- Email: [email protected]
Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization
2134
CASE REPORT DIMARAKIS ET AL COIL EMBOLIZATION OF THE ANEURYSMAL SAC
FEATURE ARTICLES
The defect in the muscularis appears to have been caused by inflammation and local trauma, resulting in weakness and spasm. The pulsion defect then formed from intraluminal esophageal pressure on the weakened wall. As the inflammatory process progressed to a chronic, fibrosing stage, the diverticulum must have retracted into the inflamed lymphadenitis in the right paratracheal region and middle mediastinum. As a result, the wall became so inflamed, especially with the inspissated secretions that it eventually perforated into the mediastinum. The surgical repair was designed to address these components (ie, a myotomy to treat the pulsion-associated esophageal spasm and a vascular pedicle to support the weakened inflamed esophageal wall). In endemic areas, histoplasmosis is the most likely cause of fibrosing mediastinitis. This was supported by the computed tomographic findings of fibrosing mediastinitis without other clinically apparent causes in our case. Pathogens are rarely cultured from the lymph nodes of fibrosing mediastinitis and require no antimicrobial treatment [3]. In a review of 95 patients seen at the Mayo Clinic with mediastinal granuloma, 10% had esophageal involvement in the form of compression, stricture, diverticulum, sinus tract formation, or tracheoesophageal fistula [4]. There are a few case reports of esophagomediastinal fistula in the literature secondary to tuberculous lymphadenitis, esophageal candidiasis, and Hodgkin’s disease [5–7]. However, none of the prior reported cases presented with acute bacterial pericarditis, as was observed in our case. Our case highlights the importance of suspecting the diagnosis of bacterial pericarditis even in patients who present subacutely, particularly if they already had partial treatment with antibiotics. Identification of the offending organism(s) and investigations into the potential mechanisms of entry into the pericardium are critical to proper diagnosis and therapy.
Drs Kabra and Welke contributed equally to this work. Dr Weintraub is supported by grants (HL– 070860 and HL– 62948) from the National Institutes of Health.
References 1. Snyder RW, Braun TI. Purulent pericarditis with tamponade in a postpartum patient due to group F streptococcus. Chest 1999;115:1746 – 8. 2. Kaufman J, Thongsuwan N, Stern E, Karmy-Jones R. Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade. Ann Thorac Surg 2003;75:288 –9. 3. Dines DE, Payne WS, Bernatz PE, et al. Mediastinal granuloma and fibrosing mediastinitis. Chest 1979:320 – 4. 4. Dukes RJ, Strimlan CV, Dines DE, et al. Esophageal involvement with mediastinal granuloma. JAMA 1976;236:2313–5. 5. Devarbhavi HC, Alvares JF, Radhikadevi M. Esophageal tuberculosis associated with esophagotracheal or esophagome-
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:2134 – 6
diastinal fistula: report of 10 cases. Gastrointest Endosc 2003; 57(4):588 –92. 6. Kim BW, Cho SH, Rha SE, et al.et al. Esophagomediastinal fistula and esophageal stricture as a complication of esophageal candidiasis: a case report. Gastrointest Endosc 2000;52(6):772–5. 7. Papp JP, Penner JA. Esophagomediastinal fistula in Hodgkin’s disease. Postgrad Med 1970;48(4):180 –3.
Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization Ioannis Dimarakis, MD, James A. C. Thorpe, FRCS, and Kostas Papagiannopoulos, MD Thoracic Surgery Unit, Leeds General Infirmary, Leeds, United Kingdom
A 29-year-old man presented to the emergency department after having been stabbed in the posterior right hemithorax twice. He underwent thoracotomy for hemodynamic instability and continuous bleeding. His postoperative recovery was complicated by the incidental finding of a posttraumatic pseudoaneurysm of the pulmonary artery. We describe successful coil embolization of the aneurysmal sac avoiding any further surgical intervention. (Ann Thorac Surg 2005;79:2134 – 6) © 2005 by The Society of Thoracic Surgeons
T
raumatic pulmonary artery pseudoaneurysms are rare entities usually recognized by their complications. Few attempts have been described regarding nonoperative management with coil embolization in order to avoid surgery. A 29-year-old man presented to casualty with penetrating chest trauma. He had sustained two stab wounds to the posterior hemithorax. Initial assessment and management was carried out in agreement with the advanced trauma life support protocol. Chest roentgenogram revealed the presence of a large hemothorax managed with an intercostal drain. The initial drainage was 1,100 mL. The patient remained hemodynamically stable and a computed tomographic chest scan showed a remaining hemothorax with no other obvious injuries. After two hypotensive episodes in the radiology department requiring volume resuscitation and persistent
Accepted for publication Dec 10, 2003. Address reprint requests to Dr Papagiannopoulos, Leeds General Infirmary, Jubilee Bldg, Level D, Great George St, Leeds LS1 3EX, UK; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.023
Ann Thorac Surg 2005;79:2134 – 6
CASE REPORT DIMARAKIS ET AL COIL EMBOLIZATION OF THE ANEURYSMAL SAC
2135
Fig 1. Erect posteroanterior chest roentgenogram. Pseudoaneurysm shown as coin lesion in the right lung field; contrast enhanced computed tomographic scan (inset) confirms this.
chest drainage (700 mL), the patient was taken to the operating room. A right posterolateral thoracotomy was carried out. During exploration, the first stab wound was found to be coming through the sixth interspace. A sweating intercostal artery along with bleeding right upper lobe laceration was identified on the oblique fissure and hemostasis was secured with parenchymal suturing. The second wound tract was confined entirely in the superficial layers of the back with no intrapleural involvement. Routine postoperative chest roentgenogram films revealed the gradual development of a well-circumscribed, noncalcified coin lesion within the right upper pulmonary field (Fig 1). A contrast enhanced computed tomographic scan of the thorax revealed a pulmonary artery pseudoaneurysm. Pulmonary angiography showed that the pseudoaneurysm was arising from a subsegmental branch of the superior segmental artery of the right lower lobe next to the oblique fissure, although the laceration and knife entry point was at the right upper lobe. Successful embolization was carried out using four detachable embolization coils (Cook detachable embolization coil systems) (Fig 2). The patient was discharged shortly after in good clinical condition. He was reviewed 3 months postoperatively with no problems.
Pseudoaneurysm and arteriovenous fistulas are two vascular complications of chest trauma [1]. Traumatic pulmonary artery pseudoaneurysms are a well described clinical entity, but they still remain rare with few cases reported. Also known as pulsating hematomas, false aneurysms are characterized by the sole presence of adventitia or even surrounding connective tissue, and they can occur after significant blunt or penetrating injury. Occasionally they may remain undetected and silent for many years [2]. The most common presentation is hemoptysis. Shortness of breath, chest pain, and hypoxia may also be present [3]. Complications include spontaneous rupture with life threatening hemorrhage prompting for early diagnosis and appropriate management. Other complications include infection and thrombus formation, which may lead to distal embolization and thrombosis [2, 3]. A traumatic pulmonary artery pseudoaneurysm has also been reported to simulate pulmonary embolism causing a differential diagnostic problem [4]. Endovascular treatment has been previously applied in lesions resulting from malignancy or iatrogenic causes such as right heart catheterization and chest tube insertion [5, 6]. Physiologic differences attributed to pressures approaching systemic values in left to right shunts, as seen in congenital cases, may deem endovascular treatment inadequate [7]. Coil deployment has been attempted in a posttraumatic lesion, but eventually the
Fig 2. Arterial phase of pulmonary arteriogram shows filling of the pulmonary artery pseudoaneurysm from a subsegmental branch of the superior segmental artery of the right lower lobe. (Inset) Embolization coils have been deployed within the sac. No further filling was seen.
FEATURE ARTICLES
Comment
2136
CASE REPORT KHAN ET AL ANGIOGRAPHIC EMBOLIZATION
Ann Thorac Surg 2005;79:2136 – 8
Angiographic Embolization of a Traumatic Pulmonary Pseudoaneurysm Ahmad A. Khan, MD, Thomas L. Bauer, MD, Mark J. Garcia, MD, D. Bruce Panasuk, MD, and Allen L. Davies, MD Section of Thoracic Surgery, Department of Surgery, Christiana Care Health Services, Newark, Delaware
FEATURE ARTICLES
Fig 3. Appearance of embolization coils on routine roentgenogram after the procedure.
patient required lung resection for uncontrolled hemoptysis [2]. It is our belief that a high index of clinical suspicion should be maintained in such cases. Ill-defined opacities that persist on routine chest roentgenograms should be further evaluated. Contrast enhanced computed tomographic scanning followed by pulmonary angiography should be performed. If feasible, endovascular coil embolization avoids further surgery with resection of healthy lung segments. Otherwise precise localization of the lesion is mandatory for preoperative surgical planning. It is generally agreed that images such as Figure 3 are going to be more common in the future with the ongoing progress of interventional radiology.
