Massive Hemothorax Research Articles

A Thoracic Complication of an Abdominal Procedure: Massive Hemothorax Following Percutaneous Transhepatic Portal Vein Angioplasty

A Thoracic Complication of an Abdominal Procedure: Massive Hemothorax Following Percutaneous Transhepatic Portal Vein Angioplasty

Iatrogenic Haemothorax: A Life-Threatening Complication Following A 12Fg Seldinger Intercostal Drain Insertion for Pneumothorax.

Iatrogenic haemothorax post-intercostal drain (ICD) insertion has not been reported in recent literature since the new British Thoracic Society (BTS) guidelines advised ultrasound-assisted procedure for pleural effusions, and a 'triangle of safety' for pneumothorax patients. Nevertheless, it should be included in the differential diagnoses as it still could happen.If it is a massive haemothorax, cardiothoracic surgeons must be notified immediately.Point-of-care ultrasound can be used to diagnose pleural fluid while awaiting a chest X-ray. However, point-of-care ultrasound will not be able to differentiate between blood and normal pleural fluid, whereby a formal chest CT can.

Pneumonectomy following penetrating trauma with ECMO as postoperative support: case report – (Lung trauma and ECMO)

BackgroundPenetrating thoracic injuries have a significant risk of morbi-mortality. Despite the advancements in damage control methods, a subset of patients with severe pulmonary vascular lesions and bronchial injuries persists. In some of these cases, post-traumatic pneumonectomy is required, and perioperative extracorporeal membrane oxygenation (ECMO) support may be required due to right ventricular failure and respiratory failure.Case descriptionA male was brought to the emergency department (ED) with a penetrating thoracic injury, presenting with massive right hemothorax and active bleeding that required ligation of the right pulmonary hilum to control the bleeding. Subsequently, he developed right ventricular dysfunction and ARDS, necessitating a dynamic hybrid ECMO configuration to support his condition and facilitate recovery.ConclusionsPenetrating thoracic injuries with severe pulmonary vascular lesions may need pneumonectomy to control bleeding. ECMO support reduces the associated mortality by decreasing the complications rate. A multidisciplinary team is essential to achieve good outcomes in severe compromised patients.

Subclavian arterial rupture due to blunt trauma injury: A case report.

Subclavian arterial injury due to blunt trauma is rare but can have devastating outcomes. Massive hemorrhage or limb ischemia might develop depending on the extent of damage, and open repair might be necessary to salvage the limb. However, life-saving treatments should be prioritized in critically unstable patients. A 21-year-old male patient who was transferred to our trauma center following a motorcycle accident. Abdominal and chest computed tomography (CT) revealed right renal injury and massive hemothorax with several rib fractures in the right chest. Right renal injury with multiple extravasations and right 8th intercostal arterial injury were detected during angiography. Emergent exploration with lateral thoracotomy was performed to manage right hemothorax. Pulsating bleeding from the thoracic roof observed in the operative field suggested a subclavian arterial injury. The unstable vital signs did not recover despite massive transfusion, and his right arm had already stiffened. Therefore, endovascular approach was adopted and the second portion of the right subclavian artery was embolized using microcoils and thrombin. Postoperative intensive care unit management performed to resuscitate patient from multiorgan failure included continuous renal replacement therapy (CRRT). After confirming the demarcation lines, transhumeral amputation of the right arm was performed on admission day 12. The patient recovered from multiorgan failure for more than 3 weeks after the accident; however, the patient survived. Limb salvage, albeit critical for quality of life, is not possible in some cases where life-saving measures require its sacrifice. In these cases, quick decision-making by the surgeon is paramount for patient survival. As illustrated in this case, endovascular approaches should be considered less invasive measures to save the patient's life.

