Interact CardioVasc Thorac Surg 2009;8:166-167. doi:10.1510/icvts.2008.178582
© 2009 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Successful angiographic embolisation of bleeding into the chest wall after chest drain insertion
Mohammed W. Khalila,*,
Trevor J. Clevelandb,
Pradip K. Sarkara and
Jagan Raoa
a Department of Cardiothoracic Surgery, Northern General Hospital, Herries Road, Sheffield, UK
b Sheffield Vascular Institute, Northern General Hospital, Herries Road, Sheffield, UK
Received 29 February 2008;
received in revised form 15 May 2008;
accepted 17 July 2008
*Corresponding author. Fax: +44 114 2610350.
E-mail address: wesam{at}doctor.com (M.W. Khalil).
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Abstract
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Peripheral arterial injuries after blunt or penetrating trauma commonly follow injuries to adjacent soft tissue and bone. The traditional approach to these injuries is by open exploration, with identification and ligation of the bleeding vessel. We describe the case of a type II respiratory failure patient who had an enormous pectoral muscle haematoma following chest drain insertion, in whom the bleeding was only controlled by angiographic embolisation following failure of surgical exploration.
Key Words: Haematoma; Embolisation; Trauma
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1. Introduction
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Intramuscular haematoma following chest drain insertion is liable to occur if the drain is inserted through pectoralis major or latissimus dorsi. The drain might act as a tamponade on the bleeding vessel so long as it is in, and haematoma will then only appear once it is removed. Treatment is by drainage of the haematoma and ligation of the bleeding vessel. However, if the bleeding vessel is elusive, then embolisation becomes the only therapeutic option for bleeding.
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2. Case report
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A 54-year-old Caucasian male with chronic obstructive pulmonary disease was admitted into our hospital with a recurrent right pneumothorax. An apical chest drain was inserted and later talc pleurodesis through the drain was carried out. He was noted to have a swelling around the drain site soon after the insertion, which was managed conservatively. After a period of observation and once his lung was re-inflated, the drain was removed and he was subsequently discharged. However, the chest wall swelling increased to eventually involve the right anterior chest wall and the axilla, for which he was readmitted four days after discharge. The swelling was about 11 cmx11 cm, tense, tender and fluctuant but not inflamed. Ultrasound of the area revealed the contents to be fluid.
The haematoma was evacuated under local anaesthesia and 1400 ml of blood with clots was evacuated, and cavity was packed with surgical and ribbon gauze, with placement of a corrugated drain. However, the dressing continued to soak with blood associated with the patient becoming progressively tachycardic. His haemoglobin levels dropped to 5.5 g/l, for which he received three units of blood. However, the bleeding continued and the patient was taken to theatre for exploration. Again blood clots were evacuated but no definite area of bleeding was identified. There appeared to be a generalized ooze of arterial blood from the deep surface of the pectoralis major, and the cavity was washed and repacked. However, he continued to bleed in the ward and, with FEV1 20% predicted, type II respiratory failure requiring nocturnal non-invasive positive pressure ventilation, he was not considered fit for another general anaesthetic. The vascular radiologist on call was contacted for consideration of angiography to identify the bleeding vessel and possible embolisation. Angiography performed from the femoral approach found active bleeding from a branch of the thoraco-acromial artery (Fig. 1). Super selective catheterisation was not possible from the same approach (due to the acute reverse angle of the artery origin from this approach), therefore the patient's right brachial artery was accessed, and embolisation was successfully achieved using coils (Fig. 2). Subsequently the patient steadily recovered with daily wound dressing, and was discharged two weeks later.
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Fig. 2. Unsubtracted image showing coils across the arterial defect (arrow) – note the position of the surgically placed packs (open arrow).
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3. Discussion
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Endovascular embolisation is commonly used to stop bleeding from a variety of vascular beds [1], and has been reported to stop bleeding from the chest wall following blunt trauma, more commonly from the internal mammary artery [2, 3]. To our knowledge, its use to stop bleeding from the thoraco-acromial artery following chest drain insertion has not been reported. This could occur if the drain is inserted through muscle tissue, as in apical insertions through the second space anteriorly. Insertion of the chest drain through the ‘triangle of safety’ (bounded by the pectoralis major, latissimus dorsi, and external oblique) will avoid the drain having to pass through muscle tissue and thus obviate injury to submuscular arteries. Our case demonstrates that immediate bleeding might not be apparent, as the drain itself may act as a tamponade to the injured vessel, and the bleeding becomes overt only after the drain is removed.
In the presence of a sizeable haemtoma, immediate management is opening the wound to evacuate the blood and ligate or cauterize the bleeding point if identified. Where the injured vessel is deep to the muscle and difficult to find, as in our case, then endoluminal embolisation should be considered.
Contrast-enhanced computed tomography can in many cases reveal the site of active bleeding, helping to direct angiographic embolisation for haemostasis. However, if a small artery is suspected, computed tomography is not an adequate investigation, and the best diagnostic option is arteriography [4, 5].
This case demonstrates that endoluminal embolisation should be considered at an early stage of uncontrolled bleeding in unstable patients unfit for general anaesthesia. Whilst embolisation will not remove the haematoma, it does provide an efficient method for stopping the bleeding, allowing for the remainder of treatment to be performed in less difficult circumstances, with the patient's condition stabilised.
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References
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- Smith DC, Senac MO, Bailey LL. Embolotherapy of a ruptured internal mammary artery secondary to blunt chest trauma. J Trauma 1982 Apr;22:333–335.[Medline]
- Nishiuchi T, Horikawa H, Hinami J, Yokota J. An unusual case of noncavitary hemorrhage revealed by intravenous contrast-enhanced computed tomography. J Emerg Med 2002 Jan;22:21–25.[CrossRef][Medline]
- Mirvis SE, Kostrubiak I, Whitley NO, Goldstein LD, Rodriguez A. Role of CT in excluding major arterial injury after blunt thoracic trauma. AJR Am J Roentgenol 1987 Sep;149:601–605.[Abstract/Free Full Text]
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Abstract
1. Introduction