References 1. Symbas PN, Goldman M, Erbesfeld MH, Vlasis SE. Pulmonary arteriovenous fistula, pulmonary artery aneurysm, and other vascular changes of the lung from penetrating trauma. Ann Surg 1980;191:336 – 40. 2. Savage SC, Zwischenberger JB, Ventura KC, Wittich GR. Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound. Ann Thorac Surg 2001;71: 1021–3. 3. Donaldson B, Ngo-Nonga B. Traumatic pseudoaneurysm of the pulmonary artery: case report and review of the literature. Amer Surg 2002;68(5):414 – 6. 4. Dillon WP, Taylor AT, Mineau DE, Datz FL. Traumatic pulmonary artery pseudoaneurysm simulating pulmonary embolism. AJR Am J Roentgenol 1982;139:818 –9. 5. Oliver TB, Stevenson AJ, Gillespie IN, et al. Pulmonary artery pseudoaneurysm due to bronchial carcinoma. Br J Radiol 1997;70:950 –1. 6. Benedetti E, Massad MG. Pulmonary artery pseudoaneurysm after tube thoracostomy. Ann Thoracic Surg 1997;64:1478 – 80. 7. Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm. Ann Thorac Surg 2001;71:727–9. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
We present a case report of a 50-year-old male who sustained a gunshot wound to the right chest. The initial thoracotomy demonstrated a nonbleeding gunshot wound in the middle lobe and was otherwise unremarkable. Later that day, after continued resuscitation, his chest tube output dramatically increased and he was taken back for redo thoracotomy. An injury to the lateral branch of the middle lobe pulmonary artery was encountered and suture ligated. The patient presented several weeks later with hemoptysis. Computed tomography of the chest demonstrated pooling of contrast in the middle lobe. Angiography confirmed the diagnosis of a pulmonary artery pseudoaneurysm and was coil embolized without difficulty. This report represents a case of coil embolization of traumatic pulmonary artery pseudoaneurysm. (Ann Thorac Surg 2005;79:2136–8) © 2005 by The Society of Thoracic Surgeons
T
raumatic pulmonary pseudoaneurysm is a rare, yet potentially lethal clinical entity, with only fifteen reported cases in the literature. Diagnosis stems from a high index of suspicion and either computed tomography or angiogram investigation. Treatment options include aneurysectomy, arterial branch ligation, pulmonary resection, or possibly intraluminal coil embolization. The use of coil embolization has not been reported in the management of traumatic pulmonary pseudoaneurysms. A 50-year-old human presented shortly after sustaining a gunshot to his right hemithorax. Initial evaluation confirmed a bullet entry site in his right fourth intercostal space, subcutaneous emphysema, and decreased breath sounds on that side. Right chest tube thoracostomy insertion yielded 400 mL of blood, and placement confirmed by chest roentgenogram. Subsequent computed tomographic (CT) scan revealed a small residual right hemothorax, no evidence of mediastinal vascular or tracheobronchial injury, and the offending bullet lodged within the posterior right lower chest wall. The patient was admitted to the trauma intensive care unit for further resuscitation. Continued bleeding from Accepted for publication Dec 10, 2003. Presented at the Poster Session of the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003. Address reprint requests to Dr Bauer, Christianacare, Section of Thoracic Surgery, 4701 Ogletown-Stanton Rd, Suite 1204, Newark, DE 19713; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.067
CASE REPORT DIMARAKIS ET AL COIL EMBOLIZATION OF THE ANEURYSMAL SAC
FEATURE ARTICLES
The defect in the muscularis appears to have been caused by inflammation and local trauma, resulting in weakness and spasm. The pulsion defect then formed from intraluminal esophageal pressure on the weakened wall. As the inflammatory process progressed to a chronic, fibrosing stage, the diverticulum must have retracted into the inflamed lymphadenitis in the right paratracheal region and middle mediastinum. As a result, the wall became so inflamed, especially with the inspissated secretions that it eventually perforated into the mediastinum. The surgical repair was designed to address these components (ie, a myotomy to treat the pulsion-associated esophageal spasm and a vascular pedicle to support the weakened inflamed esophageal wall). In endemic areas, histoplasmosis is the most likely cause of fibrosing mediastinitis. This was supported by the computed tomographic findings of fibrosing mediastinitis without