Case Study

Coil embolization of traumatic pseudoaneurysm of right internal thoracic artery

Asian Cardiovascular & Thoracic Annals 2015, Vol. 23(8) 982–984 ß The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492314530978 aan.sagepub.com

Christos Tourmousoglou1, Peter Zambakis2, Efstratios Koletsis1, Christos Prokakis1, Nikolaos Charoulis1 and Dimitrios Dougenis1

Abstract Traumatic injury to the chest and internal thoracic artery is a perplexing problem that is difficult to diagnose and open to different treatment options. Internal thoracic artery pseudoaneurysms are an extremely rare vascular abnormality. We report the case of a patient with a pseudoaneurysm of the musculophrenic artery, a branch of right internal thoracic artery, caused by a penetrating injury of the chest.

Keywords Aneurysm, false, Embolization, therapeutic, Mammary arteries, Wounds, stab

Introduction Internal thoracic artery (ITA) pseudoaneurysm is a rare vascular abnormality. Computed tomography angiography with multidetector computed tomography is ideal for the diagnosis of ITA pseudoaneurysm. Transcatheter embolotherapy is an effective nonsurgical approach. We report a case of pseudoaneurysm of the musculophrenic artery, a peripheral branch of the right ITA, which was treated by coil embolization.

Case report A 35-year-old man presented to the emergency department of our hospital with a penetrating injury to the chest (5th–6th right intercostals spaces). He had been involved in a fight the same day and was stabbed in the chest with a knife. There was no previous history of medical problems before admission. Physical examination of the chest revealed the trauma site. Routine laboratory investigation showed no abnormalities. Chest radiography on admission demonstrated a round mass in the anterior mediastinum. Computed tomographic angiography (CTA) was performed with a 16-row multi-detector computed tomography (MDCT) device (Lightspeed Siemens) using the chest

CTA thoracic aorta protocol before and after intravenous injection of 120 mL Visipaque 320 (3.5 mLs 1). An additional delayed phase was obtained at 2 min. CTA revealed a pseudoaneurysm of the musculophrenic artery (a peripheral branch of the right IMA) and acute extravasation of the contrast into the soft tissues of the right anterior thoracic wall (Figure 1). A hematoma was observed adjacent to the posterior surface of the anterior thoracic wall at the level of the diaphragm. The following day, another chest CTA was performed to evaluate surgical treatment of the acute extravasation. CTA revealed no signs of contrast extravasation in the previous position, but the size of the ITA pseudoaneurysm was large (Figure 2). Endovascular treatment was decided. The right ITA was accessed from the right common femoral artery with a 6 F catheter (6.25-Iacovidis). The pseudoaneurysm was again demonstrated after super-selective catheterization of

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Cardiothoracic Department, University Hospital of Patra, Patra, Greece Department of Radiology, University Hospital of Patra, Patra, Greece

Corresponding author: Christos Tourmousoglou, MD, MSc, MSc, PhD, 29 Bournazou St., 11521 Athens, Greece. Email: [email protected]

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Figure 1. Coronal volume-rendered reformatted image depicting the relationship of the pseudoaneurysm with the right internal thoracic artery (black arrow).

Figure 3. Superselective catheterization of the internal thoracic artery showing the pseudoaneurysm prior to coil insertion.

Figure 2. Coronal volume-rendered reformatted image revealing enlargement of the pseudoaneurysm (white arrowhead).

the ITA with a 2.7 F microcatheter (Prograde, Terumo, Japan; Figure 3). The distal part of the ITA was occluded with two 2  50-mm, one 2  25-mm, and three 4  50-mm coils. On Day 10 of admission and 9 days after the embolization, a follow-up chest CTA revealed no sign of the pseudoaneurysm. Coils were visible proximal to the previously imaged pseudoaneurysm, and the preexisting hematoma had subsided (Figure 4a and 4b).