Delayed Hemothorax Due to Thoracic Trauma with Multiple Rib Fracture: A Case Report

Recent evidence indicates that elderly who have suffered rib fractures may develop delayed massive hemothorax. Delayed enormous hemothorax after thoracic trauma is uncommon, but it is nevertheless linked to high rates of mortality. This single case report provides an overview of the ordinary and important delayed hemothorax caused by thoracic trauma with multiple rib fractures in limited healthcare facilities. We observe symptoms and chest X-rays before and after the development of delayed hemothorax. A 56-year-old man came to the hospital with complaints of shortness of breath and pain in the chest and right shoulder. The patient said that four days ago, He fell from a height of around 6 meters. After visiting the hospital four days prior, the patient was diagnosed with multiple fractures of the inferior aspect of the right ribs (costa 3-7) as well as a fracture of the right clavicle. However, the patient declined surgery and was made to return home. At that time, the patient did not experience shortness of breath. Currently, the patient is experiencing dyspnea. Blood pressure 138/91 mmHg, heart rate 89 beats per minute, respiration rate 26 times per minute, Spo2 91% room air. The chest x-ray currently shows a right hemothorax. After stabilization, the patient asked to be referred to another hospital for further treatment. Patients with multiple fractured ribs, especially with rib displacement, are at high risk of evolving delayed hemothorax. Close monitoring and observation for several days are necessary.

Transarterial embolization to treat a massive hemothorax during mechanical circulatory support via puncturing of the extracorporeal membrane oxygenation circuit

BackgroundCurrent guidelines recommend the use of mechanical circulatory support (MCS) for patients with cardiogenic shock that is refractory to medical therapy. Bleeding is the most common complication of MCS. Transarterial embolization (TAE) is often performed to treat this complication, because it is a less invasive hemostatic procedure. However, the TAE option needs to be carefully considered during MCS, as the access route may be limited during MCS.Case presentationA man in his 70 s was diagnosed with acute myocardial infarction and underwent percutaneous coronary intervention via venoarterial extracorporeal membrane oxygenation (VA-ECMO) and Impella. During treatment in the intensive care unit, he suffered damage to a branch of the internal thoracic artery during a cardiac drainage procedure, which was subsequently treated via emergency TAE.An ECMO return cannula and an Impella sheath were inserted into the patient’s right and left femoral arteries, respectively. An approach from the left brachial artery was selected, and the left internal thoracic artery was embolized. Subsequently, the patient required re-intervention to treat re-bleeding from another artery. Because it was difficult to target the target artery from the brachial one, owing to interference from the Impella catheter, the ECMO circuit near the return cannula was punctured and a guiding sheath was inserted. The ECMO flow and the patient’s blood pressure decreased following placement of this guiding sheath. We were thus able to maintain the patient’s blood pressure by increasing the infusion fluids and Impella flow, and embolize the target artery using a gelatin sponge to achieve hemostasis.ConclusionWhen TAE is difficult to perform during MCS using an approach from the upper extremities, a lower extremity approach with a sheath inserted into the ECMO circuit may represent a viable alternative.

Massive Haemo Thorax Following Ultrasound-Guided Central Venous Catheterization in an Anaesthetized Patient: A Case Report

Central venous catheterization is a commonly performed procedure in operation theatre. After the advent of ultrasound (US) guided central venous catheterization (CVC), the incidence of life-threatening complications has reduced significantly and are rare. We present a case of haemothorax in a young patient after US guided, which was inserted at the end of surgery under anaesthesia. The operator had some technical difficulty while inserting the CVC. The Haemothorax was diagnosed post-operatively in the ward after was missed clinically by radiological investigation. It was treated by inserting a 36 Fr chest drain on the second post-operative day which was removed on the seventh postoperative day and the patient was discharged to home.

Massive hemothorax diagnosed by ultrasound in patient on ECMO

Massive hemothorax diagnosed by ultrasound in patient on ECMO

Management of massive hemothorax resulting from traumatic diaphragm rupture with kidney avulsion injury by combined anterior thoracoabdominal approaches

Abstract Blunt trauma resulting in diaphragm rupture, kidney avulsion injury, and subsequent hemothorax is rare and requires immediate surgical intervention. After diagnosis, urgent laparotomy with thoracotomy is needed to control renal bleeding. However, because of limitations in imaging studies, confirming this diagnosis is not straightforward, thus underscoring the importance of proper patient’s posturing. It is recommended that in cases of massive hemothorax combined with intra-abdominal bleeding, no matter performing thoracotomy or laparotomy first, the attending surgeons have to put patients in a position appropriate for simultaneous thoracoabdominal approach. It avoids surgical delays that could lead to fatal outcomes.

