Covering the intercostal artery branching of the Adamkiewicz artery during endovascular aortic repair increases the risk of spinal cord ischemia

Objectives

This study aimed to determine the relationship between covering the intercostal artery branching of the Adamkiewicz artery (ICA-AKA) and spinal cord ischemia (SCI) during thoracic endovascular aortic repair (TEVAR).

Methods

Patients who underwent TEVAR from 2008 to 2022 were enrolled. Stent grafts covered the ICA-AKA in 108 patients (covered AKA group) and stent grafts didn't cover the ICA-AKA in 114 patients (uncovered AKA group). The characteristics of 58 patients from each group were matched based on propensity scores.

Results

No significant differences in SCI rates were detected between the covered AKA (10%; 11/108) and uncovered AKA (3.5%; 4/114) groups (P = .061). Shaggy aorta (odds ratio [OR], 5.16; 95% confidence interval [CI], 1.74-15.3, P = .003), iliac artery access (OR, 6.81; 95% CI, 2.22-20.9, P = .001), and procedural time (OR, 1.01; 95% CI, 1.00-1.02, P = .003) were risk factors for SCI in the entire cohort. Although covering the ICA-AKA (OR, 2.60; 95% CI, 0.86-7.88, P = .058) was not a significant risk factor, shaggy aorta (OR, 8.15; 95% CI, 2.07-32.1, P = .003), iliac artery access (OR, 9.09; 95% CI, 2.22-37.2, P = .002), and procedural time (OR, 1.01; 95% CI, 1.01-1.02, P = .008) were risk factors for SCI in the covered AKA group. No significant risk factors were detected in the uncovered AKA group.

Conclusions

Covering the ICA-AKA was not an independent risk for SCI in TEVAR. However, covering the ICA-AKA was indirectly associated with the risk of SCI in patients with shaggy aorta, iliac access, and procedural time.

A case of bleeding shock induced by injury of the intercostal artery following percutaneous nephrolithotripsy

Introduction

The risk of postoperative bleeding complications should be concerned to perform percutaneous nephrolithotripsy. Most of the vascular injuries occurred at the peripheral renal artery in the previous reports. We experienced a case of bleeding shock induced by the injury of the intercostal artery in the abdominal wall following percutaneous nephrolithotripsy.

Case presentation

A 56-year-old woman had been in the bleeding shock status on the 2nd day after percutaneous nephrolithotoripsy. Emergently, contrast-enhanced computed tomography was performed and extravasation of contrast agents was seen in the abdominal wall. Injuries of the intercostal artery were identified in the angiography and controlled by transcatheter arterial embolization.

Conclusion

The intercostal arteries could be injured in the anterolateral zone of the abdominal wall over the end of the ribs. Contrast-enhanced computed tomography was useful to detect the bleeding point. Transcatheter arterial embolization was an effective and safe method to control bleedings from them.

The result of prospective evaluation of 3-dimensional printing-aided extensive thoracoabdominal aorta repair

OBJECTIVES

Paraplegia is a distressing complication after open thoracoabdominal aortic aneurysm (TAAA) repair, and revascularization of T8-L2-level segmental arteries is considered pivotal to prevent paraplegia. We employed 3-dimensional (3D) printing to efficiently revascularize segmental/visceral arteries and prospectively evaluated its safety and efficacy.

METHODS

From January 1, 2020, to June 30, 2022, we prospectively enrolled patients of extent I, II, or III TAAA repair. Guidance models were 3D-printed based on preoperative computed tomography, and multibranched aortic grafts were manually constructed upon this model before surgery. The composite outcome of operative mortality, permanent stroke, and permanent spinal cord deficit (SCD) was compared with the historical control group (n = 77, in 2015-2020), subjected to similar TAAA repair without 3D printing.

