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Hemothorax Resulting from Injury to the Right Inferior Phrenic Artery following Transhepatic Procedures
LETTER TO THE EDITOR Hemothorax Resulting from Injury to the Right Inferior Phrenic Artery following Transhepatic Procedures From: Brittany Bartolome, BA Maureen P. Kohi, MD Nicholas Fidelman, MD Andrew G. Taylor, MD, PhD Kanti P. Kolli, MD Jeanne M. LaBerge, MD Robert K. Kerlan, Jr, MD Department of Radiology and Biomedical Imaging (M.P.K., N.F., A.G.T., K.P.K., J.M.L., R.K.K.) University of California, San Francisco San Francisco, California; and University of Nevada School of Medicine (B.B.) Reno, Nevada
Editor: Bleeding complications occur in 2%–3% of patients undergoing percutaneous transhepatic cholangiography or drain placement (1). Additionally, hemorrhagic complications arise in 0.06%–1.7% of percutaneous liver biopsies and may include intraperitoneal hemorrhage, intrahepatic or subscapular hematomas, and hemobilia (2). Although uncommon, hemothorax following transhepatic procedures usually results from injury to the intercostal arteries (1). Other rare sources of bleeding after transhepatic procedures include the hepatic arteries, portal vein, and hepatic veins (1,2). Herein, we present two cases of transhepatic procedures, which resulted in a right-side hemothorax following injury to the right inferior phrenic artery. Institutional review board approval was not required for these retrospective case reports. Case 1. A 54-year-old man who had undergone liver transplantation was found to have portal vein stenosis with persistent portal hypertension on routine abdominal ultrasound (US). He presented to our institution for portal vein stent placement, which was performed via a percutaneous transhepatic approach. Portography demonstrated a short-segment moderate stenosis of the main portal vein with poststenotic dilation. Following balloon dilation, a 14 40-mm Zilver stent (Cook, Bloomington, Indiana) was deployed across the stenosis, resulting in improved venous flow and portal pressures. Several hours after the procedure, the patient developed acute shortness of breath, tachycardia, and hypotension. A chest radiograph demonstrated complete opacification of the right hemithorax, suggestive of a right hemothorax. A chest tube was emergently placed at None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.038
the bedside, and more than 200 mL of bright red blood was evacuated. When in stable condition, the patient was transferred to the interventional radiology suite for angiography and possible embolization. Selective angiography of the right intercostal arteries and the hepatic arteries did not demonstrate evidence of active extravasation or vascular irregularity. A right inferior phrenic angiogram demonstrated an irregularity of the distal branches suggestive of pseudoaneurysm formation with vasospasm (Fig 1). Selective catheterization was not possible as a result of severe vasospasm. The patient was then taken to the operating room for right-sided thoracotomy, which demonstrated active bleeding along the anterior surface of the diaphragm. Electrocautery and argon beam coagulation were used to achieve hemostasis. The patient’s condition improved, and he did not experience further bleeding during his hospitalization or at the time of follow-up 3 months after the surgery. Case 2. A 59-year-old man who had undergone liver transplantation presented with increased aminotransferase levels and underwent a percutaneous liver biopsy, performed by a hepatologist at our institution. The biopsy was performed via a right midaxillary approach through the eighth/ninth rib interspace with a 16-gauge Jamshidi needle (CareFusion, Waukegan, Illinois) needle. Two days after the liver biopsy, the patient’s hematocrit level decreased, and an abdominal US study demonstrated a large subdiaphragmatic hematoma overlying the area of the liver biopsy site, with active extravasation and a large right pleural effusion. The patient presented to the interventional radiology suite for angiography and possible embolization. Selective arteriography of the right intercostal arteries and the hepatic arteries did not demonstrate evidence of arterial injury. However, active arterial extravasation was identified from a distal branch of the right inferior phrenic artery
Figure 1. Right inferior phrenic digital subtraction angiogram demonstrates irregularity of the distal branches (arrow).
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Figure 2. (a) Right inferior phrenic artery digital subtraction angiogram demonstrates active extravasation from a distal branch (solid arrow). (b) Close-up image again demonstrates active extravasation (arrow). (c) Postembolization image no longer demonstrates active extravasation, with flow preserved in the proximal inferior phrenic artery (arrow).