Delayed severe hemothorax caused by a staple line of a bullectomy performed 11 years earlier

BackgroundAt present, relatively few lung surgeries are performed without endostaplers. Although there are few staple-related adverse events, severe events must be shared to improve safety.Case presentationA 74-year-old male suddenly collapsed and was transferred to the Emergency Rescue department. He had shock vitals and contrast-enhanced CT revealed extensive right hemothorax with contrast leakage. He lost consciousness and tension massive hemothorax was suspected. We performed emergency thoracotomy at two sites and were able to achieve hemostasis and save the patient. Upon examining the patient's medical history after his condition stabilized, it was revealed that he was a lung cancer patient who was taking ramucirumab and cilostazol. In addition, the CT scan taken one month before onset revealed the bleeding site of the fifth intercostal artery were almost contact with the staple line from a prior right spontaneous pneumothorax surgery that was performed 11 years previously, which was seemed to damage the intercostal artery.ConclusionDespite the difficulty in achieving hemostasis due to drug administration history, we successfully treated a case of remote period massive hemothorax attributed to staples, thereby saving the patient. When using drugs that increase the risk of bleeding events, it may be important to consider the position of the staple line while assessing the risk. In the emergent or ICU setting, if the initial incision is not effective, the placement of a new second incision may be valuable.

Right-sided spontaneous, massive hemothorax in a 27-week pregnant lady: a case report

Spontaneous, massive hemothorax due to pulmonary varix is an uncommon, yet catastrophic cause of respiratory distress during pregnancy and postpartum. Presentation is often confused with pulmonary embolism, the treatment of which, worsens the condition. Diagnosis is challenging because of the elusive abnormalities on radiographic and bronchoscopic examination. Currently, there are no treatment guidelines for pulmonary varix. A 23-year-old pregnant lady in her second trimester, with intra-uterine fetal demise, presented to our emergency with dyspnoea, fever, and right-sided chest pain for three days. Chest X-ray and therapeutic thoracocentesis revealed massive right-sided hemothorax and computed tomography suggested pulmonary varix as the cause which was managed with emergency chest tube drainage. Massive, spontaneous hemothorax due to pulmonary varix in pregnancy is a rare occurrence, but it requires timely, multidisciplinary assessment and management for the betterment of the mother and the fetus.

Life-saving emergency surgery due to delayed massive hemothorax 7days after fall injury: a case report.

Delayed hemothorax after thoracic trauma complicates approximately 7.4-36% of blunt traumas. Cases of delayed hemothorax that suddenly increase and require surgery are rare. We report a case of delayed massive hemothorax that was not relieved by vascular embolization but was successfully treated with surgery. The patient was a 45-year-old man. He was rushed to the emergency room after falling from the 4th floor, and he underwent emergency surgery. The patient was weaned off the ventilator on postoperative day (POD) 3 but had bleeding of 500ml/h from his left chest drain on POD 7. We initially performed intrathoracic angiography for the bleeding. Bleeding from the 9th and 10th intercostal arteries was confirmed. Although vascular embolization was performed, 6h later, 500ml/h of bleeding was observed again from the drain, and emergency surgery was performed. We performed ligation of the left 9th and 10th intercostal arteries and intrathoracic hematoma removal. The patient was weaned off the ventilator 14days after the second surgery and was transferred for rehabilitation on day 50. It is necessary to constantly monitor chest drainage and hemodynamics, especially within 7days after injury, and to consider the possibility of emergency surgery.

Traumatic lung laceration secondary to avulsed lung adhesion - A case report

Pulmonary lacerations caused by an avulsion force on an adhesion between the lung and chest wall following blunt thoracic injury are very rare. They may result in pneumothorax and/or hemothorax and may not be immediately apparent clinically or radiologically.We present the case of a healthy 34-year-old male who sustained blunt thoracic injury. He was clinically stable, and his initial routine images were unremarkable. The patient was discharged home on the same day. He presented a week later with a massive hemothorax requiring surgical intervention which revealed bleeding from an avulsed adhesion between the lung and chest wall. Bleeding was successfully controlled by hemostatic agent, and the patient had an uneventful recovery.Hemothorax requiring intervention from an avulsed adhesion may occur following blunt thoracic trauma. Initial imaging and clinical finding may be misleading. Close follow up and adequate patient education should be ensured prior to discharge following seemingly trivial trauma.

