No abstract

Hemothorax due to intercostal artery hemorrhage is a rare but known complication of chest tube insertion.Here we describe a case of massive hemothorax and cardiac arrest due to hemorrhagic shock that occurred after chest tube removal. CASE PRESENTATION:A 53-year-old woman with a history of heart failure and atrial fibrillation was admitted with acute hypoxemic respiratory failure. She was found to have bilateral pleural effusions on imaging. The patient was diuresed aggressively and therapeutically anticoagulated for her atrial fibrillation. She was weaned to minimal oxygen, however continued to have a persistent right pleural effusion. Anticoagulation was held for the procedure and after informed consent, the patient underwent uncomplicated placement of a 14 Fr pigtail chest tube via Seldinger technique with immediate return of serosanguinous fluid. Initial studies were consistent with an exudative effusion. The patient resumed therapeutic anticoagulation after the procedure. After three days, fluid output had slowed, imaging showed resolution of effusion (Figure 1), and the decision was made to remove the chest tube. Immediately after removal, the newly applied dressing was noted to be saturated with fresh blood. The dressing was removed and compression was held for ten minutes at which point no further bleeding was noted. However, roughly 30 minutes later, the patient became acutely hypotensive and tachycardic. Bedside ultrasound showed a new accumulation of hyperechoic fluid in the pleural space consistent with hemothorax (Figure 2, Figure 3). Shortly thereafter, the patient became unresponsive and suffered cardiac arrest. As the patient was undergoing resuscitative efforts, an emergent surgical chest tube was placed with immediate return of a large volume of bright red blood. The patient achieved return of spontaneous circulation after receiving blood products via our institution's massive transfusion protocol and reversal of anticoagulation. A CT-Angiogram of the chest was obtained which revealed an acute bleed from the ninth intercostal artery. Thoracic arteriography confirmed active arterial extravasation at this site and so she underwent transarterial embolization of the right T9 intercostal artery. The patient eventually required VATS to evacuate the retained hemothorax, however she survived to discharge. DISCUSSION: This case describes the delayed presentation of a rare complication of chest tube insertion that was only revealed after the chest tube was removed.CONCLUSIONS: Intercostal artery injury and subsequent hemorrhage is a potentially life-threatening complication of chest tube insertion. However, this injury may not become apparent until after chest tube removal, as the tube itself may act to tamponade the affected vessel and prevent bleeding.