Posterior Mediastinal Hematoma Research Articles

Malposition of Central Venous Catheter into Coronary Sinus throughout the Persistent Left Superior Vena Cava and Other Complications Related to Catheterization.

This case concentrates on the persistent left superior vena cava (PLSVC), a rare vascular anomaly which contributes to central venous catheter (CVC) misplacement. A 72-year-old woman with renal insufficiency presented to the hospital with recurrent bleeding from her permanent CVC device placed in the right common jugular vein. An initial attempt to replace the device was unsuccessful, necessitating the placement of a secondary catheter in the left jugular vein. Shortly after the procedure, the patient developed swelling of the face and neck. Further diagnostic imaging, including a chest radiograph and computed tomography (CT), revealed CVC misplacement in the PLSVC and coronary sinus, thrombosis of the common jugular vein, and a posterior mediastinal hematoma. Conservative therapy of the mediastinal hematoma was implemented and proved effective in this case. A temporary CVC was inserted into the left femoral vein. Two months later, the catheter underwent further dysfunction and a decision was made to place a long-term permanent CVC via the right femoral vein. The patient is currently awaiting an arteriovenous fistula for dialysis use. This case emphasizes the importance of radiological techniques for CVC procedural placement, as well as the detection of congenital abnormalities. Providers regularly placing CVCs should have an in-depth knowledge of the possible complications and potential anatomical variations, especially as seen in high-risk patients.

A New Complication of Spinal Fusion Surgery for Neuromuscular Scoliosis—Posterior Mediastinal Hematoma: Case Report

BACKGROUND AND IMPORTANCE: Neuromuscular scoliosis surgery is affiliated with a high risk of perioperative and postoperative complications. We present the case of a never-before-reported complication: a posterior mediastinal hematoma. CLINICAL PRESENTATION: We present the case of a 17-year-old female patient with cerebral palsy and neuromuscular scoliosis with a progressive thoracic kyphosis to 85° and levoscoliosis to 13.5° who presented for spinal fusion surgery. Postoperatively, the patient developed persistent tachycardia despite initial resuscitation, anxiolysis, and analgesia. A computed tomography scan was obtained revealing a posterior mediastinal hematoma. The patient was managed with supportive care and recovered well. CONCLUSION: This case highlights a never-before-reported complication of spinal fusion surgery: a posterior mediastinal hematoma. Although unlikely symptomatic, a posterior mediastinal hematoma should be on the differential diagnosis for postoperative tachycardia. This case entreats us to elucidate the true incidence rate of this complication in the population.

Abstract 15645: Posterior Mediastinal Hematoma as a Rare Complication of Anti-Coagulation Use - A Case Report and Literature Review

Introduction: Posterior mediastinal hematoma (PMH) is a rare complication of anti-coagulation (AC) use. We present a complex case of a patient with a sub-massive pulmonary embolism (PE) whose care was complicated by PMH causing airway obstruction following thrombectomy. Case: A 60-year-old male with a history of prostate cancer in remission presented after a syncopal event. On admission, he was afebrile, mildly tachycardic (100bpm), normotensive (135/91), with no oxygen requirement. Laboratory data showed high sensitivity troponin 244 ng/L and BNP 82 pg/ml. CTPA revealed a saddle PE with right heart strain (PESI score 100). He was initiated on anticoagulation and underwent successful mechanical thrombectomy using a Penumbra aspiration catheter. He had acute respiratory failure later that evening, necessitating intubation. Repeat CTPA showed increased clot burden and new onset PMH (Figure 1). Of note, his AC was continued due to clot burden. A repeat thrombectomy was performed using the FlowTriever System Device (Inari Medical, Irvine, CA). Despite this intervention, he continued to struggle with extubation, and a new stridor was noted. Bronchoscopy revealed external compression of proximal trachea correlating with the PMH location. He was deemed too high risk for evacuation of the PMH. Therefore, he underwent tracheostomy to bypass the area of compression. This subsequently allowed for successful extubation. Discussion: While thrombectomy can cause iatrogenic bleeding, no bleeding was seen on the post-procedure angiogram in our patient. Thus, these findings are attributed to PMH. PMH has been reported 6 times in literature (table 1), one associated with PE. Management options include hematoma evacuation or holding AC and performing serial follow up imaging. Our patient did not undergo evacuation of hematoma, and a tracheostomy was used instead to bypass the obstruction. This highlights the need to individualize management of these complex patients.