Right thoracoabdominal stab injury penetrating with injury of the internal thoracic artery: case report and lessons in penetrating knife wounds to the chest and abdomen

Abstract. Thoraco-abdominal and transmediastinal injuries are the most challenging injuries faced by surgeons. Aim. To acquaint medical practitioners with a clinical case of diagnosis and treatment of a rare variant of damage to the right internal thoracic artery in a thoraco-abdominal injury. Materials and methods. We present a clinical case of a rare variant of damage to the right internal thoracic artery in a thoraco-abdominal injury, which was complicated by a massive hemothorax, shock and DIC syndrome. Results. The work presents data on the examination and treatment of a patient with a thoraco-abdominal stab wound. A preliminary diagnosis was established: thoraco-abdominal stab wound on the right, hemorrhagic shock. The diagnosis was established based on the patient's complaints, medical history, physical examination data, available at the time of the examination, the results of laboratory and instrumental research methods. Damage to the liver, diaphragm, and internal thoracic artery was established intraoperatively. Clinical interest is not only the rarity of this injury - injury of the internal thoracic artery, but also the therapeutic and diagnostic tactics. Conclusions. We consider this case interesting and instructive. Each wound should be evaluated from the point of view of possible injury of large vessels, in the projection of which location it is localized. The primary surgical treatment of the wound should be carried out under the strict control of an experienced surgeon, especially if the wound is located in the projection of a large vessel. The integrity of the vessel and the absence of bleeding must be confirmed! Intraoperatively, any finding should be taken into account, correlated with possible injuries, and interpreted clinically (provide a logical explanation that satisfies the clinical situation). The decision regarding treatment tactics should be made by the operating surgeon (or a board of surgeons), immediately based on the clinical situation. The surgeon must be reactive and flexible, and have the ability to quickly change the approach according to the findings.

Anesthetic Management of an Unusual Case of Severe Pulmonary Hypertensive

The perioperative management of pulmonary hypertension continues to be a great challenge for anesthesiologists. Among the various types of pulmonary hypertension, pulmonary hypertension associated with left heart disease is the most common, while pulmonary hypertensive crisis is one of the causes of perioperative mortality in these patients. We present the case of a 54-year-old female with severe valvular heart disease complicated by severe pulmonary hypertension and massive hemothorax, who underwent emergency exploratory thoracotomy, mitral valve replacement, and tricuspid valvuloplasty. The patient was in critical condition and suspected to have a pulmonary hypertension crisis. The rationale for this case report is to learn about the anesthetic management of patients with severe pulmonary hypertension.

A case report of massive hemothorax in pregnant woman with a pulmonary arteriovenous malformation: sometimes thoracotomy is the only option?

A case report of massive hemothorax in pregnant woman with a pulmonary arteriovenous malformation: sometimes thoracotomy is the only option?

Spontaneous Second Intercostal Artery Bleeding Complicated with Massive Hemothorax after Lower Limb Angioplasty Procedure

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血胸を伴う出血性ショックを来した左胃動脈瘤破裂の1例(A ruptured aneurysm of left gastric artery that progressed to right hemothorax: a case report)