other clinically apparent causes in our case. Pathogens are rarely cultured from the lymph nodes of fibrosing mediastinitis and require no antimicrobial treatment [3]. In a review of 95 patients seen at the Mayo Clinic with mediastinal granuloma, 10% had esophageal involvement in the form of compression, stricture, diverticulum, sinus tract formation, or tracheoesophageal fistula [4]. There are a few case reports of esophagomediastinal fistula in the literature secondary to tuberculous lymphadenitis, esophageal candidiasis, and Hodgkin’s disease [5–7]. However, none of the prior reported cases presented with acute bacterial pericarditis, as was observed in our case. Our case highlights the importance of suspecting the diagnosis of bacterial pericarditis even in patients who present subacutely, particularly if they already had partial treatment with antibiotics. Identification of the offending organism(s) and investigations into the potential mechanisms of entry into the pericardium are critical to proper diagnosis and therapy.
Drs Kabra and Welke contributed equally to this work. Dr Weintraub is supported by grants (HL– 070860 and HL– 62948) from the National Institutes of Health.
References 1. Snyder RW, Braun TI. Purulent pericarditis with tamponade in a postpartum patient due to group F streptococcus. Chest 1999;115:1746 – 8. 2. Kaufman J, Thongsuwan N, Stern E, Karmy-Jones R. Esophageal-pericardial fistula with purulent pericarditis secondary to esophageal carcinoma presenting with tamponade. Ann Thorac Surg 2003;75:288 –9. 3. Dines DE, Payne WS, Bernatz PE, et al. Mediastinal granuloma and fibrosing mediastinitis. Chest 1979:320 – 4. 4. Dukes RJ, Strimlan CV, Dines DE, et al. Esophageal involvement with mediastinal granuloma. JAMA 1976;236:2313–5. 5. Devarbhavi HC, Alvares JF, Radhikadevi M. Esophageal tuberculosis associated with esophagotracheal or esophagome-
© 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2005;79:2134 – 6
diastinal fistula: report of 10 cases. Gastrointest Endosc 2003; 57(4):588 –92. 6. Kim BW, Cho SH, Rha SE, et al.et al. Esophagomediastinal fistula and esophageal stricture as a complication of esophageal candidiasis: a case report. Gastrointest Endosc 2000;52(6):772–5. 7. Papp JP, Penner JA. Esophagomediastinal fistula in Hodgkin’s disease. Postgrad Med 1970;48(4):180 –3.
Successful Treatment of a Posttraumatic Pulmonary Artery Pseudoaneurysm With Coil Embolization Ioannis Dimarakis, MD, James A. C. Thorpe, FRCS, and Kostas Papagiannopoulos, MD Thoracic Surgery Unit, Leeds General Infirmary, Leeds, United Kingdom
A 29-year-old man presented to the emergency department after having been stabbed in the posterior right hemithorax twice. He underwent thoracotomy for hemodynamic instability and continuous bleeding. His postoperative recovery was complicated by the incidental finding of a posttraumatic pseudoaneurysm of the pulmonary artery. We describe successful coil embolization of the aneurysmal sac avoiding any further surgical intervention. (Ann Thorac Surg 2005;79:2134 – 6) © 2005 by The Society of Thoracic Surgeons
T
raumatic pulmonary artery pseudoaneurysms are rare entities usually recognized by their complications. Few attempts have been described regarding nonoperative management with coil embolization in order to avoid surgery. A 29-year-old man presented to casualty with penetrating chest trauma. He had sustained two stab wounds to the posterior hemithorax. Initial assessment and management was carried out in agreement with the advanced trauma life support protocol. Chest roentgenogram revealed the presence of a large hemothorax managed with an intercostal drain. The initial drainage was 1,100 mL. The patient remained hemodynamically stable and a computed tomographic chest scan showed a remaining hemothorax with no other obvious injuries. After two hypotensive episodes in the radiology department requiring volume resuscitation and persistent
Accepted for publication Dec 10, 2003. Address reprint requests to Dr Papagiannopoulos, Leeds General Infirmary, Jubilee Bldg, Level D, Great George St, Leeds LS1 3EX, UK; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.023
Ann Thorac Surg 2005;79:2134 – 6
CASE REPORT DIMARAKIS ET AL COIL EMBOLIZATION OF THE ANEURYSMAL SAC
2135
Fig 1. Erect posteroanterior chest roentgenogram. Pseudoaneurysm shown as coin lesion in the right lung field; contrast enhanced computed tomographic scan (inset) confirms this.