(Fig 2a, b). The right inferior phrenic artery was successfully embolized with a combination of gelatin sponge slurry and 3-mm 2-mm Tornado coils (Cook; Fig 2c). The patient’s condition improved, and he did not experience further bleeding during his hospitalization or at the time of follow-up 45 days after the embolization procedure. Hemothorax and hemoperitoneum are rare complications of transhepatic procedures. Although uncommon, such bleeding complications may be fatal if not treated. Therefore, prompt diagnosis and immediate intervention are imperative. In most cases of hemothorax following transhepatic procedures, the bleeding is usually caused by injury to the intercostal arteries. A few case reports (3,4) have demonstrated hemothorax caused by bleeding from the inferior phrenic artery. Ogawa et al (3) reported a case of right hemothorax caused by injury to the inferior phrenic artery in a patient who experienced blunt trauma. In addition, Masumoto et al (4) reported a case of hemothorax caused by bleeding of the right inferior phrenic in a case of a ruptured hepatocellular carcinoma. Although hemothorax caused by injury to the right inferior phrenic artery is extremely uncommon, it is important to be aware of this complication in patients
who have undergone transhepatic procedures. In the absence of active extravasation from intercostal and hepatic arteries, catheterization and angiography of the right inferior phrenic artery should be considered. Irregularity of the distal right inferior phrenic arterial branches in the absence of active extravasation from other likely sources should result in consideration of empiric embolization. In addition, if surgical intervention is undertaken for such patients, the surgeon should be advised to thoroughly evaluate the diaphragm for bleeding from branches of the inferior phrenic artery.
REFERENCES 1. Saad WE, Davies MG, Darcy MD. Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Tech Vasc Interv Radiol 2008; 11:60–71. 2. Terjung B, Lemnitzer I, Dumoulin FL, et al. Bleeding complications after percutaneous liver biopsy. Digestion 2003; 67:138–145. 3. Ogawa F, Maito M, Iyoda A, Satoh Y. Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs. Journal of Cardiothoracic Surgery 2013; 8:205. 4. Masumoto A, Motomura K, Uchimura K, Morotomi I, Morita K. Case report: hemothorax due to hepatocellular carcinoma rupture successfully controlled by transcatheter arterial embolization. Journal of Gastroenterology Hepatology 1997; 12:156–158.
Editor: Bleeding complications occur in 2%–3% of patients undergoing percutaneous transhepatic cholangiography or drain placement (1). Additionally, hemorrhagic complications arise in 0.06%–1.7% of percutaneous liver biopsies and may include intraperitoneal hemorrhage, intrahepatic or subscapular hematomas, and hemobilia (2). Although uncommon, hemothorax following transhepatic procedures usually results from injury to the intercostal arteries (1). Other rare sources of bleeding after transhepatic procedures include the hepatic arteries, portal vein, and hepatic veins (1,2). Herein, we present two cases of transhepatic procedures, which resulted in a right-side hemothorax following injury to the right inferior phrenic artery. Institutional review board approval was not required for these retrospective case reports. Case 1. A 54-year-old man who had undergone liver transplantation was found to have portal vein stenosis with persistent portal hypertension on routine abdominal ultrasound (US). He presented to our institution for portal vein stent placement, which was performed via a percutaneous transhepatic approach. Portography demonstrated a short-segment moderate stenosis of the main portal vein with poststenotic dilation. Following balloon dilation, a 14 40-mm Zilver stent (Cook, Bloomington, Indiana) was deployed across the stenosis, resulting in improved venous flow and portal pressures. Several hours after the procedure, the patient developed acute shortness of breath, tachycardia, and hypotension. A chest radiograph demonstrated complete opacification of the right hemithorax, suggestive of a right hemothorax. A chest tube was emergently placed at None of the authors have identified a conflict of interest. http://dx.doi.org/10.1016/j.jvir.2014.11.038
