Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture

Post-thoracotomy intercostal artery pseudoaneurysm manifesting as a chest wall metastasis

Intercostal artery pseudoaneurysm (IAP) represents an extremely rare vascular abnormality developing after an insult to the vascular wall with blood collection within the vascular wall layers and subsequent dilatation. Treatment options, apart from observation, include embolization, endovascular stenting, and surgical correction. We describe the case of a 73-year-old male patient with colonic adenocarcinoma pulmonary metastasis. Repetitive wedge resections and a right lower lobectomy were performed to remove multiple metastatic lesions. At follow-up assessment, the patient reported localized thoracotomy site pain progressing with time and unresponsive to oral analgesics. Chest computed tomography (CT) revealed a pseudoaneurysm of 4-cm diameter of the right 5th intercostal artery. The patient underwent embolization of the lumen and was discharged from the hospital after 24 h. Successive CT re-assessment checks were unremarkable.

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BACKGROUND

Here, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.

CASE PRESENTATION

A 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient's right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.

CONCLUSIONS

Intercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Case report: asymptomatic pseudoaneurysm of the native coronary soon after the graft anastomosis treated with off-pump repair

Background

Pseudoaneurysms (PSAs) of native coronary arteries are rare but potentially lethal complications occurring after coronary artery graft anastomosis mainly secondary to median sternotomy.

Case summary

A 61-year-old man underwent coronary artery bypass grafting because of stable angina. After the surgery, the patient was asymptomatic. A routine pre-discharge transthoracic echocardiogram was performed showing a haematoma of the apex partially involving the right ventricle with systolic colour Doppler flow going from the left ventricle to the pericardium. A coronary computed tomography scan was ordered and it revealed the presence of a PSA of the left anterior descending (LAD) artery distal to the graft anastomosis with the left internal mammary artery. An off-pump direct suture of the LAD injury through a redo sternotomy was successfully performed.

Discussion

The development of a PSA of a native coronary artery after bypass grafting is a very rare and potentially fatal condition. A correct and prompt diagnosis is crucial to avoid lethal complication.

Massive hemothorax caused by intercostal artery pseudoaneurysm:a case report

BACKGROUND

Intercostal artery pseudoaneurysm is rare and at the risk of rupture. The aetiology is always reported to be iatrogenic and traumatic injury. Embolisation is the most common therapeutic method. Here, we report a case of spontaneous intercostal artery pseudoaneurysm and cured by combining covered stent grafting and surgical management.

CASE PRESENTATION

A 60-year-old man complained of acute right back pain for 5 h. Computed tomography showed right massive hemothorax and a giant mass with distinct feeding vessel originated from the thoracic aorta within the right hemithorax. Thoracocentesis was performed, and then a covered stent was positioned across the origin of the feeding vessel. The patient was diagnosed with intercostal artery pseudoaneurysm. Finally, we successfully resected the pseudoaneurysm and ligated the proximal part of the artery. Histologic examination have proved the diagnosis. The postoperative course was uneventful, and the patient was discharged on postoperative day 10. There is no recurrence reported during follow-up.

CONCLUSIONS

Spontaneous intercostal artery pseudoaneurysm is extremly rare. Delayed hemothorax due to rupture of the pseudoaneurysm may occur years after the formation. Early diagnosis is important and a combined treatment of endovascular intervention and surgical management is feasible, especially for the case of ruptured large tumour-like mass presentation of the pseudoaneurysm.

A Unique Case of Esophageal Bleeding: Arterioenteric Fistula Secondary to Intercostal-Bronchial Trunk Pseudoaneurysm Rupture

Esophageal bleeding has a broad differential. One rare cause of esophageal bleeding is an intercostal artery pseudoaneurysm, which usually presents as hemothorax secondary to trauma or an iatrogenic cause; we identified only 9 reported cases in the English literature. Rarer still is pseudoaneurysm of the intercostal-bronchial trunk, which has not been reported in the literature. We report a 61-year-old man with an intercostal-bronchial trunk pseudoaneurysm who presented with hematemesis and signs of upper gastrointestinal bleeding without previous history of trauma. This case report serves to broaden the differential for esophageal bleeding.