chest drainage (700 mL), the patient was taken to the operating room. A right posterolateral thoracotomy was carried out. During exploration, the first stab wound was found to be coming through the sixth interspace. A sweating intercostal artery along with bleeding right upper lobe laceration was identified on the oblique fissure and hemostasis was secured with parenchymal suturing. The second wound tract was confined entirely in the superficial layers of the back with no intrapleural involvement. Routine postoperative chest roentgenogram films revealed the gradual development of a well-circumscribed, noncalcified coin lesion within the right upper pulmonary field (Fig 1). A contrast enhanced computed tomographic scan of the thorax revealed a pulmonary artery pseudoaneurysm. Pulmonary angiography showed that the pseudoaneurysm was arising from a subsegmental branch of the superior segmental artery of the right lower lobe next to the oblique fissure, although the laceration and knife entry point was at the right upper lobe. Successful embolization was carried out using four detachable embolization coils (Cook detachable embolization coil systems) (Fig 2). The patient was discharged shortly after in good clinical condition. He was reviewed 3 months postoperatively with no problems.
Pseudoaneurysm and arteriovenous fistulas are two vascular complications of chest trauma [1]. Traumatic pulmonary artery pseudoaneurysms are a well described clinical entity, but they still remain rare with few cases reported. Also known as pulsating hematomas, false aneurysms are characterized by the sole presence of adventitia or even surrounding connective tissue, and they can occur after significant blunt or penetrating injury. Occasionally they may remain undetected and silent for many years [2]. The most common presentation is hemoptysis. Shortness of breath, chest pain, and hypoxia may also be present [3]. Complications include spontaneous rupture with life threatening hemorrhage prompting for early diagnosis and appropriate management. Other complications include infection and thrombus formation, which may lead to distal embolization and thrombosis [2, 3]. A traumatic pulmonary artery pseudoaneurysm has also been reported to simulate pulmonary embolism causing a differential diagnostic problem [4]. Endovascular treatment has been previously applied in lesions resulting from malignancy or iatrogenic causes such as right heart catheterization and chest tube insertion [5, 6]. Physiologic differences attributed to pressures approaching systemic values in left to right shunts, as seen in congenital cases, may deem endovascular treatment inadequate [7]. Coil deployment has been attempted in a posttraumatic lesion, but eventually the
Fig 2. Arterial phase of pulmonary arteriogram shows filling of the pulmonary artery pseudoaneurysm from a subsegmental branch of the superior segmental artery of the right lower lobe. (Inset) Embolization coils have been deployed within the sac. No further filling was seen.
FEATURE ARTICLES
Comment
2136
CASE REPORT KHAN ET AL ANGIOGRAPHIC EMBOLIZATION
Ann Thorac Surg 2005;79:2136 – 8
Angiographic Embolization of a Traumatic Pulmonary Pseudoaneurysm Ahmad A. Khan, MD, Thomas L. Bauer, MD, Mark J. Garcia, MD, D. Bruce Panasuk, MD, and Allen L. Davies, MD Section of Thoracic Surgery, Department of Surgery, Christiana Care Health Services, Newark, Delaware
FEATURE ARTICLES
Fig 3. Appearance of embolization coils on routine roentgenogram after the procedure.
patient required lung resection for uncontrolled hemoptysis [2]. It is our belief that a high index of clinical suspicion should be maintained in such cases. Ill-defined opacities that persist on routine chest roentgenograms should be further evaluated. Contrast enhanced computed tomographic scanning followed by pulmonary angiography should be performed. If feasible, endovascular coil embolization avoids further surgery with resection of healthy lung segments. Otherwise precise localization of the lesion is mandatory for preoperative surgical planning. It is generally agreed that images such as Figure 3 are going to be more common in the future with the ongoing progress of interventional radiology.