the bedside, and more than 200 mL of bright red blood was evacuated. When in stable condition, the patient was transferred to the interventional radiology suite for angiography and possible embolization. Selective angiography of the right intercostal arteries and the hepatic arteries did not demonstrate evidence of active extravasation or vascular irregularity. A right inferior phrenic angiogram demonstrated an irregularity of the distal branches suggestive of pseudoaneurysm formation with vasospasm (Fig 1). Selective catheterization was not possible as a result of severe vasospasm. The patient was then taken to the operating room for right-sided thoracotomy, which demonstrated active bleeding along the anterior surface of the diaphragm. Electrocautery and argon beam coagulation were used to achieve hemostasis. The patient’s condition improved, and he did not experience further bleeding during his hospitalization or at the time of follow-up 3 months after the surgery. Case 2. A 59-year-old man who had undergone liver transplantation presented with increased aminotransferase levels and underwent a percutaneous liver biopsy, performed by a hepatologist at our institution. The biopsy was performed via a right midaxillary approach through the eighth/ninth rib interspace with a 16-gauge Jamshidi needle (CareFusion, Waukegan, Illinois) needle. Two days after the liver biopsy, the patient’s hematocrit level decreased, and an abdominal US study demonstrated a large subdiaphragmatic hematoma overlying the area of the liver biopsy site, with active extravasation and a large right pleural effusion. The patient presented to the interventional radiology suite for angiography and possible embolization. Selective arteriography of the right intercostal arteries and the hepatic arteries did not demonstrate evidence of arterial injury. However, active arterial extravasation was identified from a distal branch of the right inferior phrenic artery
Figure 1. Right inferior phrenic digital subtraction angiogram demonstrates irregularity of the distal branches (arrow).
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April
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2015
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Figure 2. (a) Right inferior phrenic artery digital subtraction angiogram demonstrates active extravasation from a distal branch (solid arrow). (b) Close-up image again demonstrates active extravasation (arrow). (c) Postembolization image no longer demonstrates active extravasation, with flow preserved in the proximal inferior phrenic artery (arrow).
(Fig 2a, b). The right inferior phrenic artery was successfully embolized with a combination of gelatin sponge slurry and 3-mm 2-mm Tornado coils (Cook; Fig 2c). The patient’s condition improved, and he did not experience further bleeding during his hospitalization or at the time of follow-up 45 days after the embolization procedure. Hemothorax and hemoperitoneum are rare complications of transhepatic procedures. Although uncommon, such bleeding complications may be fatal if not treated. Therefore, prompt diagnosis and immediate intervention are imperative. In most cases of hemothorax following transhepatic procedures, the bleeding is usually caused by injury to the intercostal arteries. A few case reports (3,4) have demonstrated hemothorax caused by bleeding from the inferior phrenic artery. Ogawa et al (3) reported a case of right hemothorax caused by injury to the inferior phrenic artery in a patient who experienced blunt trauma. In addition, Masumoto et al (4) reported a case of hemothorax caused by bleeding of the right inferior phrenic in a case of a ruptured hepatocellular carcinoma. Although hemothorax caused by injury to the right inferior phrenic artery is extremely uncommon, it is important to be aware of this complication in patients
who have undergone transhepatic procedures. In the absence of active extravasation from intercostal and hepatic arteries, catheterization and angiography of the right inferior phrenic artery should be considered. Irregularity of the distal right inferior phrenic arterial branches in the absence of active extravasation from other likely sources should result in consideration of empiric embolization. In addition, if surgical intervention is undertaken for such patients, the surgeon should be advised to thoroughly evaluate the diaphragm for bleeding from branches of the inferior phrenic artery.
REFERENCES 1. Saad WE, Davies MG, Darcy MD. Management of bleeding after percutaneous transhepatic cholangiography or transhepatic biliary drain placement. Tech Vasc Interv Radiol 2008; 11:60–71. 2. Terjung B, Lemnitzer I, Dumoulin FL, et al. Bleeding complications after percutaneous liver biopsy. Digestion 2003; 67:138–145. 3. Ogawa F, Maito M, Iyoda A, Satoh Y. Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs. Journal of Cardiothoracic Surgery 2013; 8:205. 4. Masumoto A, Motomura K, Uchimura K, Morotomi I, Morita K. Case report: hemothorax due to hepatocellular carcinoma rupture successfully controlled by transcatheter arterial embolization. Journal of Gastroenterology Hepatology 1997; 12:156–158.