Massive Hemorrhage From the Posterior Intercostal Artery Following Lower Partial Sternotomy: a Case Report

Abstract

Background: In recent years, partial sternotomy has been adopted as an approach for minimally invasive cardiac surgery. Lower partial sternotomy is considered a superior approach compared to full sternotomy in terms of postoperative sternum fixation. We reported a very rare complication of posterior intercostal bleeding after aortic valve replacement with lower partial sternotomy.Case presentation: A 79-year-old man underwent aortic valve replacement using lower partial sternotomy involving the right second intercostal space. The surgery was completed without any problem. However, a postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Therefore, we inserted a drainage tube immediately. His blood pressure gradually decreased despite not having much drainage from the chest tube. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed an emergency lower partial sternotomy again. We detected the origin of the bleeding in the right fourth posterior intercostal artery and obtained hemostasis with direct suture. The postoperative course was uneventful.Conclusions: This case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of a clear rib fracture. In our case, we did not identify the cause of the bleeding. However, we suggest that the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.