RESULTS

A total of 38 patients (58.6 ± 13.2 years) underwent open TAAA repair with the aid of 3D printing. Extent I, II, and III repairs were performed in 14 (36.8%), 17 (44.7%), and 7 (18.4%), respectively. Concomitant arch repair and bi-iliac reconstruction were performed in 7 (18.4%) and 6 patients (15.8%), respectively. Mean pump time was 107.7 ± 55.5 minutes. Operative mortality, permanent stroke, and permanent SCD each occurred in 1 patient (2.6%), and the incidence of the composite outcome was 7.9% (3/38). In the control group, mean pump time was 166.0 ± 83.9 minutes, significantly longer than the 3D-printing group (P < .001), and operative mortality, permanent stroke, permanent SCD, and the composite outcome occurred in 7 (9.1%), 9 (11.7%), 8 (10.4%), and 19 (24.7%), respectively.

CONCLUSIONS

Open repairs of extensive TAAA with 3D printing showed favorable safety and efficacy, which need further validation by larger studies.

Intercostal Artery Laceration after Adrenal Mass Cryoablation

We present a case of a 69-year-old male with profound Cushing's syndrome and hypercortisolemia secondary to a cortisol-secreting adrenocortical carcinoma. Patient was not a surgical candidate and subsequently underwent a successful posterior approach tumor cryoablation. The procedure was complicated by a T11 intercostal artery injury and hemothorax. The detection of the culprit injury was almost immediate and the quick response time, and treatment of the injury via an intercostal artery embolization was critical to limiting the patient's morbidity and mortality. This case discusses the technical challenges of a posterior-approach ablation, the pitfalls to avoid, and the importance of attaining rapid hemostasis.

Intercostal artery's access for type II endoleak embolization

Endoleaks represent a main issue of endovascular approach of thoracic aorta diseases and their treatment continue to be challenging. According to some authors, type II endoleaks sustained by intercostal arteries should not be treated because of the technical difficulties. However, the persistence of a pressurized aneurysmal may confer an ongoing risk of enlargement and/or aortic rupture. We describe the successful treatment of type II endoleak in two patients with an intercostal artery's access. In both cases, the endoleak was discovered during follow-up and was treated with its direct coil embolization under local anesthesia.

Delayed Tension Hemothorax With Nondisplaced Rib Fractures After Blunt Thoracic Trauma

Blunt thoracic trauma often causes rib fractures, hemothorax, and pneumothorax. Although there is no established definition regarding the duration and management of delayed hemothorax, it commonly occurs in a few days and exhibits at least one displaced rib fracture. Moreover, delayed hemothorax rarely develops tension hemothorax. A 58-year-old male who had a motorcycle accident received conservative treatment from his orthopedic doctor. He felt a sudden severe chest pain 19 days after the accident. Contrast-enhanced computed tomography (CT) of the chest revealed multiple left-sided rib fractures without displacement, left pleural effusion, and extravasation near the intercostal space of the seventh rib fracture. After transfer to our hospital and a plain CT scan, which showed a more mediastinal shift toward the right, his condition deteriorated with cardiorespiratory embarrassment, such as restlessness, hypotension, and neck vein distention. We diagnosed him with obstructive shock due to tension hemothorax. Immediate chest drainage ameliorated restlessness and elevated blood pressure. Here, we report an extremely rare and atypical case of delayed tension hemothorax after blunt thoracic trauma without displaced rib fractures.

Endovascular Preservation of Segmental Arteries During Treatment of Thoracoabdominal Aortic Aneurysm with Fenestrated/Branched Stent-Grafts: Feasibility and outcome

OBJECTIVES

To evaluate technical success, feasibility, and outcomes of endovascular preservation of segmental arteries (SAs) during fenestrated /branched endovascular aortic repair (F/B-EVAR).

METHODS

A multicenter, retrospective study was conducted on consecutive patients treated with F/B-EVAR and a branch or fenestration for SA preservation. Eleven patients (median age 57, range 45-73; 7 men) were included.

