Intercostal Artery Laceration Following Thoracentesis

Mary L Yacovone MEd RRT, Ritha Kartan MD, and Manuel Bautista MD

Intercostal artery laceration is an unusual complication following thoracentesis, and has beenreported only in elderly patients. We report a case of a 78-year-old man who developed a massivehemothorax following thoracentesis. Post-thoracentesis radiograph revealed a substantial increasein pleural fluid, and emergency chest tube insertion identified the hemothorax. He underwent rightthoracotomy for repair of the intercostal artery laceration. Key words: intercostal artery laceration;thoracentesis; hemothorax; thoracotomy. [Respir Care 2010;55(11):1495–1498. © 2010 Daedalus En-terprises]

Introduction

Thoracentesis is a common diagnostic and therapeuticprocedure, in which a percutaneously introduced needle isused to remove fluid from the pleural space. Clinically, themost common post-thoracentesis complication is pneumo-thorax, with an incidence of 3–30%.1-10 Table 1 lists post-thoracentesis complications.1-18 There are very few docu-mented cases of intercostal artery laceration duringthoracentesis, and they appear to be most commonly re-ported in the elderly.11 Intercostal artery laceration canalso occur during thoracostomy for chest tube insertion,19

and probably in patients with coarctation of the aorta,which leads to engorgement and tortuosity of the intercos-tal arteries.20 We report a case of an elderly patient whodeveloped a massive hemothorax due to an intercostal ar-tery laceration that occurred despite our following all therecommended thoracentesis procedures.

Case Report

A 78-year-old white man with a history of congestiveheart failure secondary to ischemic cardiomyopathy wasadmitted with generalized weakness and shortness of breaththat had worsened during the week prior to admission. Hecomplained of dyspnea on exertion, and orthopnea, andstated that he used 3 pillows during sleep. Chest radio-graph on admission showed a large right pleural effusion(Fig. 1). Review of the chest radiograph from 3 monthsbefore this presentation showed no pleural effusion. Hismedical history was notable for diabetes mellitus, anemiasecondary to gastrointestinal bleeding, hypothyroidism, hy-perlipidemia, coronary artery disease, coronary artery by-

Mary L Yacovone MEd RRT is affiliated with the Department of HealthProfessions, The Bitonte College of Health and Human Services, Young-stown State University, Youngstown, Ohio. Ritha Kartan MD, and Man-uel Bautista MD are affiliated with the Department of Internal Medicine,Forum Health, and with Northeastern Ohio Universities Colleges of Med-icine and Pharmacy, Youngstown, Ohio.

The authors have disclosed no conflicts of interest.

Correspondence: Mary L Yacovone MEd RRT, Department of HealthProfessions, The Bitonte College of Health and Human Services, Youngs-town State University, Youngstown OH 44515. E-mail: mlyacovone@ysu.edu.

Table 1. Complications Following Thoracentesis

ComplicationOccurrence Rate

(%)

Pneumothorax 3–30Re-expansion pulmonary edema 0.2–14Vasovagal reaction � 3Hemothorax � 1Pneumohemothorax � 1Retained intrapulmonary catheter fragments � 1Splenic laceration � 1Abdominal hemorrhage NDIntercostal artery laceration NDPulmonary hemorrhage NDSubcutaneous implantation of cancer ND

ND � no data available, though case reports of these complications suggest that theiroccurrence rate is � 1%

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pass graft of 4 vessels (in 2005), congestive heart failuresecondary to ischemic cardiomyopathy, an ejection frac-tion of 20%, inducible ventricular tachycardia, placementof an implantable cardioverter defibrillator, hypertension,carotid endarterectomy, and prostate cancer with radiationtreatment. He was an ex-smoker of 30 pack years. Hedenied any fever or chills, chest pain, cough, or hemop-tysis. His medications on presentation included carvedilol,metformin hydrochloride, enalapril, iron, levothyroxine,atorvastatin, tamsulosin hydrochloride, warfarin, aspirin,and oxygen therapy (4 L/min via nasal cannula).

