Intercostal Artery Laceration Following Thoracentesis

Mary L Yacovone MEd RRT, Ritha Kartan MD, and Manuel Bautista MD

Intercostal artery laceration is an unusual complication following thoracentesis, and has been reported only in elderly patients. We report a case of a 78-year-old man who developed a massive hemothorax following thoracentesis. Post-thoracentesis radiograph revealed a substantial increase in pleural fluid, and emergency chest tube insertion identified the hemothorax. He underwent right thoracotomy for repair of the intercostal artery laceration. Key words: intercostal artery laceration; thoracentesis; hemothorax; thoracotomy. [Respir Care 2010;55(11):1495–1498. © 2010 Daedalus En- terprises]

Introduction Case Report

Thoracentesis is a common diagnostic and therapeutic A 78-year-old white man with a history of congestive procedure, in which a percutaneously introduced needle is heart failure secondary to ischemic cardiomyopathy was used to remove fluid from the pleural space. Clinically, the admitted with generalized weakness and shortness of breath most common post-thoracentesis complication is pneumo- that had worsened during the week prior to admission. He complained of dyspnea on exertion, and orthopnea, and thorax, with an incidence of 3–30%.1-10 Table 1 lists post- stated that he used 3 pillows during sleep. Chest radio- thoracentesis complications.1-18 There are very few docu- graph on admission showed a large right pleural effusion mented cases of intercostal artery laceration during (Fig. 1). Review of the chest radiograph from 3 months thoracentesis, and they appear to be most commonly re- before this presentation showed no pleural effusion. His 11 ported in the elderly. Intercostal artery laceration can medical history was notable for diabetes mellitus, anemia 19 also occur during thoracostomy for chest tube insertion, secondary to gastrointestinal bleeding, hypothyroidism, hy- and probably in patients with coarctation of the aorta, perlipidemia, coronary artery disease, coronary artery by- which leads to engorgement and tortuosity of the intercos- tal arteries.20 We report a case of an elderly patient who developed a massive hemothorax due to an intercostal ar- Table 1. Complications Following Thoracentesis tery laceration that occurred despite our following all the Occurrence Rate recommended thoracentesis procedures. Complication (%) Pneumothorax 3–30 Re-expansion pulmonary edema 0.2–14 Vasovagal reaction Ͻ 3 Mary L Yacovone MEd RRT is affiliated with the Department of Health Hemothorax Ͻ 1 Professions, The Bitonte College of Health and Human Services, Young- Pneumohemothorax Ͻ 1 stown State University, Youngstown, Ohio. Ritha Kartan MD, and Man- Retained intrapulmonary catheter fragments Ͻ 1 uel Bautista MD are affiliated with the Department of Internal Medicine, Splenic laceration Ͻ 1 Forum Health, and with Northeastern Ohio Universities Colleges of Med- icine and Pharmacy, Youngstown, Ohio. Abdominal hemorrhage ND Intercostal artery laceration ND The authors have disclosed no conflicts of interest. Pulmonary hemorrhage ND Subcutaneous implantation of cancer ND Correspondence: Mary L Yacovone MEd RRT, Department of Health

Professions, The Bitonte College of Health and Human Services, Youngs- ND ϭ no data available, though case reports of these complications suggest that their town State University, Youngstown OH 44515. E-mail: mlyacovone@ occurrence rate is Ͻ 1% ysu.edu.

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Fig. 1. Admission radiograph shows large right pleural effusion. Fig. 2. Radiograph immediately after thoracentesis is negative for pneumothorax and shows reduced pleural effusion. pass graft of 4 vessels (in 2005), congestive heart failure secondary to ischemic cardiomyopathy, an ejection frac- 1.6, and, after obtaining informed consent, he underwent tion of 20%, inducible ventricular tachycardia, placement right thoracentesis. He was positioned upright and leaning of an implantable cardioverter defibrillator, hypertension, forward throughout the procedure. Once the fluid was lo- carotid endarterectomy, and prostate cancer with radiation cated via ultrasound, the skin was prepped and draped with treatment. He was an ex-smoker of 30 pack years. He sterile technique. The skin, the superior aspect of the peri- denied any fever or chills, chest pain, cough, or hemop- ostium of the eighth rib at the midscapular line, and the tysis. His medications on presentation included carvedilol, parietal pleura were then anesthetized with 1% lidocaine. metformin hydrochloride, enalapril, iron, levothyroxine, An 8 French catheter attached to a 50-mL syringe was atorvastatin, tamsulosin hydrochloride, warfarin, aspirin, inserted over the same tract of the superior aspect of the and oxygen therapy (4 L/min via nasal cannula). rib, and approximately 1,200 mL of light amber fluid was At the time of admission he was afebrile (36.1° C), with obtained and sent for analysis. He denied any chest dis- blood pressure 135/75 mm Hg, heart rate 78 beats/min, comfort or pain during or after the procedure. A chest respiratory rate 18 breaths/min, and oxygen saturation 94% radiograph was obtained immediately after the thoracen- while on supplemental oxygen at 4 L/min via nasal can- tesis, and he was closely monitored for changes in vital nula. Auscultation revealed normal heart sounds, a grade 3/6 signs. parasternal systolic murmur, bilateral crackles, diminished The pleural fluid analysis revealed pH 7.49, glucose breath sounds and dullness to percussion on the right side, 115 mg/dL, albumin 1.7 g/dL, lactate dehydrogenase 88 g/ and decreased tactile fremitus. Abdominal examination dL, and total protein 3.0 g/dL. Total serum protein was found a fluid wave due to ascites. Physical examination 5.7 g/dL, serum albumin was 3.1 g/dL, and serum lactate was also positive for jugular venous distention and 3ϩ dehydrogenase was 202 g/dL. The pleural fluid was tran- peripheral edema. Both his lower extremities were wrapped sudative and secondary to his congestive heart failure. The for skin erythema and skin breakdown. chest radiograph was negative for pneumothorax and Pertinent laboratory findings included hemoglobin showed a reduction in the pleural effusion (Fig. 2).