Stent-graft Repair of a True Internal Thoracic Artery Aneurysm

We present the case of a 49-year-old woman diagnosed with Sneddon's syndrome and previous endovascular embolization for cerebral and left renal artery aneurysms. The aneurysm was asymptomatic and incidentally detected as coin opacity at a preoperative X-ray performed for breast surgery. The 13-mm saccular left internal thoracic artery aneurysm engaged through a percutaneous left brachial artery access was successfully excluded with a stent graft. A 6-month follow-up computed tomography angiography confirmed the exclusion of the aneurysm, the patency of the internal thoracic artery, and the absence of endoleak or edge stenoses. True aneurysm of the internal thoracic artery is a rare entity. Stent-graft repair is a viable end effective alternative treatment for the exclusion of this lesion.

Intercostal artery pseudoaneurysm after ultrasound-guided liver biopsy: a case report and review of the literature

We present a 58-year-old woman with a right intercostal artery pseudoaneurysm after percutaneous ultrasound (US)-guided liver biopsy. The patient presented 6 days after liver biopsy with a painful, pulsatile right-sided chest wall mass at the site of biopsy needle insertion. Intercostal artery pseudoaneurysm was diagnosed with color Doppler US. Successful treatment with percutaneous US-guided injection of thrombin resulted in complete thrombosis and closure of the pseudoaneurysm. Only 12 previous cases of intercostal artery pseudoaneurysm have been reported in the English-language literature, and this is the first reported case resulting from percutaneous liver biopsy. Given how frequently percutaneous liver biopsies are performed, it is important to raise awareness of this potentially serious complication.

Intercostal artery pseudoaneurysm complicating corrosive acid poisoning: Diagnosis with CT and treatment with transarterial embolisation

Pseudoaneurysms of intercostal artery are very rare. All the published cases have been caused by trauma, either iatrogenic or otherwise. They can cause hemothorax, retroperitoneal hemorrhage or can present as pulsatile chest mass. Doppler ultrasound, contrast-enhanced CT and conventional angiogram can accurately diagnose this condition. All the reported cases have been treated by embolisation, stenting or surgery. We report an unusual case of intercostal artery pseudoaneurysm arising as a complication of corrosive poisoning presenting with hematemesis and treated by glue embolisation. The authors believe this to be the first case of intercostal artery pseudoaneurysm that is non-traumatic, complicating corrosive poisoning and presenting with hematemesis.

Intercostal artery pseudoaneurysm formation after irinotecan transarterial chemoembolization of a spinal metastasis from colorectal cancer

Over the past decade, irinotecan has become one of the first-line chemotherapeutic agents used in the treatment of metastatic colorectal cancer. Recently, irinotecan has been administered transarterially in order to perform chemoembolization in the liver. In the limited number of reports available to date using this approach, serious adverse effects have not yet been reported. In this paper, we describe the formation of an intercostal artery pseudoaneurysm after transarterial chemoembolization with irinotecan-eluting beads in a patient with spinal metastasis from colorectal cancer.

Intercostal artery pseudoaneurysm: a rare complication of transaortic transcatheter aortic valve implantation

In this case report, we present an 86-year old patient with an intercostal pseudoaneurysm after transaortic transcatheter aortic valve implantation (TAVI). This new technique of a transaortic approach is considered a possible alternative to the more usual transfemoral, trans-subclavian or transapical access site, mainly in patients with extensive peripheral arterial disease. A mini-thoracotomy or mini-sternotomy is needed to access the ascending aorta. The patient presented with a painless but progressive pulsatile mass right parasternally, 3 months after the procedure. An intercostal pseudoaneurysm was diagnosed with duplex examination and chest CT. Successful treatment with an ultrasound-guided injection of thrombin resulted in a complete obliteration of the pseudoaneurysm. Only nine reported cases of intercostal pseudoaneurysms have been reported worldwide, and this is the first case in a patient who underwent a transaortic TAVI. Since the transaortic access is used more frequently, it is important to report on possible complications of this new technique.