RESULTS

Twelve SAs were preserved. Stent-grafts were custom-made with fenestrations, branches, or a combination of both in 1, 2, and 5 patients. A t-branch was used in 2 patients and physician-modified thoracic stent-graft with a branch was used in 1 patient. Eight branches and 4 fenestrations were used for the preservation of 12 SAs. Four fenestrations and 1 branch for SAs were not bridged and were left for the perfusion of the corresponding SAs. Technical success was achieved in 10/11 (91%) patients. No early mortality occurred. Early morbidities included renal insufficiency without dialysis in 1 patient and partially delayed paraplegia in 1 patient. Pre-discharge computed tomography angiography (CTA) showed patency of all SAs. No early aortic-related re-interventions were required. The median follow-up was 30 (range 10-88) months. Late death occurred in 1 patient. Two SAs occluded in 1 patient with two un-stented fenestrations at 1-year follow-up CTA. This patient did not develop spinal cord ischemia (SCI). Other SAs remained patent during follow-up. One patient with type IIIc endoleak was treated by relining of bridging stents.

CONCLUSION

Endovascular preservation of SAs with F/B-EVAR for thoracoabdominal aortic aneurysm is feasible and safe in selected patients and may add to preventive measures for SCI.

[Diagnostic capabilities of spinal MR angiography and spinal MR tractography in a patient with motor neuron disease]

Motor neuron diseases (MND) include two main forms - amyotrophic lateral sclerosis (ALS) and spinal muscular atrophy (SMA). A certain part of these diseases is hereditary, while etiology of sporadic cases remains unknown. Both entities are known to develop because of motoneurons damage. Difference between them lies in the state of the descending pyramidal pathways. The pyramidal pathways in SMA are intact, as brain pyramidal neurons are not affected, thus pathology of SMA is restricted to anterior horns of spinal cord. Meanwhile, most forms of ALS arise due to loss of both cerebral and spinal motoneurons, which, in addition to anterior horn lesion, leads to pyramidal descending pathways damage either in brain or in spinal cord. While pathological distinction between these two entities is clear and definite, the clinical difference remains obscure. We present the case of 41-year old patient with MND, in whom spinal MR tractography has revealed lateral columns to be intact that proves the utility of spinal MR tractography in differential diagnosis between ALS and SMA. Given that ischemic diseases of the spinal cord often occur with a clinical picture of MND, we also examined this patient using spinal MRI angiography, revealing a pronounced narrowing and tortuosity of the spinal arteries, complicated by occlusion of the right twelve intercostal artery.

Aortic Intramural Hematoma due to Intercostal Artery Aneurysms

BackgroundIntercostal artery aneurysms (ICA) are rare vascular disease. A rupture of ICA is a possible mechanism of intramural aortic hematoma (IH). We report a case with IH and ICAs without clear etiology. Case presentation: A 64-year-old man was admitted to our emergency room with a sudden onset of acute diffused abdominal and chest pain, radiating to the back. Without previous traumatic insult, a computed tomographic angiography scan (CTA) revealed an IH beginning inferior to the left subclavian artery extending to the level of the celiac trunk. Follow-up CTA demonstrated a stable maximal IH thickness diameter of 11 mm, maximal aortic diameter of 40 mm, a new left hemorrhagic pleural effusion, and a focal contrast enhancement at T9 level. Due to these findings, thoracic endovascular aortic repair (TEVAR) was performed. During follow up, T9 focal enhancement continues to grow and an additional one developed. Selective angiography was performed demonstrating a connection to the costal artery and the aortic lumen, confirming ICA. Successful embolization with micro coils was performed. During follow up, additional 2 ICAs developed and treated with embolization. CTA three months later showed a complete resolution of the IH and obliteration of all treated ICAs. Infectious, inflammatory and connective tissue disease investigations were undertaken without a clear etiology. Conclusions: This is a case of IH and ICAs, in the absence of a clear etiology which were successfully treated by endovascular procedures TEVAR and coil embolization. It is not clear whether the hematoma was the source of the ICA or the other way round. Lack of ICAs in the initial CTA might be due to the pressure exerted by the hematoma or that they were too small to be detected but continued to grow on follow up. Rupture of these micro-aneurysms is a possible mechanism of intramural aortic hematoma.