8.1 g/L, CO2 content 30 mmol/L, blood urea nitrogen 45 mg/ Approximately 2 hours after the thoracentesis, he com- dL, creatinine 1.5 mg/dL, and INR [prothrombin time in- plained of chest pain and shortness of breath, and his blood ternational normalized ratio] 4.5. Chest radiograph on his pressure dropped to 80/40 mm Hg. On physical examina- second hospital day revealed an increase in the right ef- tion he was diaphoretic and his skin was pale. Another fusion. He continued to complain of dyspnea and orthop- chest radiograph revealed a substantial increase in the right nea and had failed diuretic therapy. pleural opacity (Fig. 3). A hemothorax was immediately The pulmonary service was consulted for a diagnostic suspected, and surgery was consulted for chest tube inser- and therapeutic thoracentesis. After evaluation, the pulmo- tion. He underwent emergency chest tube insertion, which nologist agreed to perform a thoracentesis once his INR immediately drained a large amount of blood and clots. He was less than 2.0, and vitamin K and fresh frozen plasma was transported to the operating room for exploration and were administered. On his third hospital day, his INR was control of bleeding in the right chest cavity. Right antero-

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Fig. 3. Radiograph approximately 2 hours after thoracentesis shows a right pleural opacity, which was found to be a hemothorax from an intercostal artery laceration during thoracentesis. lateral thoracotomy revealed a right hemothorax full of clots compressing the right lung and mediastinum, and a bleeding intercostal artery. Intraoperatively he received Fig. 4. Anatomy of the intercostal rib space. 4 units of packed red blood cells, 3 units of fresh frozen plasma, 1 unit of platelets, and 1,300 mL of crystalloid. Estimated blood loss was 2 L. The intercostal artery was to and immediately following the thoracentesis. In retro- repaired and a second chest tube was inserted. Postoper- spect, we believe that the choice of the 8 French catheter ative hemoglobin was 9.3 g/L and hematocrit was 27.2%. may have increased the risk of intercostal artery laceration He tolerated the procedure well and was transported in in this patient. We hypothesize that this patient’s history of stable condition to the intensive care unit. The following coronary artery bypass graft may have produced thoracic day he was weaned from mechanical ventilation and ex- anatomical changes. Coronary artery bypass graft can cause tubated. rib fractures, abnormal rib cage motion, and pleural fibro- sis,23-27 which could increase the risk of intercostal artery Discussion laceration. This case emphasizes the importance of under- standing the anatomy of the rib cage and the anatomical Thoracentesis is a diagnostic and therapeutic procedure changes in the elderly. that is routinely performed for evaluation of pleural effu- Understanding the rib and intercostal space anatomy is sion. Clinical judgment determines if the information ob- key to choosing the proper thoracentesis technique. Be- tained from pleural fluid analysis is important for diag- tween each rib is the intercostal space, which is largely nostic and therapeutic intervention. The most commonly filled with the external and internal intercostal muscles. reported thoracentesis complication is puncture of the vis- Also within the intercostal space and beneath the costal ceral pleura, which can cause a pneumothorax. Ultrasound grove of the rib is a neurovascular bundle made of inter- guidance allows the physician to determine a more accu- costal vein, artery, and nerve. The intercostal arteries lie rate needle insertion depth into the intercostal space and between the intercostal vein and nerve. Each intercostal thus reduces the incidence of pneumothorax.9,21 Evalua- artery passes obliquely and laterally to the angle of the tion of rib-space width or visualization of arterial blood superior rib (Fig. 4). The patient is positioned upright and flow is not determined with the current method of pleural leaning forward to increase the area within the intercostal ultrasonography.21,22 Furthermore, ultrasound guidance space. A site midway between the spine and axillary line does not completely replace the physical examination and is selected because the ribs are easily palpated in that confirmation of the appropriate site for thoracentesis. location. The needle is inserted 1 to 2 interspaces below In this case thoracentesis was performed in the recom- the level where the percussion note becomes dull and frem- mended manner. Ultrasound guidance and chest radiograph itus is absent. If ultrasound guidance is used, the patient were also employed to evaluate the pleural effusion prior position must be precisely maintained during the thora-

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