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Radiology
ENDOVASCULAR MANAGEMENT OF TRAUMATIC PSEUDOANEURYSM OF INTERCOSTAL ARTERY.
Case 32: Contributed by Dr. Amol Bhalekar
A 71-year-old man presented with pain in the chest and dyspnea with a intercostal drainage tube in situ inserted at another facility. He had had a bullock horn injury one month back with penetration into the chest. He had then developed a hemopneumothorax for which the intercostal drain had been inserted. The bleeding had stopped after a few hours. This patient now complained of rebleed through the intercostal drain and his hemoglobin had fallen to 5 gm%, for which he had received two units of blood.
A plain and contrast enhanced CT scan of the thorax was performed. This showed multiple rib fractures on the right side with a hemothorax. On post contrast scans, there was a traumatic pseudoaneurysm of a right intercostal artery
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Endovascular treatment was performed through a 5 Fr right transfemoral arterial access. Using 4 Fr cobra catheter, an intercostal artery angiogram was performed. This confirmed bleed from the offending intercostal artery pseudoaneurysm.
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A 3Fr ‘Progreat’ microcatheter and microwire was used to access the small tortuous intercostal artery. The microcatheter could not be placed in the distal artery due to the extreme tortuosity of the artery. Hence, the intercostal artery was occluded more proximally using two microcoils (0.018’).
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Post embolization angiogram revealed complete occlusion of the intercostal artery with no filling of the aneurysm.
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Post-procedure, the patient was stable and there was complete stoppage of bleeding from Intercostal tube . The patient was further managed conservatively for the residual haemopneumothorax. No further episodes of acute bleeding occurred.
DISCUSSION:
Intercostal artery injuries including dissection, occlusion, pseudoaneurysm and arteriovenous fistula (AVF) may result from both penetrating and blunt trauma to the chest. However, intercostal artery pseudoaneurysm is a rare entity. Its etiology may include blunt and penetrating thoracic trauma, ICD insertion, percutaneous hepatobiliary interventional procedures, pleural biopsy, pleural tapping and CT guided biopsy of chest masses. Intercostal artery pseudoaneurysm is at risk for rupture and hence early diagnosis and treatment before rupture is mandatory.
Percutaneous transcatheter embolization is a safe and effective method of treating pseudoaneurysms. Percutaneous transcatheter embolization is the intravascular deposition of particulate, liquid, or mechanical agents or autologous blood clot to produce intentional vessel occlusion. Embolic vascular occlusion may be performed at any level from large arteries or veins to the capillary beds and it may be temporary or permanent in nature. Percutaneous transcatheter embolization may be undertaken with curative or palliative intent.
Coils, as used in this patient, are made from stainless steel, platinum or titanium wire. Some are coated with Dacron fibers to elicit greater thrombogenic reactions. A coil is generally packaged in a deployment needle, which is used to load the coil into the catheter. Once inside the catheter, the coil is advanced with a standard angiographic wire. Typically, the stiff end of the guidewire is used to introduce the coil into the catheter and the floppy end to deploy the coil. The tip of the catheter is positioned at the desired point of embolization and the coil is pushed out the end. As it is deployed, the coil assumes its shape and final diameter. Most often, a "nest" of coils is deployed to occlude the artery fully. Care must be taken when deploying microcoils, since they assume the shape of the catheter through which they are deployed. This formation can cause occlusion of the delivery catheter, and the embolization may fail.
The decision to perform percutaneous transcatheter embolization should be made after considering the risks and benefits to each patient. Coagulopathy, sepsis, and renal failure are relative contraindications to percutaneous transcatheter embolization. Appropriate efforts should be made to correct or improve these conditions prior to the procedure. Lack of safe access to the target is another contraindication to treatment. Stable catheter position may not be achieved in a minority of patients.