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Intercostal Was Performed, and the Patient Arteriovenous Fistula Recovered Uneventfully 976 Bilton,. Webb, Foster, Mulvenna, Dodd of factor VIII and it also releases plasminogen tion in haemaglobin than when he had activator from endothelial cells.9 previously been admitted for haematemesis. Vasopressin has been used to control bleed- Severe haemoptysis in chronic lung disease ing from oesophageal varices. Its plasma half is uncommon and pressor agents should not Thorax: first published as 10.1136/thx.45.12.976 on 1 December 1990. Downloaded from life is about 24 minutes and it is most effective be used routinely owing to the side effects of when given by infusion. The site of action is water retention and bronchoconstriction. probably arteriolar smooth muscle, through They may, however, have a useful con- an increase in the intracellular concentration servative role in the management of patients of inositol phosphates, which mobilise with cystic fibrosis who have severe lung and intracellular calcium, causing contraction. liver disease. The bronchial and mesenteric arteries both arise directly from the aorta. We hoped to reproduce the effect of pressor agents on the 1 Penketh ARL, Wise A, Mearns MB, Hodson M, Batten JC. mesenteric vasculature in the bronchial cir- Cystic Fibrosis in adolescents and adults. Thorax 1987; culation. The effect of the pressor agents in 42:526-32. 2 King AD, Cumberland DC, Brennan SR. Management of stopping pulmonary bleeding may have been severe haemoptysis by bronchial artery embolisation in a fortuitous; but the immediate termination of patient with cystic fibrosis. Thorax 1989;44:523-4. occasions, 3 Sweezey NB, Fellows K. Bronchial artery embolisation for profuse bleeding on separate severe Hemoptysis in Cystic Fibrosis. Chest 1990; initially with desmopressin and subsequently 97:1322-6. with a bolus and infusion of vasopressin, was 4 Stern RC, Wood RC, Boat TF, et al. Treatment and prognosis ofmassive hemoptysis in cystic fibrosis. Am Rev impressive. We are not aware of any publica- Respir Dis 1978;117:825-8. tions describing the action of pressor agents 5 Jones DJ, Davies RJ. Massive haemoptysis. Br Med J in either man or 1990;300:889-90. on the bronchial circulation 6 Correspondence. Massive haemoptysis. Br Med J 1990; animals (personal communication from Parke 300:1270-1. Davis). 7 Haponik EF, Chin R. Hemoptysis: clinicians' perspectives. Chest 1990;97:469-75. There was no difficulty in distinguishing 8 Salzman EW, Weinstein MJ, Weintraub RM, et al. Treat- between a large haemoptysis and a ment with desmopressin acetate to reduce blood loss after in this He was observed cardiac surgery. N Engl J Med 1986;314:1402-6. haematemesis patient. 9 Manucci PM, Aberg M, Nilsson M, Robertson B. Mechan- to cough up a large amount of blood and was isms of factor VIII increase after vasoactive drugs. Br J grossly breathless with a much smaller reduc- Haematol 1975;30:81-93. Thorax 1990;45:976-978 http://thorax.bmj.com/ were ligated and pleural decortication Intercostal was performed, and the patient arteriovenous fistula recovered uneventfully. due to pleural biopsy Recently we encountered a previously on September 29, 2021 by guest. Protected copyright. unreported complication of closed pleural biopsy-namely, the occurrence of a J-H Lai, H-C Yan, S-J Kao, S-C Lee, traumatic arteriovenous fistula of the inter- C-Y Shen costal artery and vein. Abstract Case report Division of Chest A 32 year old woman was admitted with fever Medicine A 32 year old woman had a pleural J-H Lai biopsy for a left pleural effusion, which (38 3°C) and a productive cough. There was H-C Yan showed caseating granuloma typical of no history of previous lung disease, chest S-J Kao fourth trauma, or excessive bleeding. She was very C-Y Shen tuberculosis. When the biopsy specimen was removed considerable slim (36 kg). Physical examination disclosed Division of Chest nothing abnormal apart from dullness to per- Surgery bleeding occurred from the puncture S-C Lee site. Four days later a bruit was audible cussion and decreased breath sounds over the Tri-Service General over the punctured area, radiating to the left lower lung field. Diagnostic thoracocen- Hospital, National back. Eight days after the procedure the tesis was performed and 20 ml yellowish Defense Medical patient had a massive bleed into the left serous fluid removed. Center, Taipei, was Taiwan, Republic of pleural space. Selective aortic angio- The next day a closed pleural biopsy China graphy showed an arteriovenous fistula performed through the 9th intercostal space at Address for reprint requests: between the 9th intercostal artery and the posterior axillary line with a Cope needle. Division of Chest Medicine, a in the inter- Before biopsy the patient appeared tense and Tri-Service General vein and pseudoaneurysm Hospital, 622 Ting Chow costal punctured area. Thoracotomy fearful. After injection of a local anaesthetic Road, Taipai, Taiwan, from the site of the three pleural specimens were obtained