Spontaneous intercostal artery bleeding in a hemodialysis patient

Spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support: a case report

BACKGROUND

Intercostal artery bleeding often occurs in a single vessel; in rare cases, it can occur in numerous vessels, making it more difficult to manage.

CASE PRESENTATION

A 63-year-old Japanese man was admitted to the emergency department owing to sudden chest and back pain, dizziness, and nausea. Emergency coronary angiography revealed myocardial infarction secondary to right coronary artery occlusion. After intra-aortic balloon pumping, percutaneous coronary intervention was performed in the right coronary artery. At 12 hours following percutaneous coronary intervention, the patient developed new-onset left anterior chest pain and hypotension. Contrast-enhanced computed tomography revealed 15 sites of contrast extravasation within a massive left extrapleural hematoma. Emergency angiography revealed contrast leakage in the left 6th to 11th intercostal arteries; hence, transcatheter arterial embolization was performed. At 2 days after transcatheter arterial embolization, his blood pressure subsequently decreased, and contrast-enhanced computed tomography revealed the re-enlargement of extrapleural hematoma with multiple sites of contrast extravasation. Emergency surgery was performed owing to persistent bleeding. No active arterial hemorrhage was observed intraoperatively. Bleeding was observed in various areas of the chest wall, and an oxidized cellulose membrane was applied following ablation and hemostasis. The postoperative course was uneventful.

CONCLUSION

We report a case of spontaneous intercostal artery bleeding occurring simultaneously in numerous vessels during antithrombotic therapy with mechanical circulatory support that was difficult to manage. As bleeding from numerous vessels may occur during antithrombotic therapy, even without trauma, appropriate treatments, such as transcatheter arterial embolization and surgery, should be selected in patients with such cases.

First case of cough-induced combined intercostal artery rupture with partial diaphragm tear

We describe a case of vigorous cough-induced left intercostal artery rupture with partial diaphragmatic tear in a 60-year-old obese male with chronic obstructive pulmonary disease. He presented with left hemothorax, a rapidly spreading chest and abdominal wall hematoma, and progression of anemia. Computed tomography (CT) scan revealed a bleeding focus from the left 8th intercostal artery. CT-guided surface marking of the bleeding point was done over the chest wall. The patient underwent open thoracotomy with drainage of clotted hemothorax and ligation of bleeding intercostal artery. Incidentally, a partial diaphragm tear was detected during the surgery which was repaired. The combined presentation of cough-induced intercostal artery rupture with partial diaphragm tear is not reported earlier. Awareness of these co-existing pathologies can facilitate timely diagnosis and appropriate life-saving management.

Spontaneous bleeding of thoracoacromial artery mimicking tunneled cuffed catheter-related complication: A case report

RATIONALE

The chronic complications caused by the tunneled cuffed catheter in chronic dialysis patients are infection and catheter dysfunction. While bleeding due to this access can occur occasionally.

PATIENT CONCERNS

We present a 92-year-old woman with a 6-year history of regular hemodialysis (HD). For the past 2 years, she has been receiving HD via a tunneled cuffed catheter placed in the right internal jugular vein. She suffered from a right chest subcutaneous hematoma near the catheter without recent trauma. The increasing size of hematoma after dialysis, and the oozing from the outlet of the catheter were also observed.

DIAGNOSIS

Computed tomography of chest and angiography were done and showed that the hematoma was caused by thoracoacromial artery bleeding, which was near the puncture site of the tunneled cuffed catheter.

INTERVENTIONS

Fluid resuscitation, blood transfusion, surgical drainage, and parenteral antibiotics were prescribed.

OUTCOMES

Patient recovered fully without any further sequelae.

LESSONS

Spontaneous bleeding of thoracoacromial artery is rare and clinicians should keep in mind as a differential diagnosis in patient with new-onset hematoma over anterior chest wall. Early diagnosis and treatment are important in such cases.