Intercostal artery pseudoaneurysm due to stab wound

Transcription

1 Intercostal artery pseudoaneurysm due to stab wound Seishiro Sekino, MD, a Hisato Takagi, MD, PhD, a Hajime Kubota, MD, PhD, b Takayoshi Kato, MD, a Yukihiro Matsuno, MD, PhD, a and Takuya Umemoto, MD, PhD, a Shizuoka, Japan Intercostal artery pseudoaneurysm is extremely rare, and only six cases have been reported in the English literature. We describe a case of intercostal artery pseudoaneurysm due to a stab wound, review the literature, and discuss therapeutic modalities. Intercostal artery pseudoaneurysm is at risk for early rupture, and diagnosis before rupture is mandatory. Although embolization is considered to be a feasible therapeutic method, we would emphasize the significance of the anatomic features of the intercostal arteries: multiple blood supplies into the pseudoaneurysm, such as the anterior and posterior intercostal arteries, and musculophrenic artery. (J Vasc Surg 2005;42:352-6.) Intercostal artery pseudoaneurysm is extremely rare, and only six cases have been reported in the English literature. 1-6 We describe a case of intercostal artery pseudoaneurysm due to a stab wound, review the literature, and discuss therapeutic modalities. CASE REPORT A 36-year-old man attempted suicide by stabbing his left chest with a knife. Physical examinations showed a cm stab wound on the midclavicular line and in the sixth intercostal space. The wound was assumed to be 5 cm deep by examination with a probe and was assumed to reach into the thoracic cavity. Chest x-ray photography showed left pleural effusion without pneumothorax. Computed tomography (CT) scans with contrast medium showed a 2 3-cm nonenhanced mass, within which the intercostal artery was enhanced, in the chest wall (Fig 1, A). The mass compressed the lateral segment of the liver and was suspected to be a hematoma. Thoracocentesis was performed, and 2000 ml of bloody fluid was drained. The patient recovered from hemorrhagic shock with blood transfusion, and little blood was drained after the thoracocentesis. On the second hospital day, the thoracostomy tube was removed because the amount of the drained fluid was only 70 ml/d. On the ninth hospital day, rethoracocentesis and blood transfusion were performed because of increased hemothorax on chest radiographs and the progression of anemia. Chest CT scans with contrast medium showed an enhanced mass in the intercostal space (Fig 1, B). Doppler ultrasound scans showed blood flow within the homogeneous low-echoic lesion. Arteriography of the musculophrenic artery via the internal thoracic artery showed a pseudoaneurysm of the sixth intercostal artery (Fig 2, A). The patient underwent embolization of the sixth anterior intercostal artery just branched from the musculophrenic artery via the internal thoracic artery with a microcatheter (3F Fastracker-325 Infusion Catheter; Boston Scientific, Cork, From the Departments of Cardiovascular Surgery a and Radiology, b Shizuoka Medical Center. Competition of interest: none. Reprint requests: Hisato Takagi, MD, PhD, Department of Cardiovascular Surgery, Shizuoka Medical Center, Nagasawa, Shimizu-cho, Sunto-gun, Shizuoka , Japan ( kfgth973@ybb.ne.jp) /$30.00 Copyright 2005 by The Society for Vascular Surgery. doi: /j.jvs Ireland) and microcoils (0.46-mm Tornado Embolization Microcoil Platinum; Cook, Bloomington, Ind). Postembolization arteriography of the musculophrenic artery via the internal thoracic artery showed no enhancement of the pseudoaneurysm (Fig 2, B). Arteriography of the sixth posterior intercostal artery via the descending thoracic aorta showed interruption of the artery just proximal to the pseudoaneurysm (Fig 2, C). Doppler ultrasound scans showed a little flow within the pseudoaneurysm. Two weeks after the embolization, however, Doppler ultrasound scans showed increased flow within the pseudoaneurysm, and chest CT scans with contrast medium revealed the enhanced pseudoaneurysm. Arteriography of both the musculophrenic artery via the internal thoracic artery (Fig 3, A) and the sixth posterior intercostal artery via the descending thoracic aorta (Fig 3, B) showed no enhancement of the pseudoaneurysm. Arteriography of the eighth posterior intercostal artery via the descending thoracic aorta showed the musculophrenic artery feeding the pseudoaneurysm (Fig 3, C). We embolized the sixth posterior intercostal artery and the musculophrenic artery via the seventh and eighth posterior intercostal arteries with the microcatheter and microcoils in the same way as the first embolization. Chest CT scans with contrast medium showed the nonenhanced pseudoaneurysm two weeks after the re-embolization, and Doppler ultrasound scans confirmed no flow within the pseudoaneurysm two months after the intervention. DISCUSSION Intercostal artery pseudoaneurysm has been seldom reported, and there have been only six cases in the English literature. 1-6 The clinical findings of these cases are summarized in the Table. Six patients were men, and one was a woman; they ranged in age from 31 to 85 years (mean, 59 years). Symptoms were hemothorax in five patients and a pulsatile mass in one. Causes of the pseudoaneurysm were surgical procedures approached by way of the intercostal space in five patients and trauma in two patients, including the present case. A stab wound has not been described as the cause except for in our patient. Most patients experienced hemothorax and needed blood transfusions. In patients with massive hemothorax after chest trauma or surgical procedures via the intercostal space, an intercostal artery pseudoaneurysm should be sus-