Spontaneous intercostal artery bleeding in a patient with alcohol-induced liver cirrhosis

Spontaneous intercostal artery bleeding is a rare disease seen in cirrhosis and can present with hemodynamically significant blood loss anemia, hypotension, and shock. Transcatheter arterial embolization is an effective treatment for severe cases.

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.

Right Scapular Swelling Revealed to Be a Spontaneous Lateral Chest Wall Hematoma: An Intriguing Case Report

Chest wall hematoma commonly occurs as a result of blunt thoracic trauma. We report an intriguing case of spontaneous lateral chest wall hematoma that presented with right scapular swelling and tenderness on palpation having hemodynamic instability without any prior history of recent trauma or surgery. Chest x-ray and ultrasound were carried out at the time of admission to evaluate the swelling, followed by contrast-enhanced CT (CECT) of the chest to identify and localize the bleeder. Transcatheter arterial embolization (TAE) of the intercostal artery was performed to treat the condition successfully. CECT is found to be vitally important in localizing bleeders. Other possible options include exploratory thoracotomy, video-assisted thoracic surgery (VATS) exploration, and angiography.

[Free sensate intercostal artery perforator flap for hand soft tissue reconstruction]

Objective

To investigate the effectiveness of free sensate intercostal artery perforator flap for the hand soft tissue reconstruction.

Methods

Between March 2010 and September 2015, 19 cases of hand soft tissue defect were repaired with free sensate intercostal artery perforator flap, including 16 males and 3 females, aged from 18 to 53 years, with an average of 35.2 years. The defect was located in the dorsum of the hand in 15 cases and in the palm in 4 cases. The causes of injury were traffic accident injury in 8 cases, hot crush injury in 5 cases, strangulation injury in 4 cases, and avulsion injury in 2 cases. All of them were full-thickness skin and soft tissue defects of hand with exposure of phalanges, tendons, blood vessels, and nerves. The size of defect was 10.0 cm×7.0 cm to 17.0 cm×8.0 cm. There were 12 cases of emergency operation and 7 cases of selective operation. The thickness of flap was 10-25 mm, and the size of the flap ranged from 10.0 cm×7.5 cm to 17.0 cm×8.0 cm. The vascular pedicle of the flap was anastomosed with the snuff nest branch of the radial artery (12 cases), the main radial artery (7 cases), and there accompanying vein, and the intercostal nerve cutaneous branch of the flap was anastomosed with the lateral cutaneous nerve of the forearm. The donor site was closed directly (14 cases) or repaired with medium thickness skin graft (5 cases).

Results

All of the flaps and skin grafts survived; the wounds in the donor and recipient sites healed by first intention. All 19 patients were followed up 10- 18 months, with an average of 12.7 months. After operation, the appearance and function of the hand recovered well, and there was no flap bloated. The two-point discrimination of the flap was 7-11 mm, with an average of 8.8 mm. Only linear scars left in the patients with direct closure of the donor site. The sensory function of the donor site was not significantly affected, and the hand function recovered satisfactorily.

Conclusion

Free sensate intercostal artery perforator flap is a valuable and reliable technique for the hand soft tissue defect.

Incidental haemothorax after sublobar resection: did staple line scratch chest wall?

We herein report a case of life-threatening haemothorax that occurred 40 days after pulmonary segmentectomy in a 60-year-old man. The patient uneventfully underwent resection of the apical and posterior segments of the right upper lobe by video-assisted thoracic surgery for early-stage lung cancer. An emergency operation of haemostat for active bleeding from the intercostal artery was successful via a right thoracotomy. The bleeding point was in the vicinity of the staple line dividing the intersegmental plane. This case reveals that scratch by staples can cause haemothorax through incidental injury of the intercostal artery.

