Repeated embolization of intercostal arteries after blunt chest injury
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- Nemoto, C., Ikegami, Y., Suzuki, T. et al. Gen Thorac Cardiovasc Surg (2014) 62: 696. doi:10.1007/s11748-013-0269-6
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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.
KeywordsBlunt chest injuryEmbolizationHemothoraxPseudoaneurysm
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 .
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 . However, this is a highly invasive procedure, and it is sometimes difficult to control the hemorrhage despite thoracotomy . 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 . 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 . The mechanism underlying the formation of such pseudoaneurysms remains unclear. However, since aneurysm rupture can be potentially fatal, with shock and sudden death , 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 . 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.
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.