pseudostratified ciliated epithelial cells, mucinous glands, and cartilage compatible with the diagnostic criteria for a bronchogenic cyst. Malignant transformation was not observed. Common clinical presentations of bronchogenic cysts include pain, dyspnea, and cough. Although rare, the risk of hemorrhage from bronchogenic cysts and subsequent development of hemothorax should not be underestimated.
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Affiliation(s)
- Takaya Suzuki
- Department of Respiratory Medicine, Aomori Prefectural Center Hospital, 2-1-1, Higashitsukurimichi, Aomori, 030-0913, Japan.
| | - Satoshi Kamata
- Department of Respiratory Medicine, Aomori Prefectural Center Hospital, 2-1-1, Higashitsukurimichi, Aomori, 030-0913, Japan
| | - Nobuyuki Sato
- Department of Respiratory Medicine, Aomori Prefectural Center Hospital, 2-1-1, Higashitsukurimichi, Aomori, 030-0913, Japan
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Vincze B, Lázár I, Mezei P, Almássy S, Tóth I. [Spontaneous haemothorax - thoracic surgeon and intervention radiologist successful cooperation]. Magy Seb 2018; 71:155-162. [PMID: 30540512 DOI: 10.1556/1046.71.2018.4.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
The definition of spontaneous haemothorax is accumulation of blood within the pleural space without trauma or iatrogenic causes. A case of a 17-year-old male patient with a history of multiple abnormal arterial fistulas between systemic circulation and pulmonary circulation as a cause of bleeding is presented. An overview of the causes, the clinical features of haemothorax and the interventional radiological methods that can solve some causes of haemothorax are presented in connection of our case report.
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Affiliation(s)
- Balázs Vincze
- Mellkassebészeti Részleg, Mellkas- és Érsebészeti Osztály, Borsod-Abaúj-Zemplén Megyei Központi Kórház és Egyetemi Oktatókórház 3526, Miskolc, Szentpéteri kapu 72-76
| | - István Lázár
- Klinikai és Intervenciós Radiológiai Centrum, Intervenciós Radiológiai Osztály, Borsod-Abaúj-Zemplén Megyei Központi Kórház és Egyetemi Oktatókórház Miskolc
| | - Péter Mezei
- Mellkassebészeti Részleg, Mellkas- és Érsebészeti Osztály, Borsod-Abaúj-Zemplén Megyei Központi Kórház és Egyetemi Oktatókórház 3526, Miskolc, Szentpéteri kapu 72-76
| | - Sándor Almássy
- Mellkassebészeti Részleg, Mellkas- és Érsebészeti Osztály, Borsod-Abaúj-Zemplén Megyei Központi Kórház és Egyetemi Oktatókórház 3526, Miskolc, Szentpéteri kapu 72-76
| | - Imre Tóth
- Mellkassebészeti Részleg, Mellkas- és Érsebészeti Osztály, Borsod-Abaúj-Zemplén Megyei Központi Kórház és Egyetemi Oktatókórház 3526, Miskolc, Szentpéteri kapu 72-76
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Jeong SC, Kim JJ, Choi SY, Kim YH, Kim IS. Successful surgical treatment of massive spontaneous hemothorax due to intrathoracic secondary degeneration of a neurofibroma from mediastinal involvement of type 1 neurofibromatosis. J Thorac Dis 2018; 10:E203-E206. [PMID: 29707374 DOI: 10.21037/jtd.2018.01.170] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Massive hemothorax caused by a mediastinal mass is extremely rare. Herein, we present a case of successful surgery for a massive hemothorax caused by intrathoracic cystic hemorrhagic degeneration of a neurofibroma in a patient with neurofibromatosis type 1 (NF1). A 44-year-old man with NF1 was admitted to our emergency department for chest pain and dyspnea. Image studies revealed a massive hemothorax caused by a posterior mediastinal mass adjacent to the descending aorta and the spinal canal. The tumor, located at the fourth to the sixth thoracic vertebra, had diffusely and extensively infiltrated around proliferative vessels. It was successfully excised via thoracostomy after aortic cross-clamping preparation. Final pathology revealed that the tumor was cystic hemorrhagic degeneration of a neurofibroma from mediastinal involvement of NF1. The patient had an uneventful postoperative course and was discharged on the 10th postoperative day. There was no recurrence of tumor or hemothorax six months after surgery.
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Affiliation(s)
- Seong Cheol Jeong
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Gyeonggi-do 480-717, Korea
| | - Jae Jun Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Gyeonggi-do 480-717, Korea
| | - Si Young Choi
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Gyeonggi-do 480-717, Korea
| | - Yong Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Gyeonggi-do 480-717, Korea
| | - In Sub Kim
- Department of Thoracic and Cardiovascular Surgery, Uijeongbu St. Mary's Hospital, The Catholic University of Korea College of Medicine, Gyeonggi-do 480-717, Korea
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Sanna S, Bertolaccini L, Brandolini J, Argnani D, Mengozzi M, Pardolesi A, Solli P. Uniportal video-assisted thoracoscopic surgery in hemothorax. J Vis Surg 2017; 3:126. [PMID: 29078686 DOI: 10.21037/jovs.2017.08.06] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/04/2017] [Indexed: 11/06/2022]
Abstract
The management of hemothorax (spontaneous or, more often, due to thoracic trauma lesions), follows basic tenets well-respected by cardiothoracic surgeons. In most, a non-operative approach is adequate and safe, with a defined group of patients requiring only tube thoracostomy. Only a minority of patients need a surgical intervention due to retained hemothorax, persistent bleeding or incoming complications, as pleural empyema or entrapped lung. In the early 1990s, the rapid technological developments determined an increase of diagnostic and therapeutical indications for multiport video-assisted thoracoscopic surgery (VATS) as the gold standard therapy for retained and persistent hemothorax, allowing an earlier diagnosis, total clots removal and better tubes placement with less morbidity, reduced post-operative pain and shorter hospital stay. There is no consensus in the literature regarding the timing for draining hemothorax, but best results are obtained when the drainage is performed within the first 5 days after the onset. The traditional multi-port approach has evolved in the last years into an uniportal approach that mimics open surgical vantage points utilizing a non-rib-spreading single small incision. Currently, in experienced hands, this technique is used for diagnostic and therapeutic interventions as hemothorax evacuation as like as the more complex procedures, such as lobectomies or bronchial sleeve and vascular reconstructions.
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Affiliation(s)
- Stefano Sanna
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
| | - Luca Bertolaccini
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
| | - Jury Brandolini
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
| | - Desideria Argnani
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
| | - Marta Mengozzi
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
| | | | - Piergiorgio Solli
- Department of Thoracic Surgery, AUSL Romagna Teaching Hospital, Forlì, Italy
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