At the time of admission he was afebrile (36.1° C), withblood pressure 135/75 mm Hg, heart rate 78 beats/min,respiratory rate 18 breaths/min, and oxygen saturation 94%while on supplemental oxygen at 4 L/min via nasal can-nula. Auscultation revealed normal heart sounds, a grade 3/6parasternal systolic murmur, bilateral crackles, diminishedbreath sounds and dullness to percussion on the right side,and decreased tactile fremitus. Abdominal examinationfound a fluid wave due to ascites. Physical examinationwas also positive for jugular venous distention and 3�peripheral edema. Both his lower extremities were wrappedfor skin erythema and skin breakdown.

Pertinent laboratory findings included hemoglobin8.1 g/L, CO2 content 30 mmol/L, blood urea nitrogen 45 mg/dL, creatinine 1.5 mg/dL, and INR [prothrombin time in-ternational normalized ratio] 4.5. Chest radiograph on hissecond hospital day revealed an increase in the right ef-fusion. He continued to complain of dyspnea and orthop-nea and had failed diuretic therapy.

The pulmonary service was consulted for a diagnosticand therapeutic thoracentesis. After evaluation, the pulmo-nologist agreed to perform a thoracentesis once his INRwas less than 2.0, and vitamin K and fresh frozen plasmawere administered. On his third hospital day, his INR was

1.6, and, after obtaining informed consent, he underwentright thoracentesis. He was positioned upright and leaningforward throughout the procedure. Once the fluid was lo-cated via ultrasound, the skin was prepped and draped withsterile technique. The skin, the superior aspect of the peri-ostium of the eighth rib at the midscapular line, and theparietal pleura were then anesthetized with 1% lidocaine.An 8 French catheter attached to a 50-mL syringe wasinserted over the same tract of the superior aspect of therib, and approximately 1,200 mL of light amber fluid wasobtained and sent for analysis. He denied any chest dis-comfort or pain during or after the procedure. A chestradiograph was obtained immediately after the thoracen-tesis, and he was closely monitored for changes in vitalsigns.

The pleural fluid analysis revealed pH 7.49, glucose115 mg/dL, albumin 1.7 g/dL, lactate dehydrogenase 88 g/dL, and total protein 3.0 g/dL. Total serum protein was5.7 g/dL, serum albumin was 3.1 g/dL, and serum lactatedehydrogenase was 202 g/dL. The pleural fluid was tran-sudative and secondary to his congestive heart failure. Thechest radiograph was negative for pneumothorax andshowed a reduction in the pleural effusion (Fig. 2).

Approximately 2 hours after the thoracentesis, he com-plained of chest pain and shortness of breath, and his bloodpressure dropped to 80/40 mm Hg. On physical examina-tion he was diaphoretic and his skin was pale. Anotherchest radiograph revealed a substantial increase in the rightpleural opacity (Fig. 3). A hemothorax was immediatelysuspected, and surgery was consulted for chest tube inser-tion. He underwent emergency chest tube insertion, whichimmediately drained a large amount of blood and clots. Hewas transported to the operating room for exploration andcontrol of bleeding in the right chest cavity. Right antero-

Fig. 1. Admission radiograph shows large right pleural effusion. Fig. 2. Radiograph immediately after thoracentesis is negative forpneumothorax and shows reduced pleural effusion.

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lateral thoracotomy revealed a right hemothorax full ofclots compressing the right lung and mediastinum, and ableeding intercostal artery. Intraoperatively he received4 units of packed red blood cells, 3 units of fresh frozenplasma, 1 unit of platelets, and 1,300 mL of crystalloid.Estimated blood loss was 2 L. The intercostal artery wasrepaired and a second chest tube was inserted. Postoper-ative hemoglobin was 9.3 g/L and hematocrit was 27.2%.He tolerated the procedure well and was transported instable condition to the intensive care unit. The followingday he was weaned from mechanical ventilation and ex-tubated.