2 JOURNAL OF VASCULAR SURGERY Volume 42, Number 2 Sekino et al 353 Fig 1. A, Computed tomographic (CT) scans with contrast medium showed a 2 3-cm nonenhanced mass, within which the intercostal artery was enhanced, in the chest wall. B, Chest CT scans with contrast medium showed the enhanced mass in the intercostal space. pected. In three cases, including the present one, delayed hemothorax due to suspicious rupture of an unnoticed intercostal artery pseudoaneurysm occurred two to four weeks after trauma or surgical procedures. Intercostal artery pseudoaneurysm may be at risk for early rupture after the formation, and diagnosis before rupture is important. Regarding the treatment of intercostal artery pseudoaneurysms, two patients underwent surgical therapy, one received conservative management, and four received endovascular intervention: embolization in three patients and cover stent grafting in one. Recently, embolization has been considered to be the first therapeutic method of ruptured pseudoaneurysm. 3 In hepatic arterial pseudoaneurysms due to percutaneous interventions or peripancreatic pseudoaneurysms associated with pancreatitis, the success rates of embolization are more than 75% Although we also performed coil embolization for the intercostal artery pseudoaneurysm, recurrent blood flow within the pseudoaneurysm was shown two weeks later. Aoki et al 6 have performed aneurysmectomy after unsuccessful embolization of a ruptured intercostal artery pseudoaneurysm. Several authors 3,4 have reported endovascular interventions except for coil embolization. Yamakado et al 3 have reported that embolization with n-butyl cyanoacrylate is a feasible and useful treatment for ruptured pseudoaneurysms, including an intercostal artery pseudoaneurysm, difficult to control by coil embolization alone. Callaway et al 4 have used a covered coronary stent in the internal thoracic artery for an intercostal artery pseudoaneurysm. We failed to interrupt the blood supply into the pseudoaneurysm completely for the first time because of insufficient knowledge of anatomic features of the intercostal arteries. The first arteriograph showed that the pseudoaneurysm was fed not by the sixth posterior intercostal artery but by the sixth anterior intercostal artery, and embolization of the only sixth anterior intercostal artery was performed. In the second arteriograph, however, it was revealed that the musculophrenic artery, into which the seventh and eighth posterior intercostal arteries flowed, fed the pseudoaneurysm. The internal thoracic artery divides into the musculophrenic and superior epigastric arteries at the level of the sixth intercostal space, and the musculophrenic artery gives off anterior intercostal arteries to the lower intercostal spaces (the sixth to ninth intercostal spaces in this case; Fig 3, D). In case of endovascular intervention for an intercostal artery pseudoaneurysm, we should note multiple blood supplies into the pseudoaneurysm, such as the anterior and posterior intercostal arteries and musculophrenic artery. Type II endoleaks after endovascular repair of abdominal aortic aneurysms and congenital arteriovenous malformations are fed by multiple feeding arteries, and the intercostal artery pseudoaneurysm in this case was also fed by the anterior and posterior intercostal arteries and musculophrenic artery. Initial attempts at treating these lesions include coiling of the feeding artery. However, because of continued perfusion from other feeding vessels that may be small and sometimes invisible at the time of the initial coiling, treatment failures have been often encountered. For this reason, the current recommendation for treatment of these conditions has evolved to embolizing the nidus, or the aneurysm itself, as opposed to the feeding artery. 15 In our case, embolization of the pseudoaneurysm itself may have resulted in initial success. The presence of multiple vessels feeding the endoleak is associated with a significantly higher failure rate after transarterial embolization, and in these cases, the translumbar approach may be a more effective treatment. However, in type II endoleaks with a small nidus, it may be difficult to enter the nidus

3 354 Sekino et al JOURNAL OF VASCULAR SURGERY August 2005 Fig 2. A, Arteriography of the musculophrenic artery via the internal thoracic artery showed a pseudoaneurysm of the sixth intercostal artery. B, Postembolization arteriography of the musculophrenic artery via the internal thoracic artery showed no enhancement of the pseudoaneurysm. C, Arteriography of the sixth posterior intercostal artery via the descending thoracic aorta showed interruption of the artery just proximal to the pseudoaneurysm.