症例は50歳代女性，心窩部痛と呼吸苦で発症し，近医にて胸水を指摘されて前医を受診した。前医では，単純CT検査で血性胸腹水，食道壁肥厚，膵周囲の脂肪織濃度の上昇を認め，2日間加療したが改善を認めないため精査目的に当院へ紹介された。来院時，四肢末梢に湿潤を認め，脈拍110/分，血圧80/50mmHg（ドパミン9μg/kg/min）であった。造影CT検査で右血性胸水と食道裂孔ヘルニア，胸部中部以下の食道から胃噴門部小弯側にかけての血腫を認めたが，食道や肺野など胸部には出血源を認めなかった。腹腔内には血性腹水とともに，胸部中部食道周囲から胃小彎側に連続する血腫を認め，内部に直径1.5cmの左胃動脈瘤を認めた。左胃動脈瘤破裂による出血が，食道裂孔を介して縦隔へ進展し，胸腔内に穿破して血胸に至ったものと推測した。血胸に対して単回の胸腔穿刺，左胃動脈瘤破裂に対して血管造影による塞栓術を施行した。翌日から経口摂取を開始し，血胸が再燃することもなく経過は良好で，第22病日に自宅退院した。腹部内臓動脈瘤破裂による出血が食道裂孔を介して胸腔内に穿破し，血胸を契機に診断された稀な症例を経験したので報告する。 A 59–year–old woman visited her local hospital with dyspnea and epigastric pain. A chest X–ray showed a right pleural effusion. The patient consulted a second hospital where she was treated for two days, but due to her unstable vital signs, she was transferred to our hospital. A contrast–enhanced CT scan revealed a right hemothorax and esophageal hiatal hernia. While there was no source of bleeding in the thoracic cavity, there was an intra–abdominal hemorrhage from a ruptured aneurysm of the left gastric artery. The suspected cause of the hemothorax was bleeding from a ruptured aneurysm that entered the thoracic cavity through the esophageal hiatus. We performed a transcatheter arterial embolization for the ruptured aneurysm. After treatment, the patient recovered without significant incidents and was discharged on the 22nd day of hospitalization. We speculated that the hemorrhage from the rupture of the gastric aneurysm extended through the esophageal hiatus into the mediastinum and perforated into the thoracic cavity, resulting in a hemothorax. Since such conditions are rare, we will report this case with a review of the literature. 腹部内臓動脈瘤は破裂すれば出血性ショックにより致死的状況に至ることもある重篤な疾患である。本邦の腹部内臓動脈瘤破裂として報告されている症例の多くは腹腔内出血による出血性ショックを呈している 1, 2。しかし，今回我々は左胃動脈瘤破裂による出血が食道裂孔ヘルニアを介して縦隔，胸腔内へ進展し，出血性ショックを来した症例を経験したので，文献的考察を加えて報告する。 本論文は，個人情報保護法に基づいて匿名化がなされており，本人から論文報告に関する同意を得ている。また，本論文は倫理委員会の承諾を要する事項として該当しない。 症 例：50歳代の女性 主 訴：心窩部痛 現病歴：搬送6日前に突然の心窩部痛，呼吸困難感が出現し，食事摂取ができなくなった。搬送2日前に近医を受診したところ，胸水を指摘され前医を紹介された。前医受診時より血圧が低下しており，単純CT検査で血性胸腹水，食道壁肥厚，膵周囲の脂肪織濃度の上昇を認め急性膵炎などが疑われた。2日間の入院加療後も改善に乏しく，循環動態の維持にカテコラミン投与を要する状態となったため，当院救命救急センターへ搬送された。 既往歴：特記事項なし 生活歴：ビール１本/日，喫煙なし 来院時現症：意識清明。軽度の呼吸困難感の訴えを認めるが呼吸促拍はなく，呼吸数22/分，酸素飽和度97%（3L/min），顔面蒼白，四肢末梢に冷感湿潤を認め，脈拍110/分，血圧80/50mmHg（ドパミン 9µg/kg/min）。左背部痛の訴えがあるものの圧痛は認めなかった。 血液検査：RBC 213×104 /μL，Hb 6.7g/dL（前医受診時 Hb 9.8g/dL）と著明な貧血を認めた。血小板数や凝固検査には異常を認めなかった。 画像検査：胸腹部造影CT検査；胸部CTでは右血胸，滑脱型食道裂孔ヘルニアを認め，周囲に縦隔血腫，左少量胸水を認めた。腹部CTでは直径1.5cmの左胃動脈瘤を認め（Fig. 1a），周囲の血腫は胸部中部食道周囲から胃小弯側へ連続していた（Fig. 1b）。左肝動脈は左胃動脈から分岐しており，肝左葉外側区に微小動脈瘤を認めた。食道や肺野には出血源を認めなかった。 An enhanced CT scan of the abdomen revealed a pseudoaneurysm of the left gastric artery. Computed tomography (CT) of the chest showed a right massive hemothorax，a slipped esophageal hiatal hernia, and a mediastinal fluid collection (black arrow). 