Course and Variation of the Intercostal Artery by CT Scan

Helm, Emma; Rahman, Najib M.; Talakoub, Omid; Fox, Dov; Gleeson, Fergus

doi:10.1378/chest.12-1285

Cited by 66 publications

(59 citation statements)

References 7 publications

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“…This is the rationale behind the recommendation to insert needles just above the superior border of the rib. However, imaging studies have consistently demonstrated that the vessels lie exposed posteriorly, especially in elderly patients and in more cephalad rib spaces 3. For this reason, the posterior approach should be avoided if possible and a lateral approach, within the ‘safe triangle’, minimises risks of ICA laceration.…”

Section: Discussionmentioning

confidence: 99%

“…Proper site selection for pleural interventions is important as this minimises the likelihood of ICA laceration. In a recent large study, Helm et al 3 identified that ICA is exposed within the intercostal space in the first 6 cm lateral to the spine using CT pulmonary angiograph and mapping of the ICA course. The variability of ICA is greater in older people and in more cephalad rib spaces and decreases with lateral distance from the spinous process.…”

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confidence: 99%

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Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention

Psallidas

Helm

Maskell

et al. 2015

Thorax

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To cite: Psallidas I, Helm EJ, Maskell NA, et al. Thorax 2015;70:802-804.Pleural interventions are commonly performed in both elective and emergency settings. They include simple thoracocentesis, closed pleural biopsy (with or without image guidance), intercostal drain (ICD) insertion, in-dwelling pleural catheter insertion and medical thoracoscopy. Complications of pleural procedures are common but their incidence is often under-recognised. Higher operator experience and the use of image guidance are key factors demonstrated to significantly reduce the frequency of complications. 1 Injury to the intercostal artery (ICA) is an infrequent but potentially life-threatening complication of all pleural interventions. Pleural haemorrhage is reported to occur in up to 2% of thoracocenteses, up to 13% of ICD insertions and up to 4% of thoracoscopies. 2 The true incidence of ICA laceration and consequent pleural haemorrhage is likely to be higher due to under-reporting of complications seen in retrospective case series.The British Thoracic Society has published guidelines for the insertion of ICDs, 1 aiming to reduce the potential harm of ICD insertion. Although these recommendations are likely to reduce certain complications such as drain insertion into abdominal or thoracic viscera, they do not specifically address the possibility of ICA injury. Proper site selection for pleural interventions is important as this minimises the likelihood of ICA laceration. In a recent large study, Helm et al 3 identified that ICA is exposed within the intercostal space in the first 6 cm lateral to the spine using CT pulmonary angiograph and mapping of the ICA course. The variability of ICA is greater in older people and in more cephalad rib spaces and decreases with lateral distance from the spinous process. Additionally, another important parameter is the management protocol for intrapleural haemorrhage. This should be in place prior to any pleural interventions to avoid life-threatening delays.We present three cases of iatrogenic ICA injury in different clinical circumstances, from three different institutions in the UK and USA and make recommendations for avoiding and dealing with ICA injury. CASE 1A middle-aged patient was admitted with acute left-sided pleuritic pain and sudden onset dyspnoea. Four months prior to this admission, the patient underwent a left upper lobe wedge resection for a T1 N0 M0 adenocarcinoma of the lung. Medical history also included epilepsy, transient ischaemic attack, hypertension and alcohol abuse. The initial differential diagnosis included pulmonary embolus and therefore treatment dose low molecular weight heparin was given and a CT pulmonary angiogram (CTPA) was arranged. The CTPA did not show any evidence of pulmonary embolus but demonstrated a new small right pleural effusion.

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Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention

Psallidas

Helm

Maskell

et al. 2015

Thorax

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“…While most physicians use ultrasound merely to mark the site for needle insertion before setting up for the procedure, real-time ultrasound using a sterile sleeve allows sampling of previously unreachable small loculated effusions and occasionally allows parietal pleural biopsies. Furthermore, recent evidence suggests that pre-procedural identification of the intercostal artery, the course of which can be unpredictable, is easily achieved with a high-frequency probe and could help avoid rare but potentially fatal bleeding complications 20– 22 . Ultrasound examination immediately after the procedure can indirectly suggest the occurrence of pneumothorax by the disappearance of the typical “sliding” sign, representing the sliding of visceral and parietal pleura over each other.…”

Section: Diagnosis Of Pleural Diseases: Non-invasive Studiesmentioning

confidence: 99%

Diagnostic approach to pleural diseases: new tricks for an old trade

2017

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The burden of pleural diseases has substantially increased in the past decade because of a rise in the incidence of pleural space infections and pleural malignancies in a patient population that is older and more immunocompromised and has more comorbidities. This complexity increasingly requires minimally invasive diagnostic options and tailored management. Implications for patients are such that the limitations of current diagnostic methods need to be addressed by multidisciplinary teams of investigators from the fields of imaging, biology, and engineering. Ignored for a long time as an epiphenomenon at the crossroad of many unrelated medical problems, pleural diseases are finally getting the attention they deserve and have spurred a vibrant and exciting field of research.

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“…This allows the clinician to target the largest pocket, while ensuring entry into the effusion via the most comfortable and safe route. For example, a posterior pocket of pleural fluid may be entered at a lower volume lateral site and directed into the pocket of fluid, avoiding the risk of intercostal vasculature disruption associated with posterior placements . When this is not possible, vasculature in the region of placement can be assessed with Doppler to reduce the risk of encountering any aberrant blood vessels.…”

Section: Role Of Interventional Pulmonology In Diagnosticsmentioning

confidence: 99%

Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

Breen

Daneshvar

2014

Respirology

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Pleural infection is a major problem that affects 80 000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.

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Course and Variation of the Intercostal Artery by CT Scan

Cited by 66 publications

References 7 publications

Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention

Iatrogenic injury to the intercostal artery: aetiology, diagnosis and therapeutic intervention

Diagnostic approach to pleural diseases: new tricks for an old trade

Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

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