Abstract 9056: The Association Between Thoracic Injuries Due to Chest Compression and Short-Term Prognosis in Patients With Non-traumatic Out-of-Hospital Cardiac Arrest

Background: The current guidelines emphasize that high-quality chest compression is essential for improving the survival in out-of-hospital cardiac arrest (OHCA) patients. However, it may lead to thoracic injuries which is a potential factor of poor prognosis. Method: Between June 2017 to July 2019, we collected Utstein-style data on 384 consecutive adult patients with non-traumatic OHCA who were transferred to our hospital. Full-body CT scan was performed and thoracic injuries were defined as rib fracture, sternum fracture, hemorrhagic pleural effusion, pneumothorax, sternum posterior bleeding, mediastinal hematoma, or mediastinal emphysema. We identified the predictors for thoracic injuries and evaluated the relationship between thoracic injuries and prognosis. Results: Patients with thoracic injuries (Group-T) were 234 (76%). The duration of chest compression in Group-T was 43 min, which was significantly longer than that in patients without thoracic injuries (Group-N, 32 min, p<0.001). ROC curve analysis identified a duration of chest compression of 35 minutes as the optimal cut off for predicting thoracic injuries (area under the curve 0.73). Multivariate analysis revealed that age (OR: 1.03, 95%CI: 1.01-1.05, p=0.005) and duration of chest compression (OR: 1.07, 95%CI: 1.04-1.09, p<0.001) were independent predictors of thoracic injuries. The rate of obtaining return of spontaneous circulation (ROSC), 30-day survival and favorable neurologic outcome were larger in Group-N than Group-T. In patients with achieving ROSC, Kaplan-Meier curves showed a significantly higher cumulative survival rates in Group-N compared to that in Group-T during follow-up of 30 days (Log-rank test p=0.009). Conclusion: Age and duration of chest compression were independent predictors for thoracic injuries due to chest compression in non-traumatic OHCA patients. Moreover, the presence of thoracic injuries was associated with poor short-term prognosis.

Iatrogenic Posterior Mediastinal Hematoma Secondary to Internal Jugular Vein Cannulation: A Case Report

Iatrogenic Posterior Mediastinal Hematoma Secondary to Internal Jugular Vein Cannulation: A Case Report

Mediastinal hematoma secondary to syndesmophyte fracture in ankylosing spondylitis

Ankylosing spondylitis is an inflammatory rheumatoid disease with severe osteoporosis affecting the spine with a tendency to fracture. Cervical spine fractures resulting in posterior mediastinal hematoma are rare. We present a patient with widened mediastinum secondary to fracture of a cervical ankylosing spondylitis and discuss its presentation and the current literature on the disease.

Panique dans l’oreillette

Posterior mediastinal hematoma in a rare and potentially lethal disease and is frequently consecutive to a traumatism. We report the original case of a 88-year-old male admitted to our department for lipothymia and syncope related to a severe compression of the left atrium by an important mediastinal hematoma mimicking in transthoracic echocardiography an obstructive intraatrial mass.

A Case of a Bullet Penetrating the Esophagus

Purpose: We present a case of a bullet visualized during endoscopy after gun shot wound in which no surgical or endoscopic intervention was needed for a good outcome. Results: Patient is a 21 year old female with recent gun shot injury who came to emergency room complaining of epigastric pain. One month ago, she presented with gun shot wounds and was found to have three bullet fragments in her body-two fragments in her left leg and one large fragment between the esophagus and aorta without extravasation from heart, aorta or great vessel. Barium swallow study did not show any esophageal injury at the time. She had multiple medical complications during that hospitalization, including pneumomediastinum, right hemothorax and pneumothorax, and posterior mediastinal hematoma. Surgical removal of this bullet fragment was not done due to difficult positioning and risk associated with operative intervention. During the most recent admission, the patient presented with epigastric pain and nausea that became progressively worse the last few days. Swallowing exacerbated the pain. She denied difficulty protecting her airway, dysphagia, emesis, hematemesis, or hemoptysis. Initial CT scan was concerning for shift in position of bullet compared to previous imaging. Gastroenterology team was consulted, as it was difficult to discern if the bullet penetrated the esophagus. EGD was performed and the bullet was seen embedded in mucosa of the lower esophagus. Gastrograffin esophagram did not show any contrast extravasation. Aortogram showed no focal aortic or arterial injury. The surgery team discharged the patient without surgical intervention, as she was tolerating a diet and did not have evidence of vasculature injury. Few weeks later, plain films showed the bullet having migrated into the small intestine. One week later, the bullet was in the left colon. EGD and flexible sigmoidoscopy were performed without retained bullet. Esophageal mucosa was completely normal without any abnormalities. Conclusion: This is a case of a bullet that fully penetrated the esophagus over time without any complications. No surgical or endoscopic intervention was required, with the esophageal mucosa healing completely on its own.Figure 1

A new aortic injury score predicts early rupture more accurately than clinical assessment

The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.