with- Republic of China showed bleeding Accepted 11 June 1990 pleural biopsy. The intercostal vessels out incident; but when a fourth specimen was Intercostal arteriovenousfistula due to pleural biopsy 977 Figure 1 Selective aortic tered. These have included angiogram showing the pneumothorax, intercostal artery in 9th haemothorax,2 pancreatic injury with intercostal space (t); the pseudocyst formation, penetrating injury of Thorax: first published as 10.1136/thx.45.12.976 on 1 December 1990. Downloaded from 9th intercostal vein (J) the or mediastinal was opacified during the diaphragm spleen,3 arterial phase, presumably emphysema, subcutaneous abscess, subcutan- because of the eous haematoma,4 empyema,1 and seeding of arteriovenousfistula. The malignant cells into the needle tract.5 The use pseudoaneurysm of the intercostal artery is shown of sonographic guided pleural biopsy may reduce these complications, especially for the wall of an encapsulated pleural effusion.6 An inadvertent tear of an intercostal artery or vein due to closed pleural biopsy occasion- ally results in massive haemothorax; but we have been unable to find a report of any similar case of a persistent arteriovenous fis- tula following pleural biopsy. Intercostal vessels usually course along the interior aspect of the lower margin of the rib (fig 2). To avoid injury to the intercostal vessels the thoracocentesis or biopsy needle should be inserted immediately above the upper edge of the lower rib and the needle cutting edge should be directed downward. The specific cau'se of the intercostal vas- cular injury in this case is unclear. Movement of the chest wall, unexpected cough, or other taken blood suddenly gushed from the punc- mechanical factors could have misdirected the tured region and the patient fainted. Her withdrawal channel of the cutting needle. The blood pressure was 80/50 mm Hg. After being intercostal arteriogram showed that the inter- maintained in the Trendelenburg position for costal artery and vein were considerably below about five minutes she regained consciousness the inferior margin of the superior (9th) rib, and her blood pressure returned to normal. and this may have made these vessels more Pleural biopsy specimens showed caseating vulnerable to trauma. It is not clear why the granuloma typical of tuberculosis and massive intrapleural bleed from the pseudo- antituberculous chemotherapy was started. aneurysm was delayed for eight days. The patient remained well for four days after Presumably a haematoma formed initially the pleural biopsy, though a loud bruit was after the injury to the intercostal artery and http://thorax.bmj.com/ heard by auscultation over the site of the vein and this evolved to produce a fistula biopsy, with radiation to the back. The patient between the artery and vein, the haematoma refused further invasive diagnostic procedures producing the pseudoaneurysm. The high until eight days after the biopsy, when she pressure within the pseudoaneurysm usually fainted suddenly and was found to be hypo- presents some time after the original trauma, tensive. A chest radiograph showed that the volume of the left pleural effusion had increased. The haemoglobin concentration on September 29, 2021 by guest. Protected copyright. had fallen to 7-5 g/dl. Intravenous fluid and a blood transfusion were given, her blood pressure was stabilised, and she regained consciousness. Pleural intubation was accom- plished and about 800 ml of grossly blood stained fluid was obtained. Selective aortic angiography disclosed an arteriovenous fistula and a pseudoaneurysm in the 9th left inter- costal space at the site of the pleural biopsy (fig 1). A left thoracotomy was performed. A large blood clot and more than 2 litres of fresh blood were found in the pleural cavity. Continuous bleeding was noted at a small puncture site, corresponding to the pleural biopsy area. The intercostal artery and vein were ligated, and pleural decortication per- formed. The patient recovered uneventfully. Discussion Diagnostic thoracocentesis and pleural biopsy have been recognised for decades as valuable invasive diagnostic procedures.' Closed Figure 2 Diagram of the positional relationships pleural biopsy is a blind procedure and trau- between intercostal artery, vein, nerve, ribs, and matic complications are sometimes encoun- intercostal space. 978 Lai, Yan, Kao, Lee, Shen and may explain the delayed bleeding in this literature and report of 132 biopsies. Ann Intern Med 1958;48:344-62. patient. 2 Morone N, Algranti E, Barreto E. Pleural biopsy with Cope the need for care in and Abrams needles. Chest 1987;92:1050-2. This case emphasises Thorax: first published as 10.1136/thx.45.12.976 on 1 December 1990. Downloaded from 3 MacDonald RS. Pleural aspiration and biopsy [letter]. Br the selection of a site adjacent to the upper Med J 1980;280:1088. margin of the inferior rib when a pleural 4 Mestitz P, Purves MJ, Pollard AC. Pleural biopsy in the diagnosis ofpleural effusion. A report on 200 cases.
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