搬入後経過：乳酸リンゲル液の急速輸液を行うとともに輸血を開始した。搬入後より呼吸困難感が増悪し，仰臥位の維持が困難となったため，右血胸に対し慎重に胸腔穿刺を施行したところ，約830mLの血性排液を認めた。穿刺後，呼吸困難感の改善を認め，輸血投与後よりバイタルサインの安定を得た。左胃動脈瘤からの出血が食道裂孔ヘルニアを介して血胸に進展したものと推測し，動脈瘤に対して緊急interventional radiology（IVR）による止血術を行う方針とした。 腹部血管造影：腹腔動脈からの造影では，直径1.5cmの左胃動脈瘤を認め（Fig. 2a），瘤よりも近位より分岐する左胃動脈分枝，瘤末梢から分岐する左肝動脈を金属コイルでisolationし，瘤内をNBCA（n–butyl–2–cyanoacrylate）により塞栓した（Fig. 2b）。 Celiac artery angiography showed a pseudoaneurysm of the left gastric artery and left hepatic artery. Transcatheter arterial embolization (TAE) was done successfully. Arterial flow for the aneurysm was shut out. 入院後経過：後日判明したmyeloperoxidase–anti–neutrophil cytoplasmic antibodies（MPO–ANCA）や，proteinase–3–anti–neutrophil cytoplasmic antibodies （PR3–ANCA）などの血管炎マーカーはいずれも陰性であり，微小動脈瘤形成の所見から，臨床的に節性動脈中膜壊死（segmental arterial mediolysis: SAM）と診断した。濃厚赤血球4単位の輸血投与と緊急IVR後は循環動態の安定が得られた。呼吸器症状も改善し第2病日から経口摂取を開始した。胸水の再貯留は認めず，その後も血胸が再燃することはなかった。IVR後大きな合併症なく経過は良好で，第22病日に独歩で退院した。その後発症から1年までの時点では，新たな動脈瘤の形成もなく経過している。 腹部内臓動脈瘤は比較的稀な疾患であり，その発生頻度は0.01～2%とされている。Stanleyらの腹部内臓動脈瘤1,118例の集計によると，脾動脈が最も多く656例（58.7%），次いで肝動脈が227例（20.2%），上腸間膜動脈瘤89例（7.9%）と続くのに対し，胃動脈瘤は53例（4.7%）であると報告されている 3。 腹部内臓動脈瘤の成因としては，動脈硬化，神経線維種症I型やEhlers–Danlos症候群などの先天性疾患，腹部外傷，ベーチェット病や高安病，多発血管炎などの膠原病，正中弓状靭帯圧迫症候群，慢性膵炎などの炎症性疾患などがあるが，近年画像診断の進歩に伴って，SAMが注目されている 4。SAMは1976年にSlavinらにより提唱された疾患概念 5で，腹部内臓動脈の中膜が分節性に融解し動脈瘤を呈する病態である。稲田らの報告によると，SAMと診断された患者の35.7%に多発動脈瘤を認めており，一般的には異所性，異時性に動脈瘤を形成することが多いとされている 6。 SAMの確定診断は切除標本からの病理学的診断によってなされていたが，近年，画像診断の進歩や開腹手術と比較して低侵襲であるIVRが動脈瘤治療の第一選択となってきており，病理学的確診が得られる機会が少なくなってきた。内山ら 7は腹部内臓動脈瘤の中で，①中高年の患者，②炎症性変化や動脈硬化性病変などの基礎疾患がない患者，③突然の腹腔内出血で発症，④血管造影で血管の数珠状の不正な拡張と狭小化を認める，の4項目をSAMの特徴とし，これに合致するものをSAMと診断する臨床的診断基準を提唱している。本症例においては，中年女性であること，非動脈硬化性，非炎症性であること，血管造影検査で左胃動脈だけでなく左肝動脈外側区領域にも動脈瘤を形成し，特徴的な数珠状変化も認めていたことから臨床的にSAMと診断した。 また，胃動脈瘤の中では左胃動脈瘤破裂が最も多く報告されている。医学中央雑誌による検索では，左胃動脈瘤破裂の本邦報告例は25例であり，いずれも腹腔内出血あるいは消化管出血によるショック症状で搬送されていた。海外においては，腹部内臓動脈瘤破裂に伴い胸水貯留を呈した症例についての報告 8, 9, 10が散見される。一般に，腹部内臓動脈瘤破裂は血性腹水の貯留を認めるが，本症例の場合は血胸を呈していた。横隔膜を隔てた液体成分の移動に関して，腹腔内圧の上昇に伴い，横隔膜小孔を通じて胸腔内へ液体成分が漏出した症例報告がみられる。本症例では，滑脱型食道裂孔ヘルニアが存在し，腹腔内における血腫が食道裂孔を介して腹腔から縦隔へ連続していた。食道裂孔は伸縮性を持つ約3cmの筋性管で，左右の横隔膜脚内側縁により境界される。食道裂孔を形成する筋束は右脚の内側部から送られ，これが食道を包むようにめぐっており，下部食道～胃噴門部は横隔食道膜という靭帯に固定されている。食道裂孔ヘルニアとは，加齢によりこの横隔食道膜が弛緩することにより胃の一部が胸腔側に逸脱した状態である。食道は漿膜を持たず，周囲は疎な結合組織と脂肪組織に覆われているため，食道胃接合部手術における剥離は容易である。また，右胸腔とは薄い食道臓器鞘で接していることから，剥離操作時には右胸腔開放に注意を要する。腹部内臓動脈瘤破裂症例で，合併する食道裂孔ヘルニアを通じて胸腔穿破，胸水貯留を来した報告は少数にみられ 11, 12，食道裂孔ヘルニア内の胃穿孔から縦隔気腫や膿瘍を形成した報告例 13もある。また，慢性膵炎における仮性膵嚢胞で，嚢胞が後腹膜を頭側へ進展することで食道裂孔を貫き，胸腔へ穿破，内瘻を形成したことで膵性胸水貯留を来した症例も報告されている 14。食道裂孔部が弛緩した状態では，食道周囲の結合組織が疎であることによる血腫の下縦隔への進展，そこに接する胸膜穿破が起こりうると考える。本症例は，画像診断では血胸の原因となる病変を肺，胸膜，食道に認めず，単回の胸腔穿刺ドレナージとIVRによる止血術で血胸の再燃を認めなかった。左胃動脈瘤破裂による出血が，腹腔内の圧が上昇したことで，最も抵抗の少ない食道裂孔ヘルニア部から疎な結合組織を通じて縦隔へ進展し，壁側胸膜を穿破して血胸に至ったものと推測した。 右血胸を伴い出血性ショックを呈した左胃動脈瘤破裂の症例を経験した。腹腔内を出血源とする血液が，食道裂孔ヘルニアを介して主に胸腔内へと進展した可能性が考えられた。 共著者全員が利益相反はない。

