Spontaneous haemothorax as a complication of anti-coagulation following coronary angioplasty

A Case of Bilateral Hemorrhagic Pleural Effusion Due to Dual Antiplatelet Therapy in a Dialysis Patient

Etiologies of hemorrhagic pleural effusions (hemithoraces) are multifactorial. They can be traumatic, non-traumatic, or idiopathic in nature. In this report, we present a rare case of a 64-year-old male with end-stage renal disease (ESRD) on chronic hemodialysis and dual antiplatelet therapy (DAPT), due to a recent history of coronary arterial stent placement, who presented with progressive shortness of breath for one month. The CT of the chest revealed bilateral large pleural effusions (left > right) with a complete collapse of the left lung and partial collapse of the right lung. Ultrasound-guided left-sided thoracentesis revealed hemorrhagic pleural effusions. After the discontinuation of DAPT, drainage from the right-sided pleural effusion via a pigtail catheter showed continued drainage of pleural fluid without hemorrhage. The effusion on the left side was also noted to have resolved on the repeat chest X-ray. Prompt recognition of this rare cause of any hemorrhagic pleural effusion is essential for patients on dialysis to avoid complications. This report focuses on the possible etiology and potential complications of a hemorrhagic pleural effusion, followed by a brief discussion on the rare but significant association involving the incidence of a hemorrhagic pleural effusion in a dialysis patient receiving DAPT.

[Thoracoscopic repair of postoperative intrapleural complications]

AIM

To justify and develop the indications for thoracoscopic procedures in patients with complications after advanced cardiothoracic surgery including combined and simultaneous operations.

MATERIAL AND METHODS

From 2013 to 2017 was performed treatment of complication in 27 patients undergoing various cardiothoracic intervention with the use of thoracoscopic technology.

RESULTS

We have analyzed immediate results of thoracoscopic operations in 27 patients with various intrapleural complications after advanced cardiothoracic surgery. Satisfactory results of these interventions confirm safety of thoracoscopic technologies and serve as an argument in favor of this direction in thoracic surgery.

Multiple-site bleeding at pleural adhesions and massive hemothorax following percutaneous coronary intervention with stent implantation: A case report

An elderly male patient with coronary heart disease underwent coronary angiography, which revealed bilateral severe coronary artery stenosis. Four stents were implanted, and at 5 h post-surgery, typical hemorrhagic shock appeared. Echocardiography verified heavy bleeding in the right thoracic cavity. Emergency angiography excluded injury or perforation of the coronary artery, aorta, right subclavian artery and brachiocephalic artery. Considering the patient's history of chronic obstructive pulmonary disease and severe cough during the operation, it was suspected that hemothorax was induced by a blood vessel rupture in the pleura. Video-assisted thoracic examination confirmed the tearing of pleural adhesion bands and bleeding at three sites in the pulmonary pleura and parietal pleura. According to the reported case, bleeding as a result of the laceration of pleural adhesions is an important cause of hemothorax that should be considered after exclusion of other common causes of pleural hemorrhage.

Spontaneous Hemothorax Following Cardiac Surgery

We report a case of spontaneous hemothorax after aortic valve replacement in a 72-year-old female resulting from rupture of a pleural adhesion leading to hemodynamic instability. doi: 10.1111/jocs.12729 (J Card Surg 2016;31:211-213).

Non-traumatic and spontaneous hemothorax in the setting of forensic medical examination: a systematic literature survey

Spontaneous hemothorax is a well-known yet seldom-reported entity in forensic literature. While trauma-related hemothorax is frequently encountered in a medicolegal setting, non-traumatic and spontaneous hemothorax are relatively uncommon entities. The wide range of causes that can trigger fatal intrathoracic bleeding include thoracic aortic dissection, followed by vascular malformations, various oncological diseases, and connective tissue abnormalities. In rare instances, extramedullary hematopoiesis, ectopic pregnancy, congenital heart defects, amyloidosis, or parasitic diseases may constitute a source of bleeding. This etiological heterogeneity may, as a result, cause diagnostic difficulties during post-mortem elucidation of hemothorax. It should be borne in mind that hemothorax after low-energy trauma does not exclusively indicate traumatic hemorrhage, hence, the non-traumatic origin of bleeding must be taken into consideration. In this paper, we present a systematic review of the relevant literature enriched by the results of our observations to investigate the etiologies and recommendations for the post-mortem diagnosis of spontaneous hemothorax in an attempt to better delineate the possible medicolegal considerations. It is important that forensic pathologist as well as clinicians are aware of the diseases that could potentially give rise to fatal hemothorax.

Spontaneous hemothorax following anticoagulation with low-molecular-weight heparin

OBJECTIVE

To report a case of spontaneous hemothorax following anticoagulation with low-molecular-weight heparin (LMWH) for the management of suspected pulmonary embolism.

CASE SUMMARY

A 66-year-old man with a background history of breast carcinoma was admitted with pleuritic chest pain. He was initially managed as a suspected case of pulmonary embolism. Dalteparin, an LMWH, was started at a maximum dose of 18,000 units subcutaneously once daily, according to British national prescribing guidelines. On day 4, following 3 doses of dalteparin, the patient developed acute respiratory distress attributable to a massive right hemothorax confirmed by computed tomography pulmonary angiography (CTPA) and intercostal drainage of 1500 mL of frank blood. CTPA identified no pulmonary embolus or vascular abnormalities. Reaccumulation of hemothorax occurred over the 48 hours following drain removal, necessitating insertion of a second drain, which removed 1400 mL of blood-stained fluid. The patient's hemoglobin decreased from 12.7 to 8.5 g/dL and he received a 3-unit blood transfusion. Histologic assessment of pleural fluid revealed no malignancy and results of video-assisted thoracoscopic surgery were normal. Discontinuation of dalteparin on day 4 led to resolution of symptoms.

DISCUSSION

The causal association between anticoagulant therapy and spontaneous hemothorax remains relatively uncommon. The striking temporal relationship between commencing dalteparin on day 1 and subsequent development of effusion on day 4, following 3 doses of LMWH, led us to believe that the bleed occurred as a result of the therapy. Exclusion of other causes strengthened this conclusion. Application of the Naranjo probability scale categorized this adverse reaction as being probably due to LMWH.

CONCLUSIONS

Spontaneous hemothorax is a rare phenomenon in conjunction with LMWH but should be considered in cases of acute respiratory distress following commencement of LMWH.