Tissue classification in intercostal and paravertebral ultrasound using spectral analysis of radiofrequency backscatter

Paravertebral and intercostal nerve blocks have experienced a resurgence in popularity. Ultrasound has become the gold standard for visualization of the needle during injection of the analgesic, but the intercostal artery and vein can be difficult to visualize. We investigated the use of spectral analysis of raw radiofrequency (RF) ultrasound signals for identification of the intercostal vessels and six other tissue types in the intercostal and paravertebral spaces. Features derived from the one-dimensional spectrum, two-dimensional spectrum, and cepstrum were used to train four different machine learning algorithms. In addition, the use of the average normalized spectrum as the feature set was compared with the derived feature set. Compared to a support vector machine (SVM) (74.2%), an artificial neural network (ANN) (68.2%), and multinomial analysis (64.1%), a random forest (84.9%) resulted in the most accurate classification. The accuracy using a random forest trained with the first 15 principal components of the average normalized spectrum was 87.0%. These results demonstrate that using a machine learning algorithm with spectral analysis of raw RF ultrasound signals has the potential to provide tissue characterization in intercostal and paravertebral ultrasound.

Complex Endovascular Aortic Repair With a Branched Endograft to Revascularize 5 Renovisceral Vessels and an Intercostal Artery in a Marfan Patient

Purpose: To report a case of thoracoabdominal aortic aneurysm (TAAA) repair treated with a multibranched stent-graft including a prophylactic branch for a large intercostal artery in a Marfan patient at risk for spinal cord ischemia (SCI). Case Report: A 43-year-old man with Marfan syndrome presented with a type IV thoracoabdominal aortic aneurysm (TAAA) and history of multiple previous cardiac and aortic operations over the past 28 years. The maximum diameter of the aneurysm was 60 mm. The patient had 2 right renal arteries and 2 reimplanted segmental arteries (1 occluded). With the goal of preserving both right renal arteries and the large intercostal artery, a 6-branch, custom-made stent-graft was planned and manufactured. Bilateral femoral and right brachial artery access was used. The intercostal artery was catheterized and connected to the retrograde branch from a femoral access. Final angiography and predischarge computed tomography angiography (CTA) showed unimpeded flow to all 6 target vessels. The patient was discharged on postoperative day 10 without clinical signs of SCI. Six-month follow-up CTA demonstrated exclusion of the TAAA and patency of all 6 branches. Conclusion: Multibranched endovascular aortic repair with a branch to a large intercostal artery was technically feasible and clinically successful.

[Occurrence of a lethal outcome due to iatrogenic damage of an intercostal vessel during a pleural puncture procedure]

A rare case of a lethal outcome due to iatrogenic damage to the intercostal vessel, a collateral branch of the posterior intercostal artery, is described. The little-known features of the topography of this vessel (location on the upper edge of the underlying rib), which requires further study in the context of variable anatomy, are given. The risks associated with deviations from the traditionally recommended sites of pleural puncture (below the eighth intercostal space to the scapular line) are substantiated. An analysis of the characteristics of bleeding arising from the intercostal vessels (from two ends, under high pressure, etc.) is given, which implies the extreme importance of a timely diagnosis. Differing points of view on the legal assessment of malpractice when care is delivered by a series of doctors, and the legal necessity of determining the 'point of no return' (the latest moment after the onset of bleeding, in which medical aid can still prevent an unfavorable outcome), are considered. An opinion is expressed on the need for the active participation (initiative) of an expert in the provision of expertise.

[Application of vascular augmentation of an extra-long latissimus dorsi flap through an intercostal artery in limb wound repair]

Objective

To explore the clinical application of vascular augmentation of an extra-long latissimus dorsi flap through an intercostal artery in limb wound repair.

