General Thoracic and Cardiovascular Surgery

, Volume 62, Issue 11, pp 696–699

Repeated embolization of intercostal arteries after blunt chest injury

Authors

    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Yukihiro Ikegami
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Tsuyoshi Suzuki
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Yasuhiko Tsukada
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Yoshinobu Abe
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Jiro Shimada
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
  • Choichiro Tase
    • Department of Emergency and Critical Care MedicineFukushima Medical University School of Medicine
Case Report

DOI: 10.1007/s11748-013-0269-6

Cite this article as:
Nemoto, C., Ikegami, Y., Suzuki, T. et al. Gen Thorac Cardiovasc Surg (2014) 62: 696. doi:10.1007/s11748-013-0269-6

Abstract

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.

Keywords

Blunt chest injuryEmbolizationHemothoraxPseudoaneurysm

Introduction

Conventionally, thoracotomy is used to control hemorrhage in the thoracic cavity. Blunt chest injury that involves multiple rib fractures can occasionally result in bleeding from the intercostal arteries. Embolization of intercostal arteries is a potential therapeutic option for arterial bleeding from the chest wall in such cases [1].

Case

A 67-year-old man (weight 61 kg, height 162 cm) suffered a fall from a height of approximately 2 m. He was transported to our hospital by ambulance. On arrival, his blood pressure was 103/70 mmHg, the heart rate was 84 beats per min (bpm), and percutaneous oxygen saturation (SpO2) was 95 % (6 L/min was delivered via an oxygen mask in the ambulance). An enhanced computed tomography (CT) scan showed right hemopneumothorax; multiple rib fractures (1st–8th right ribs and the 2nd and 3rd left ribs); and fractures in the right clavicle, right scapula, and the 3rd–6th spinous processes. A thoracostomy tube was immediately inserted and a hemorrhage involving 450 mL of blood was confirmed. We assumed that the hemorrhage was mainly from the chest wall because of the multiple rib fractures. Therefore, embolization was selected as the first-line therapy. Enhanced CT confirmed severe extravasation around the site of the broken rib near the 4th and 5th intercostal arteries; subsequently, we successfully embolized both these intercostal arteries using gelatin (spongel®) (Astellas Pharma Inc. Japan) to control the hemorrhage (Fig. 1). The amount of hemorrhage drained from the thoracic cavity gradually reduced; however, at day 5 of admission, it was observed to increase again. Enhanced CT revealed the formation of an intercostal artery pseudoaneurysm (Fig. 2). Digital subtraction angiography confirmed the presence of the pseudoaneurysm in the 5th intercostal artery; we therefore performed secondary embolization to treat this pseudoaneurysm (Fig. 3). Secondary embolization was performed using several coils (Cook, USA) Subsequently, the amount of hemorrhage being drained decreased remarkably and the drainage tube was removed 14 days after the patient’s admission. He was discharged from our emergency center 20 days after the initial injury. The time course of hemorrhage and the treatment are shown in Fig. 4.
https://static-content.springer.com/image/art%3A10.1007%2Fs11748-013-0269-6/MediaObjects/11748_2013_269_Fig1_HTML.jpg
Fig. 1

Severe extravasations were shown on distal side of 4th intercostal artery and around the sites of the broken ribs near the 4th and 5th intercostal arteries (a, b). To prevent the inflow of gelatin to the anterior spinal artery, the embolization was conducted from the distal side. The disappearance of the extravasation was confirmed (c, d)

https://static-content.springer.com/image/art%3A10.1007%2Fs11748-013-0269-6/MediaObjects/11748_2013_269_Fig2_HTML.jpg
Fig. 2

The arterial phase of enhanced computed tomography revealed pooling of the contrast agents around the right side of the vertebral body. Therefore, we strongly suspected the formation of a pseudoaneurysm

https://static-content.springer.com/image/art%3A10.1007%2Fs11748-013-0269-6/MediaObjects/11748_2013_269_Fig3_HTML.jpg
Fig. 3

A pseudoaneurysm in the 5th intercostal artery was confirmed by digital subtraction angiography at the same location as found on enhanced computed tomography (a). After the secondary embolization (b)

https://static-content.springer.com/image/art%3A10.1007%2Fs11748-013-0269-6/MediaObjects/11748_2013_269_Fig4_HTML.gif
Fig. 4

After the first embolization, the amount of hemorrhage decreased remarkably but did not stop. On the 5th day, the hemorrhage increased again; therefore, following computed tomography, we performed a second embolization. The hemorrhage then gradually decreased and eventually ceased. Subsequently, blood transfusions were no longer necessary. RCC-LR red cell concentrates–leukocytes reduced, FFP fresh-frozen plasma. One unit of RCC-LR or FFP equaled 200 mL of donated blood

Discussion

When a patient with injuries to the thoracic cavity is hemodynamically unstable due to massive hemorrhage, thoracotomy should be performed immediately. Thoracotomy is indicated when continuous hemorrhage of above 500–1000 mL from a drainage tube is confirmed [2]. However, this is a highly invasive procedure, and it is sometimes difficult to control the hemorrhage despite thoracotomy [3]. In this patient, although we initially planned an emergent thoracotomy to control the hemorrhage, the patient was hemodynamically stable and enhanced CT clearly demonstrated bleeding from the intercostal arteries. Therefore, embolization therapy was performed before thoracotomy for both the primary and secondary hemorrhage episodes.

Previously, a few studies have reported the effectiveness of embolization for controlling bleeding from intercostal arteries [1]. However, this technique is considered to be highly operator-dependent, with variable results. Thus, when patients become hemodynamically unstable or massive hemorrhage continues, an immediate switch to thoracotomy is advised.

Few reports have described embolization of a pseudoaneurysm in an intercostal artery resulting from pleural taps or stub wounds [4, 5] or internal causes such as neurofibromatosis [6, 7]; moreover, pseudoaneurysms after blunt chest injury are very rare [8]. The mechanism underlying the formation of such pseudoaneurysms remains unclear. However, since aneurysm rupture can be potentially fatal, with shock and sudden death [9], close follow-up is essential for patients with damaged intercostal arteries and rib fractures. In most cases, ruptures of such pseudoaneurysms cause hemothorax, so that if these patients who experienced severe blunt chest injury complain sudden dyspnea, chest pain, or back pain, they should consult emergency center immediately.

In the present case, it is possible that performing primary embolization of the intercostal artery using coils on the proximal side may have avoided the formation of the pseudoaneurysm. A previous study has reported spinal cord injury after embolization [10]. Therefore, for the secondary embolization, considering the risks of embolizing the anterior spinal artery, we used coils instead of gelatin and selectively embolized the 5th intercostal artery without any complications.

Conclusion

The causes of pseudoaneurysm formation following damage to the intercostal arteries remain unclear; however, patients with damaged intercostal arteries and rib fractures should be carefully monitored for hemorrhagic complications. Intercostal artery embolization is a valuable therapeutic option for controlling hemorrhage arising from the chest wall.

Copyright information

© The Japanese Association for Thoracic Surgery 2013