References 1. Symbas PN, Goldman M, Erbesfeld MH, Vlasis SE. Pulmonary arteriovenous fistula, pulmonary artery aneurysm, and other vascular changes of the lung from penetrating trauma. Ann Surg 1980;191:336 – 40. 2. Savage SC, Zwischenberger JB, Ventura KC, Wittich GR. Hemoptysis secondary to pulmonary pseudoaneurysm 30 years after a gunshot wound. Ann Thorac Surg 2001;71: 1021–3. 3. Donaldson B, Ngo-Nonga B. Traumatic pseudoaneurysm of the pulmonary artery: case report and review of the literature. Amer Surg 2002;68(5):414 – 6. 4. Dillon WP, Taylor AT, Mineau DE, Datz FL. Traumatic pulmonary artery pseudoaneurysm simulating pulmonary embolism. AJR Am J Roentgenol 1982;139:818 –9. 5. Oliver TB, Stevenson AJ, Gillespie IN, et al. Pulmonary artery pseudoaneurysm due to bronchial carcinoma. Br J Radiol 1997;70:950 –1. 6. Benedetti E, Massad MG. Pulmonary artery pseudoaneurysm after tube thoracostomy. Ann Thoracic Surg 1997;64:1478 – 80. 7. Endovascular stent graft treatment of a pulmonary artery pseudoaneurysm. Ann Thorac Surg 2001;71:727–9. © 2005 by The Society of Thoracic Surgeons Published by Elsevier Inc
We present a case report of a 50-year-old male who sustained a gunshot wound to the right chest. The initial thoracotomy demonstrated a nonbleeding gunshot wound in the middle lobe and was otherwise unremarkable. Later that day, after continued resuscitation, his chest tube output dramatically increased and he was taken back for redo thoracotomy. An injury to the lateral branch of the middle lobe pulmonary artery was encountered and suture ligated. The patient presented several weeks later with hemoptysis. Computed tomography of the chest demonstrated pooling of contrast in the middle lobe. Angiography confirmed the diagnosis of a pulmonary artery pseudoaneurysm and was coil embolized without difficulty. This report represents a case of coil embolization of traumatic pulmonary artery pseudoaneurysm. (Ann Thorac Surg 2005;79:2136–8) © 2005 by The Society of Thoracic Surgeons
T
raumatic pulmonary pseudoaneurysm is a rare, yet potentially lethal clinical entity, with only fifteen reported cases in the literature. Diagnosis stems from a high index of suspicion and either computed tomography or angiogram investigation. Treatment options include aneurysectomy, arterial branch ligation, pulmonary resection, or possibly intraluminal coil embolization. The use of coil embolization has not been reported in the management of traumatic pulmonary pseudoaneurysms. A 50-year-old human presented shortly after sustaining a gunshot to his right hemithorax. Initial evaluation confirmed a bullet entry site in his right fourth intercostal space, subcutaneous emphysema, and decreased breath sounds on that side. Right chest tube thoracostomy insertion yielded 400 mL of blood, and placement confirmed by chest roentgenogram. Subsequent computed tomographic (CT) scan revealed a small residual right hemothorax, no evidence of mediastinal vascular or tracheobronchial injury, and the offending bullet lodged within the posterior right lower chest wall. The patient was admitted to the trauma intensive care unit for further resuscitation. Continued bleeding from Accepted for publication Dec 10, 2003. Presented at the Poster Session of the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003. Address reprint requests to Dr Bauer, Christianacare, Section of Thoracic Surgery, 4701 Ogletown-Stanton Rd, Suite 1204, Newark, DE 19713; e-mail: [email protected].
0003-4975/05/$30.00 doi:10.1016/j.athoracsur.2003.12.067