Discussion

Thoracentesis is a diagnostic and therapeutic procedurethat is routinely performed for evaluation of pleural effu-sion. Clinical judgment determines if the information ob-tained from pleural fluid analysis is important for diag-nostic and therapeutic intervention. The most commonlyreported thoracentesis complication is puncture of the vis-ceral pleura, which can cause a pneumothorax. Ultrasoundguidance allows the physician to determine a more accu-rate needle insertion depth into the intercostal space andthus reduces the incidence of pneumothorax.9,21 Evalua-tion of rib-space width or visualization of arterial bloodflow is not determined with the current method of pleuralultrasonography.21,22 Furthermore, ultrasound guidancedoes not completely replace the physical examination andconfirmation of the appropriate site for thoracentesis.

In this case thoracentesis was performed in the recom-mended manner. Ultrasound guidance and chest radiographwere also employed to evaluate the pleural effusion prior

to and immediately following the thoracentesis. In retro-spect, we believe that the choice of the 8 French cathetermay have increased the risk of intercostal artery lacerationin this patient. We hypothesize that this patient’s history ofcoronary artery bypass graft may have produced thoracicanatomical changes. Coronary artery bypass graft can causerib fractures, abnormal rib cage motion, and pleural fibro-sis,23-27 which could increase the risk of intercostal arterylaceration. This case emphasizes the importance of under-standing the anatomy of the rib cage and the anatomicalchanges in the elderly.

Understanding the rib and intercostal space anatomy iskey to choosing the proper thoracentesis technique. Be-tween each rib is the intercostal space, which is largelyfilled with the external and internal intercostal muscles.Also within the intercostal space and beneath the costalgrove of the rib is a neurovascular bundle made of inter-costal vein, artery, and nerve. The intercostal arteries liebetween the intercostal vein and nerve. Each intercostalartery passes obliquely and laterally to the angle of thesuperior rib (Fig. 4). The patient is positioned upright andleaning forward to increase the area within the intercostalspace. A site midway between the spine and axillary lineis selected because the ribs are easily palpated in thatlocation. The needle is inserted 1 to 2 interspaces belowthe level where the percussion note becomes dull and frem-itus is absent. If ultrasound guidance is used, the patientposition must be precisely maintained during the thora-

Fig. 3. Radiograph approximately 2 hours after thoracentesis showsa right pleural opacity, which was found to be a hemothorax froman intercostal artery laceration during thoracentesis.

Fig. 4. Anatomy of the intercostal rib space.

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centesis. The needle should pass over the superior aspectof the rib to decrease the likelihood of injury to the neu-rovascular bundle that traverses the inferior rib margin.

Increase in tortuosity of intercostal arteries and decreasein the “safe area” (the space between the superior aspect ofthe lower rib and the lowest point of the intercostal artery)for thoracentesis appear to occur with aging.11 This in-creases the likelihood of intercostal artery laceration in theelderly, so extreme caution and strict adherence to therecommended thoracentesis techniques are essential.Proper thoracentesis techniques, including physical exam-ination confirmation of appropriate thoracentesis site, cor-rect patient positioning, ultrasound guidance, and closepost-thoracentesis monitoring, did not avoid intercostal ar-tery laceration in our patient, but the close monitoring didallow for early diagnosis and treatment.

The possibility that catheter diameter and distortion ofour patient’s intercostal anatomy may have caused theintercostal artery laceration should also be considered. Thiscase led to a change in catheter selection in our practice.Now we routinely substitute an 18-gauge angiocatheter forthe catheter that is currently part of the kit.

This case report emphasizes a thoracentesis complica-tion that is more likely in an elderly patient. Althoughintercostal artery laceration is rare, it should be considereda potential thoracentesis complication, particularly in theelderly. Every attempt should be made to minimize thisrisk. Close monitoring is necessary, and catheter size shouldbe carefully considered in the planning of thoracentesis inelderly patients.

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