Intercostal artery pseudoaneurysm due to thoracentesis: diagnosis with three-dimensional computed tomographic angiography

Intercostal artery pseudoaneurysm is extremely rare, with only a few case reports in the literature. Presented in this case report is a patient who developed an intercostal artery pseudoaneurysm after thoracentesis for recurrent pleural effusion. Diagnosis traditionally required arteriography; however, as shown in this case, the resolution of current multidetector computed tomography scanners and the routine acquisition of isotropic data sets with 3-dimensional visualization enable identification and detailed characterization of small vascular lesions such as these.

Imaging appearances and endovascular management of uncommon pseudoaneurysms

Pseudoaneurysms are uncommon and their aetiology is varied. They occur in numerous anatomical locations and present with a multitude of clinical presentations sometimes life-threatening. This review describes the causes, sites, and presentations of uncommon pseudoaneurysms, as well as illustrating their diagnostic appearances and endovascular management.

Traumatic intercostal artery pseudoaneurysm following a bicycle accident

In this article we present a fatal case of a ruptured intercostal artery pseudoaneurysm that occurred a number of years after an incident in which the patient suffered a blunt-trauma injury. A long interval between blunt trauma and this type of fatality has rarely been reported. This case discusses a 49-year-old woman who was found dead at her home by her husband and was referred for autopsy because the cause of death was uncertain. Her past medical history was unknown; however, it was learned that she had a bicycle accident 4 years previously and had sustained injuries to the left side of her body. During the autopsy, healed fractures in the bones of the left lower rib cage and a large amount of blood in the left thorax were observed. Furthermore, a hematoma, containing a small rupture was found in the left tenth intercostal space adjacent to the thoracic vertebrae. Histological examinations showed that the wall of the left tenth intercostal artery was ruptured, with recent blood clots including fibrin. Additionally, in the lesion where the tunica adventitia was disrupted, the dissecting cavity was filled with blood. We concluded that the woman died of hemorrhagic shock resulting from a ruptured intercostal artery pseudoaneurysm that formed as a result of the injury incurred from the bicycle accident 4 years before.

Intercostal artery pseudoaneurysm due to stab wound

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.

Pseudoaneurysm of the Internal Mammary Artery as an Unusual Cause of Post-sternotomy Hemorrhage: The Role of Multislice Computed Tomography in the Diagnosis and Treatment Planning

Pseudoaneurysm of the internal mammary artery (IMA) following median sternotomy is extremely rare. To date, the reported cases are only in single figures. The majority of these pseudoaneurysms were suspected from the clinical presentation, echocardiography or computed tomography (CT) but were only confirmed on contrast angiography. This case report demonstrates the current ability to carry out detailed vascular imaging on a 16-slice CT scanner. This accurate delineation of the pseudoaneurysm allowed targeted therapeutic embolization to be performed without unnecessary angiographic imaging.

Endovascular Therapy of a Ruptured Intercostal Artery Aneurysm

PURPOSE

To report the endovascular management of a rare ruptured intercostal artery aneurysm.

CASE REPORT

A 45-year-old man presented with acute upper back and chest pain. Computed tomography of the chest revealed a ruptured intercostal artery aneurysm. The lesion was treated by endovascular coil embolization distal to the aneurysm and aortic stent-grafting of the intercostal artery origin.

CONCLUSIONS

Ruptured intercostal artery aneurysms can be treated by endovascular techniques. If coil embolization of the intercostal artery origin is not possible, additional aortic stent-grafting can be necessary.