Methods

Between January 2016 and December 2017, 5 patients with limb wounds were treated with the extra-long latissimus dorsi flaps. The vascular augmentation of the extra-long latissimus dorsi flap through the intercostal artery was applied during the operation. There were 4 males and 1 female, with an average age of 45.8 years (range, 43-59 years). The time from post-traumatic admission to flap repair was 7-25 days (mean, 12.3 days). The causes of injury included machine injury in 2 cases, traffic accident in 2 cases, and roller crush injury in 1 case. The wounds were located at the anterior of upper limb in 3 cases, the posterior of upper limb in 1 case, and the posterior of leg in 1 case. The size of wounds ranged from 26 cm×8 cm to 38 cm×10 cm. The size of the latissimus dorsi flap ranged from 36 cm×6 cm to 43 cm×7 cm. The size of the muscle flap ranged from 36 cm×10 cm to 43 cm×15 cm. The donor sites were closed directly.

Results

The distal flap necrosis occurred in 1 case and healed after symptomatically treatment. The other flaps survived completely. The wounds and incisions at donor sites healed by first intention. All patients were followed up 8-18 months with an average of 14.9 months. At last follow-up, the flaps had satisfactory appearances, soft textures, and function of sweating.

Conclusion

Application of vascular augmentation of the extra-long latissimus dorsi flap through the intercostal artery in repair of limb wound can reduce the incidence of distal flap necrosis and achieve satisfactory effectiveness.

Massive hemothorax after computed tomography-guided lung tumor biopsy: An unusual but disastrous complication

Intercostal artery injury during transthoracic puncture is rare but is accompanied by high rates of morbidity and mortality. We report a case with metachronous double primary esophageal cancers and development of multiple lung nodules. Tissue proof for the lung nodules is required to guide the following treatment protocol. Our patient died soon after computed tomography‐guided lung tumor biopsy was performed, as a result of procedure‐related massive and uncontrolled hemothorax. The cause is likely intercostal artery injury related to the transthoracic puncture. After review of our case and the wide variation in intercostal artery courses, we identify several considerations that should be included in procedural planning to further decrease the risk of intercostal artery injury during transthoracic puncture, including avoiding choosing target lesions at the posterior lung, keeping the puncture needle as close to the superior rib margin as possible, and checking the density of new pleural fluid. In addition, it is important to inform clinical doctors when the risk of periprocedural vascular injury is high.

Physician-performed ultrasound can accurately screen for a vulnerable intercostal artery prior to chest drainage procedures

BACKGROUND AND OBJECTIVE

Laceration of the intercostal artery during pleural procedures is a rare but serious complication. This study evaluates the utility of thoracic ultrasound (US) to screen for a vulnerable vessel compared with the gold standard computed tomography (CT).

METHODS

Before undergoing contrast-enhanced CT chest, thoracic US was performed on 50 patients with a high-end and portable machine, and an attempt made to visualize the vessel at three positions across the back to the axilla. These positions were labelled with radio-opaque fiducial markers. On both US and CT images, the location of the vessel at each position, relative to the overlying rib, was calculated and compared.

RESULTS

The vessel was unshielded by a rib according to CT in 114 of the 133 positions. The sensitivity, specificity and negative predictive value of portable US to image the vessel, when it was within the intercostal space on CT, was 0.86, 0.30 and 0.27 respectively. The performance of a high-end machine was not significantly different. The median time required for a pulmonologist to locate the vessel was 42 s and 18 s for the portable and high-end US respectively.

CONCLUSIONS

US can be used to screen for a vulnerable vessel prior to pleural procedures, in a time amenable to use in clinical practice. Further, it is achievable by a pulmonologist using a portable US machine. If thoracentesis or chest tube insertion is being performed on a patient at increased risk of bleeding, screening for a vulnerable vessel with US prior to beginning the procedure is recommended.