Massive hemothorax due to inferior phrenic artery injury after blunt trauma
© Aoki et al. 2015
Received: 28 September 2015
Accepted: 19 November 2015
Published: 24 November 2015
Injury to the inferior phrenic artery after blunt trauma is an extremely rare event, and it may occur under unanticipated conditions. This case report describes an injury to the left inferior phrenic artery caused by blunt trauma, which was complicated by massive hemothorax, and treated with transcatheter arterial embolization (TAE).
An 81 year-old female hit by a car while walking at the traffic intersection was transferred to the emergency department, computed tomography scanning revealed active extravasations of the contrast medium within the retrocrural space and from branches of the internal iliac artery. The patient underwent repeated angiography, and active extravasation of contrast medium was observed between the retrocrural space and the right pleural space originating from the left inferior phrenic artery. The injured left inferior phrenic artery was successfully embolized with N-butyl cyanoacrylate, resulting in stabilization of the patient’s clinical condition.
Inferior phrenic artery injury should be recognized as a rare phenomenon and causative factor for hemothorax. TAE represents a safe and effective treatment for this complication and obviates the need for a thoracotomy.
KeywordsInferior phrenic artery Blunt trauma Transcatheter arterial embolization N-butyl cyanoacrylate
Injury to the inferior phrenic artery after blunt trauma is an extremely rare event, and it may occur under unanticipated conditions. In the present case, blunt trauma led to left inferior phrenic artery injury associated with massive hemothorax, which was treated with TAE alone. To the author’s knowledge, this is the first report of massive hemothorax due to inferior phrenic artery injury treated definitively by TAE. Furthermore, previous cases of inferior phrenic artery injury after blunt trauma are reviewed.
Following a collision with a car while walking at the traffic intersection, an 81 year-old female was transferred to the emergency department by helicopter. The patient had medication for hypertension and wasn’t on antiplatelet or anticoagulant medications. On hospital arrival (50 min after injury) the patient was alert, with a systolic/diastolic blood pressure (SBP/DBP) of 126/86 mmHg, a heart rate of 110 beats/min. Physical examination revealed tenderness in the pelvic region and contusion in the left knee joint. Initial laboratory studies revealed the following values; hemoglobin, 12.0 g/dl; white blood cell (WBC) count, 11,500/μl; platelet count, 16.9 × 104/μl; creatinine (Cr), 0.45 mg/dl; prothrombin time international ratio, 1.00; activated partial thromboplastin time, 26.5 s; Arterial blood gas analysis measured on arrival revealed the following values; pH, 7.430; PCO2, 30.6 mmHg; PO2, 69.0 mmHg; HCO3 −, 21.8 mmol/l; base excess, −3.6 mmol/l; lactate, 2.4 mmol/l.
This was an unusual case of hemothorax because it was not accompanied by damage to the thoracic and abdominal organs. Only one case was previously reported in which hemothorax was caused by inferior phrenic artery injury, without multiple organ injury , however, this is the first report of an injured left inferior phrenic artery injury resulting in contralateral right hemothorax. Data from the present case suggest that damage to the left inferior phrenic artery injury led to a hemorrhage in mediastinum, which subsequently ruptured into the right pleural region.
The characteristics of the reported cases of inferior phrenic artery injury due to blunt trauma
Embolic material of TAE
Polyvinyl alcohol particles
Intraperitoneal hemorrhage and Subcapsular hematoma
TAE and thoracotomy
Lee et al. described a patient with inferior phrenic artery injury accompanied by diaphragmatic injury, and laparotomy was selected . Laparotomy is the best choice for single stage restoration. The present case was definitively treated by TAE and not accompanied by diaphragmatic injury, however, the combination of laparoscopy and thoracoscopy could be safe management and more useful for detecting the diaphragmatic injury .
In the other four cases, there were no concomitant injuries and complications. TAE may circumvent the need for thoracotomy or laparotomy, if the arterial injury is not associated with diaphragmatic rupture and stomach herniation into the left hemithorax . TAE is commonly considered the most reliable and feasible therapeutic alternative to thoracotomy for control of intrathoracic arterial hemorrhages [9, 10] and is useful alternative treatment for a thoracotomy, which could be fatal in this 80+ year old patient. The authors propose that TAE represents the optimal strategy for management of inferior phrenic artery injury without diaphragmatic injury, and advances in microcatheter designs and embolic agents have contributed to the safety and effectiveness of TAE.
In the summary we described the case of the left inferior phrenic artery injury who suffered blunt trauma. The findings suggest that hemothorax may be induced by inferior phrenic artery injury and this is very rare phenomenon. TAE can be a safe and effective treatment for the inferior phrenic artery bleeding and obviates the need for a thoracotomy.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
There is no one to acknowledge except for the co-authors listed.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Ogawa F, Naito M, Iyoda A, Satoh Y. Report of a rare case: occult hemothorax due to blunt trauma without obvious injury to other organs. J Cardiothorac Surg. 2013;8:205.PubMed CentralView ArticlePubMedGoogle Scholar
- Pick JM, Anson BJ. The inferior phrenic artery: origin and suprarenal branches. Anat Rec. 1940;78:413–27.View ArticleGoogle Scholar
- Loukas M, Hullett J, Wagner T. Clinical anatomy of the inferior phrenic artery. Clin Anat. 2005;18(5):357–65.View ArticlePubMedGoogle Scholar
- Jones BV, Vu D. Diagnosis of posttraumatic pericardial tamponade by plain film and computed tomography and control of bleeding by embolotherapy of the left inferior phrenic artery. Cardiovasc Intervent Radiol. 1993;16(3):183–5.View ArticlePubMedGoogle Scholar
- Mizobata Y, Yokota J, Yajima Y, Sakashita K. Two cases of blunt hepatic injury with active bleeding from the right inferior phrenic artery. J Trauma. 2000;48(6):1153–5.View ArticlePubMedGoogle Scholar
- Lee JW, Kim S, Kim CW, Kim KH, Jeon TY. Massive hemoperitoneum due to ruptured inferior phrenic artery pseudoaneurysm after blunt trauma. Emerg Radiol. 2006;13(3):147–9.View ArticlePubMedGoogle Scholar
- Yonemitsu T, Kawai N, Sato M, Tanihata H, Takasaka I, Nakai M, et al. Evaluation of transcatheter arterial embolization with gelatin sponge particles, microcoils, and n-butyl cyanoacrylate for acute arterial bleeding in a coagulopathic condition. J Vasc Interv Radiol. 2009;20(9):1176–87.View ArticlePubMedGoogle Scholar
- Ochsner MG, Rozycki GS, Lucente F, Wherry DC, Champion HR. Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report. J Trauma. 1993;34(5):704–9.View ArticlePubMedGoogle Scholar
- Carrillo EHHB, Senler SO, Dykes JR, Maniscalco SP, Richardson JD. Embolization therapy as an alternative to thoracotomy in vascular injuries of the chest wall. Am Surg. 1998;64:7.Google Scholar
- Chemelli AP, Thauerer M, Wiedermann F, Strasak A, Klocker J, Chemelli-Steingruber IE. Transcatheter arterial embolization for the management of iatrogenic and blunt traumatic intercostal artery injuries. J Vasc Surg. 2009;49(6):1505–13.View ArticlePubMedGoogle Scholar