J ENDOVASC THER 2004;11:219–221
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Endovascular Therapy of a Ruptured Intercostal Artery Aneurysm Ingolf To¨pel, MD; Markus Steinbauer, MD; Christian Paetzel, MD*; and Piotr M. Kasprzak, MD Departments of Surgery and *Radiology, University Hospital Regensburg, Germany. l
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Purpose: To report the endovascular management of a rare ruptured intercostal artery aneurysm. Case Report: A 45-year-old man presented with acute upper back and chest pain. Computed tomography of the chest revealed a ruptured intercostal artery aneurysm. The lesion was treated by endovascular coil embolization distal to the aneurysm and aortic stentgrafting of the intercostal artery origin. Conclusions: Ruptured intercostal artery aneurysms can be treated by endovascular techniques. If coil embolization of the intercostal artery origin is not possible, additional aortic stent-grafting can be necessary. J Endovasc Ther 2004;11:219–221 Key words: intercostal artery, aneurysm, rupture, endovascular repair, coil embolization, stent-graft l
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The rupture of an intercostal artery aneurysm is a rare source of acute chest pain and hemothorax. Intercostal artery aneurysms appear as false aneurysms after vascular injuries during procedures such as sternotomy,1 laparoscopic nephrectomy,2 percutaneous biliary procedures,3 or aortic coarctation repair.4 Furthermore, intercostal artery aneurysms have been described in patients with neurofibromatosis type I (von Recklinghausen’s disease).5,6 We describe the clinical presentation, diagnosis, and interdisciplinary treatment of a patient with a ruptured intercostal artery aneurysm of indeterminate etiology.
CASE REPORT A 45-year-old man presented to an urban hospital with acute severe upper back and chest pain. After computed tomography (CT) of the chest revealed a left-sided hemothorax, the
patient was transferred to our center with the presumptive diagnosis of a ruptured thoracic aortic aneurysm. At the time of arrival at our emergency department, the patient was in a stable cardiopulmonary condition (blood pressure 140/85 mmHg, pulse 90/min). He still complained of severe chest and upper back pain. Other than basal crackles over the left lung, the physical examination of the heart, lung, abdomen, and extremities was unremarkable. The patient had a past medical history of hypertension, hyperuricemia, and obesity (body mass index 29.8 kg/m2). The surgical history included an appendectomy and a tonsillectomy, but neither the history nor the physical examination showed any signs of neurofibromatosis. The patient denied any trauma to the chest or abdomen in the past. The CT scans of the chest showed a ruptured aneurysm of the 8th left intercostal ar-
Address for correspondence and reprints: Ingolf To¨pel, MD, Department of Surgery, University Hospital Regensburg, 93042 Regensburg, Germany. Fax: 49-941-944-6910; E-mail:
[email protected] Q 2004 by the INTERNATIONAL SOCIETY
OF
ENDOVASCULAR SPECIALISTS
Available at www.jevt.org
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Figure 1 l CT scan of the chest shows a ruptured aneurysm (arrow) of the 8th left intercostal artery with a hemothorax on the left side.
tery with a left-sided hemothorax (Fig. 1). An intra-arterial digital subtraction angiogram (DSA) of the thoracic aorta confirmed the diagnosis. During the same procedure, a 5-F catheter was advanced selectively into the 8th left intercostal artery. The angiogram showed the aneurysm with a short proximal neck of about 8 mm (Fig. 2A). After intensive review of the imaging studies among the vascular surgery team and the interventional radiologists, the decision was made to coil embolize the distal part of the intercostal artery and to place an aortic stent-graft to exclude the aneurysm from inflow because the proximal neck of the aneurysm was too short to safely place coils there. The distal part of the artery was embolized with Trufill detachable platinum coils (Cordis Endovascular, a Johnson & Johnson company, Miami Lakes, FL, USA), which halted the distal outflow from the aneurysm sac. Under local anesthesia and via a left femoral artery access, a 28375-mm PowerLink stent-graft (Endologix, Inc., Irvine, CA, USA) was placed, occluding the origin of the 8th intercostal artery and completely excluding the aneurysm (Fig. 2B). After this procedure, the patient was symptom-free and had no complaints; he was discharged 2 days later. Over a 6-month follow-up, the patient had been symptom-free
J ENDOVASC THER 2004;11:219–221
Figure 2 l (A) Selective intra-arterial digital subtraction angiogram of the left 8th intercostal artery; the arrow indicates the aneurysm sac. (B) After coil embolization and placement of an aortic stentgraft, the aneurysm is completely excluded from the feeding vessels (white arrow points to the stent-graft and the black arrow to the coils in the intercostal artery).
and without complaints. A CT scan at 6 month showed correct stent-graft position without signs of leakage or dislocation.
DISCUSSION Intercostal artery aneurysms have been described in patients with neurofibromatosis type I.5,6 Although the etiology is not completely clear, lesions have arisen due to compression by an adjacent tumor, intramural thickening, and vascular dysplasia. In the patient we encountered, no clinical or radiological signs of neurofibromatosis could be found. Furthermore, false intercostal artery aneurysms were reported as sequelae of vascular injuries from a variety of interventions.1–4 Our patient had no operative procedures performed in the chest, lung, or spine and had no intravascular catheterization. The patient denied any trauma, so an iatrogenic or traumatic origin of the aneurysm was excluded. After the diagnosis was made in this patient, we immediately placed coils in the distal intercostal artery to block the retrograde flow of the aneurysm and positioned a stent-graft over the intercostal artery origin because of the short proximal neck of the aneurysm. It would appear that percutaneous transarterial coil embolization is an appropriate treatment
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for intercostal artery aneurysms. If the proximal aneurysm neck is too short to place coils, additional aortic stent-grafting may be necessary.
REFERENCES 1. Callaway MP, Wilde P, Angelini G. Treatment of a false aneurysm of an intercostal artery using a covered intracoronary stent-graft and a radial artery puncture. Br J Radiol. 2000;73:1317– 1319. 2. Bluebond-Langner R, Pinto PA, Kim FJ, et al. Recurrent bleeding from intercostal arterial pseudoaneurysm after retroperitoneal laparoscopic radical nephrectomy. Urology. 2002;60: 1111.
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3. Casas JD, Perendreu J, Gallart A, et al. Intercostal artery pseudoaneurysm after a percutaneus biliary procedure: diagnosis with CT and treatment with transarterial embolization. Comput Assist Tomogr. 1997;21:729–730. 4. Myerson SG, Pennell DJ. Intercostal artery aneurysm post coarctation repair diagnosed by magnetic resonance angiography. J Cardiovasc Magn Reson. 2000;2:137–138. 5. Kipfer B, Lardinois D, Triller J, et al. Embolization of a ruptured intercostal artery aneurysm in type I neurofibromatosis. Eur J Cardiothorac Surg. 2001;19:721–723. 6. Niimi M, Ikeda Y, Kan S, et al. Re: Spontaneous rupture of an intercostal artery due to neurofibromatosis type I disease treated by percutaneous embolization [Letter]. Cardiovasc Intervent Radiol. 2002;25:160–161.