Discussion An ITA pseudoaneurysm (or branch pseudoaneurysm) is a rare vascular abnormality that commonly results from insertion of a catheter or central venous line into the subclavian vessels, penetrating chest trauma, sternotomy, or chest wall infections.1 The course of the internal thoracic artery shows why it is vulnerable to

penetrating parasternal injuries, blunt trauma, or sternal fractures. The average flow rate in the internal thoracic artery is 150 mLmin 1 and blood loss of 1 liter within a few minutes is possible.2 There is a rich collateral network of the internal thoracic arteries in the mediastinum and pericardium so an injury could result in hematoma, hemothorax, tamponade, complete transection, or formation of a pseudoaneurysm. Under the influence of sustained arterial pressure, blood dissects into the tissues and forms a perfused sac that communicates with the arterial lumen.3 ITA pseudoaneurysm might present as a pulsatile mass, hematoma, mediastinal hematoma, or hemothorax, with or without hemodynamic instability.1,4 The anatomic position and size of the ITA pseudoaneurysm are key points in the therapeutic approach. The best imaging modality for the diagnosis of ITA pseudoaneurysm is computed tomographic angiography with MDCT where the ITA pseudoaneurysm might appear as a contrast-filled sac with an adjacent vessel.3 We have described a pseudoaneurysm of the musculophrenic artery, a peripheral branch of ITA, which is very rare. The diagnosis was made by MDCT and the therapeutic approach was achieved by the cooperation of cardiac surgeons and radiologists. Pseudoaneurysms are treated by surgical repair, ultrasound-guided compression, or occlusion of the ITA using various embolic materials and thrombin injection directly into the pseudoaneurysm.5

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Figure 4. (a, b) Follow-up images showing no flow within the previously detected pseudoaneurysm.

Therapeutic embolization is performed using gelfoam,6 an autologous clot,7 alcohol, or Gianturco coils. Transcatheter embolization is performed using steel coils that are placed within the pseudoaneurysm. Another option is embolization of the feeding vessel.3 Potential complications of the procedure include embolization of the vertebral or subclavian arteries, but this could be avoided by selective catheterization.6 The existence of a rich collateral vascular network limits the possibility of chest wall infarction after selective embolization. Besides, injection of embolic material into the ITA distal to the arterial lesion prevents retrograde collateral flow to the bleeding site.6 If the ITA is truncated and not actively bleeding, it is difficult to decide if it should be embolized. ITA pseudoaneurysms might be life-threatening because of hemorrhage. Endovascular embolotherapy offers an effective and safe alternative to surgical management, and might be the preferred treatment. Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.

Conflict of interest statement

References 1. Nasir A, Viola N and Livesey S. Iatrogenic pseudoaneurysm of internal mammary artery: case report and literature review. J Card Surg 2009; 24: 355–356. 2. Ritter DC and Chang FC. Delayed hemothorax resulting from stab wounds to the internal mammary artery. J Trauma 1995; 39: 586–589. 3. Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ and Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005; 25: S173–S189. 4. Chemelli AP, Chemelli-Steingruber IE, Bonaros N, et al. Coil embolization of internal mammary artery injured during central vein catheter and cardiac pacemaker lead insertion. Eur J Radiol 2009; 71: 269074. 5. Tamim WZ, Arbid EJ, Andrews LS and Arous EJ. Percutaneous induced thrombosis of iatrogenic femoral pseudoaneurysms following catheterization. Ann Vasc Surg 2000; 14: 254–259. 6. Husted JW, Stock JR and Manella WJ. Traumatic anterior mediastinal hemorrhage: control by internal mammary artery embolization. Cardiovasc Intervent Radiol 1982; 5: 268–270. 7. Harrington DP, Barth KH, Baker RR, Truax BT, Abeloff MD and White RI Jr. Therapeutic embolization for hemorrhage from locally recurrent cancer of the breast. Radiology 1978; 129: 307–310.

None declared.

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Coil embolization of traumatic pseudoaneurysm of right internal thoracic artery.

Traumatic injury to the chest and internal thoracic artery is a perplexing problem that is difficult to diagnose and open to different treatment optio...
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