4 JOURNAL OF VASCULAR SURGERY Volume 42, Number 2 Sekino et al 355 Fig 3. Arteriography of both the musculophrenic artery via the internal thoracic artery (A) and the sixth posterior intercostal artery via the descending thoracic aorta (B) showed no enhancement of the pseudoaneurysm. C, Arteriography of the eighth posterior intercostal artery via the descending thoracic aorta showed the musculophrenic artery feeding the pseudoaneurysm. D, The internal thoracic artery divides into the musculophrenic and superior epigastric arteries at the level of the sixth intercostal space, and the musculophrenic artery gives off anterior intercostal arteries to the lower intercostal spaces (the sixth to ninth intercostal spaces in this case). MPA, Musculophrenic artery; ICA, intercostal artery; ITA, internal thoracic artery; SEA, superior epigastric artery; P, pseudoaneurysm.

5 356 Sekino et al JOURNAL OF VASCULAR SURGERY August 2005 Reported cases of intercostal artery pseudoaneurysm Study Age (y) Sex Symptom Cause Treatment Casas et al 1 85 M Hemothorax Percutaneous biliary procedure Embolization Atherton and Morgan 2 31 F Hemothorax Thoracoscopic sympathectomy Oversewing Yamakado et al 3 62 M Hemothorax Percutaneous microwave Embolization coagulation therapy for hepatocellular carcinoma Callaway et al 4 69 M Pulsatile mass Sternotomy wiring Covered stent grafting Bluebond-Langner et al 5 59 M... Retroperitoneal laparoscopic Conservative management nephrectomy Aoki et al 6 68 M Hemothorax Blunt trauma Aneurysmectomy plus proximal ligation (unsuccessful embolization) This case 36 M Hemothorax Stab wound Embolization through a translumbar approach, and transarterial embolization, which allows easier access to such endoleaks, is preferred. 15 In our patient, we did not perform direct percutaneous access because the pseudoaneurysm was considered too small to be punctured precisely. Intercostal artery pseudoaneurysm is rare and at risk for early rupture, and diagnosis before rupture is mandatory. Although embolization is considered to be a feasible therapeutic method, we would emphasize the significance of the anatomic features of the intercostal artery. REFERENCES 1. Casas JD, Perendreu J, Gallart A, Muchart J. Intercostal artery pseudoaneurysm after a percutaneous biliary procedure: diagnosis with CT and treatment with transarterial embolization. J Comput Assist Tomogr 1997;21: Atherton WG, Morgan WE. False aneurysm of an intercostal artery after thoracoscopic sympathectomy. Ann R Coll Surg Engl 1997;79: Yamakado K, Nakatsuka A, Tanaka N, Takano K, Matsumura K, Takeda K. Transcatheter arterial embolization of ruptured pseudoaneurysms with coils and n-butyl cyanoacrylate. J Vasc Interv Radiol 2000;11: Callaway MP, Wilde P, Angelini G. Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture. Br J Radiol 2000;73: Bluebond-Langner R, Pinto PA, Kim FJ, Hsu T, Jarrett TW. Recurrent bleeding from intercostal arterial pseudoaneurysm after retroperitoneal laparoscopic radical nephrectomy. Urology 2002;60: Aoki T, Okada A, Tsuchida M, Hayashi J. Ruptured intercostal artery pseudoaneurysm after blunt thoracic trauma. Thorac Cardiovasc Surg 2003;51: Boudghene F, L Hermine C, Bigot JM. Arterial complications of pancreatitis: diagnostic and therapeutic aspects in 104 cases. J Vasc Interv Radiol 1993;4: Mauro MA, Jaques P. Transcatheter management of pseudoaneurysms complicating pancreatitis. J Vasc Interv Radiol 1991;2: Golzarian J, Nicaise N, Deviere J, et al. Transcatheter embolization of pseudoaneurysms complicating pancreatitis. Cardiovasc Intervent Radiol 1997;20: Gambiez LP, Ernst OJ, Merlier OA, Porte HL, Chambon JP, Quandalle PA. Arterial embolization for bleeding pseudocysts complicating chronic pancreatitis. Arch Surg 1997;132: Savader SJ, Trerotola SO, Merine DS, Venbrux AC, Osterman FA. Hemobilia after percutaneous transhepatic biliary drainage: treatment with transcatheter embolotherapy. J Vasc Interv Radiol 1992; 3: Hidalgo F, Narvaez JA, Rene M, Dominguez J, Sancho C, Montanya X. Treatment of hemobilia with selective hepatic artery embolization. J Vasc Interv Radiol 1995;6: Okazaki M, Ono H, Higashihara H, et al. Angiographic management of massive hemobilia due to iatrogenic trauma. Gastrointest Radiol 1991; 16: Nicholson T, Travis S, Ettles D, et al. Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy. Cardiovasc Intervent Radiol 1999;22: Rhee SJ, Ohki T, Veith FJ, Kurvers H. Current status of management of type II endoleaks after endovascular repair of abdominal aortic aneurysms. Ann Vasc Surg 2003;17: Submitted Feb 28, 2005; accepted Mar 31, 2005.