Emergent Median Sternotomy for Mediastinal Hematoma: A Rare Complication following Internal Jugular Vein Catheterization for Chemoport Insertion—A Case Report and Review of Relevant Literature

Mediastinal hematoma is a rare complication following insertion of a central venous catheter with only few cases reported in the English literature. We report a case of a 71-year-old female who was admitted for elective chemoport placement. USG guided right internal jugular access was attempted using the Seldinger technique. Resistance was met while threading the guidewire. USG showed a chronic clot burden in the RIJ. A microvascular access was established under fluoroscopic guidance. Rest of the procedure was completed without any further issues. Following extubation, the patient complained of right-sided chest pain radiating to the back. Chest X-ray revealed a contained white out in the right upper lung field. She became hemodynamically unstable. Repeated X-ray showed progression of the hematoma. Median Sternotomy showed posterior mediastinal hematoma tracking into right pleural cavity. Active bleeding from the puncture site at RIJ-SCL junction was repaired. Patient had an uneventful recovery. Injury to the central venous system is the result of either penetrating trauma or iatrogenic causes as in our case. A possible explanation of our complication may be attributed to the forced manipulation of the dilator or guidewire against resistance. Clavicle and sternum offer bony protection to the underlying vital venous structures and injuries often need sternotomy with or without neck extension. Division of the clavicle and disarticulation of the sternoclavicular joint may be required for optimum exposure. Meticulous surgical technique, knowledge of the possible complications, and close monitoring in the postprocedural period are of utmost importance. Chest X-ray showed to be routinely done to detect any complication early.

Posterior Mediastinal Hematoma after a Fall from Standing Height: A Case Report

Posterior Mediastinal Hematomas (PMHs) secondary to a fall from standing height are uncommon, with only one previous case reported in the literature. We describe a case of a 78-year-old male with multiple medical comorbidities, who was transferred to Montreal General Hospital (MGH) with a posterior mediastinal hematoma (PMH) after sustaining a fall from standing height. On initial assessment, the patient was hemodynamically stable and complained of mild chest pain, dyspnea, fatigue, and diaphoresis. The patient's airway was secured via endotracheal intubation fearing impending respiratory compromise secondary to an enlarging PMH. The patient was admitted to ICU where over the next 3 days he was managed conservatively via careful monitoring of his hemodynamic and hematologic indices. Repeat CT scanning indicated reduction in size of the PMH. The patient was discharged on hospital day eight. This case describes the assessment, evaluation, and conservative management of PMH in a complicated patient receiving prior anticoagulation. A review of the literature regarding the epidemiology of PMH and the management of both unstable and stable PMHs is also presented.

A Posterior Mediastinal Hematoma Causing Tracheal Obstruction After Internal Jugular Cannulation for Cardiac Surgery

MANY COMPLICATIONS FROM central venous catheterization have been reported after the internal jugular vein approach. The authors report a posterior mediastinal hematoma after coronary artery bypass graft (CABG) surgery, which was assumed to be caused by malpositioning of the internal jugular catheter or guidewire into the azygos venous system.

後縦隔血腫により二期的胸骨閉鎖を必要とした胸部大動脈瘤破裂の１例

症例は70歳男性．平成20年2月に胸部大動脈瘤破裂を発症した．来院時CTで破裂に伴う後縦隔血腫により心臓が圧迫されていた．同日緊急手術となり弓部大動脈置換術を行ったが，胸骨ワイヤーで閉じると心臓が圧迫され血圧が著明に低下した．両側開胸とし後縦隔へ到達したが血腫を十分には除去できず胸骨を開けたままICU入室となった．術後3日目に再度閉胸を試み，40 mmHg程度の血圧低下を認めたが昇圧剤などで循環動態を保てるため，そのまま閉胸となった．その後も順調に経過し術後43日目に退院となった．

Posterior mediastinal hematoma – a rare case following a fall from standing height: a case report

IntroductionWe present a previously unreported complication of a fall from standing height.Case presentationA 76-year-old woman sustained blunt chest trauma resulting from a fall from standing height. She was diagnosed with a mediastinal hematoma, and did well with supportive care. Follow up CT angiograms on days 2 and 4 of hospital stay revealed a stable hematoma and she did not require any intervention.ConclusionMediastinal hematoma has been reported secondary to trauma, coagulation abnormalities and hematologic malignancies, but it not been reported secondary to a fall from standing height. Factors predisposing to a hematoma in this case were aspirin therapy and a modest elevation of INR secondary to chronic hepatitis C.