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

Abstract

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.

Assessment of patient-reported outcome measures in pleural interventions

“…Pleural procedures are associated with potential significant harm, and being able to predict which patients will not gain symptom relief would be of great value. 17 …”

Diagnostic Accuracy of Lateral Decubitus Chest Radiography before Pleural Maneuvers for the Management of Pleurisies in the Era of Chest Ultrasound

“…The potential presence of pleural adhesions is crucial to evaluate before all diagnostic or therapeutic pleural maneuvers because of the increasing risk of lung injury and sometimes lack of access to the pleural cavity [16-18]. The prediction of pleural adhesions is useful to choose the port site before a thoracentesis, a percutaneous pleural biopsy or a thoracoscopy [19].…”

Bleeding after Percutaneous Transhepatic Biliary Drainage: Incidence, Causes and Treatments

“…The intercostal artery runs inferior to each respective rib, and risk of injury to the intercostal artery can be reduced by crossing above rather than below the rib [ 30 ]. The intercostal artery, however, can be redundant/tortuous within the intercostal space, especially in older patients, and is at risk for injury even when puncture is performed immediately above the rib [ 31 ].…”