Traumatic intercostal arterial bleeding controlled with a novel surgical technique: a case report
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A blunt thoracic trauma may cause arterial bleeding requiring operative treatment or endovascular embolization or endovascular aortic stenting. A novel damage control technique to stop such bleeding is presented.
We present the case of an 82-year-old Caucasian man who experienced rib fractures I-VII on the left side and bleeding from damaged intercostal arteries after a blunt thoracic trauma. Emergency thoracotomy was performed.
Effective hemostasis was achieved by using a rolled surgical swab and inserting it against the chest wall next to the aorta with sutures pulled through the intercostal muscles and then sutured to the back side of the patient. The patient died four days after the surgery due to a head injury sustained in the car crash.
KeywordsBleeding Hemothorax Surgery Emergency Thoracotomy Trauma Blunt
Intrathoracic hemorrhage is a common finding associated with blunt thoracic trauma, especially in older people . It is often related to traumatic intercostal artery (ICA) injuries associated with rib fractures [2, 3]. When the bleeding is self-limiting, chest tube insertion and fluid resuscitation represent the treatments of choice. If the conservative treatment is not sufficient and the bleeding continues, then exploratory thoracotomy or endovascular embolization or endovascular aortic stenting may be treatment options [4, 5, 6]. Bleeding from the posterior intercostal artery deep in the chest can be very difficult to control . We describe a novel damage control technique to stop the bleeding from injured intercostal arteries.
He was transferred to the intensive care unit (ICU) but soon his hemoglobin value dropped and his abdomen became swollen. He was taken back to the OR and laparotomy was performed. Rupture and bleeding from the mesentery of the transverse colon were detected. Transverse colectomy and transverse colostomy were undertaken. The patient was treated in the ICU during the following days. There was no further post-operative bleeding from the thoracic or abdominal cavities and he was hemodynamically stable. However, he remained unconscious. Repeated head CT revealed the presence of traumatic intracerebral hemorrhage. He died on the fourth post-operative day due to this head injury.
Exploratory thoracotomy has traditionally been the treatment of choice for persistent hemothorax after blunt thoracic trauma. In recent years, the feasibility and reliability of transcatheter arterial embolization have been demonstrated to be beneficial in controlling the bleeding from an injured ICA [6, 8]. Endovascular aortic stenting has also been used successfully to control bleeding from an ICA . In our case, these types of endovascular treatments were not viable options because the bleeding was so intense that an emergency thoracotomy had to be performed.
Bleeding from an ICA deep in the posterior chest wall may be difficult to control surgically . There was bleeding from several ICAs very close to the thoracic aorta of our patient. There are no straightforward surgical methods to control this kind of arterial bleeding. In this patient, it was impossible to stop the bleeding with traditional surgical techniques. In order to prevent exsanguination, damage control hemostasis was achieved with the surgical technique we have described above. In our case, this novel technique worked well in controlling the bleeding from the intercostal arteries. We had planned to perform a definitive repair with an aortic stent-graft and to remove the surgical swab during re-thoracotomy some days later. Our patient died due to a head injury incurred in the car crash on the fourth post-operative day.
The damage control technique we describe is an option when the bleeding from ICAs is difficult to control by traditional surgical procedures.
Written informed consent for publication could not be obtained from the patient’s next-of-kin despite all reasonable attempts. The case is important for public health and every effort has been made to conceal the identity of our patient. There is no reason to believe that our patient’s next-of-kin would object to this publication.
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