Ruptured mycotic aneurysm of intercostal arteries associated with vertebral osteomyelitis: a case report

BackgroundHere, we report a rare case of massive hemothorax caused by rupture of an intercostal artery pseudoaneurysm associated with pyogenic spondylodiscitis, which was successfully treated with endovascular intervention.Case presentationA 49-year-old man with schizophrenia, idiopathic esophageal rupture, postoperative mediastinal abscess, and pyothorax, diagnosed with pyogenic spondylodiscitis caused by methicillin-resistant Staphylococcus aureus. Magnetic resonance imaging and computed tomography (CT) showed extensive vertebral body destruction. The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and 10 days after first surgery, posterior fixation with instrumentation. Seven days after second surgery, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right T8 intercostal artery and active contrast extravasation from it. This seemed ruptured mycotic aneurysms involving intercostal vessels. These vessels were successfully embolized using micro-coils. Then, the patient completed the prescribed antimicrobial therapy in the hospital without any complications.ConclusionsIntercostal artery aneurysms are rare vascular abnormalities. They have the risk of rupture and may sometimes cause hemothorax and can be potentially life-threatening. Ruptured intercostal artery pseudoaneurysms are a good indication of endovascular intervention, and prompt embolization saved the life of the patient in this case report. This case report highlights the possibility of a ruptured intercostal mycotic aneurysm in patients with pyogenic spondylodiscitis and reminds physicians to be alert of this rare but potentially fatal complication.

Massive hemothorax secondary to internal jugular vein central venous catheter placement in a patient undergoing spinal surgery complicated by chest trauma: a case report

BackgroundPlacement of a central venous catheter (CVC) is a common procedure for spinal surgery and is relatively safe under ultrasound guidance.Case presentationWe report the case of a 56-year-old female who underwent ultrasound-guided placement of an internal jugular vein CVC for fluid replacement during spinal surgery for thoracic vertebral burst compression fracture and multiple rib fractures as a result of a high-altitude fall injury. Hemothorax developed intraoperatively. During a thoracotomy, the tip of the CVC was found within the chest cavity. The presence of chest trauma may impact on clinician’s appreciation of the potential complications of internal jugular vein CVC placement.ConclusionThe present case demonstrates the need for clinical awareness of the potential complications of CVC placement in patients with chest trauma and the need for adequate training in this technique.