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Avoiding Vessel Laceration in ThoracentesisA Role of Vascular Ultrasound With Color Doppler: A Role of Vascular Ultrasound With Color Doppler FREE TO VIEW

Mio Kanai, MD; Hiroshi Sekiguchi, MD
Author and Funding Information

From the Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research, Rochester, MN.

CORRESPONDENCE TO: Hiroshi Sekiguchi, MD, Division of Pulmonary and Critical Care Medicine, Gonda 18 S, Mayo Clinic, 200 First St SW, Rochester, MN 55905; e-mail: Sekiguchi.Hiroshi@mayo.edu


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):e5-e7. doi:10.1378/chest.14-0814
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Thoracentesis is considered a relatively safe and well-established procedure commonly done at the bedside with minimal risk of complication. Thoracentesis-related hemothorax is uncommon; however, it may be life-threatening. We describe a case of a 19-year-old woman with persistent fever and pleural effusion, in which thoracentesis resulted in tension hemothorax due to intercostal artery laceration. It is important for proceduralists to understand not only the tortuosity of the intercostal artery covering 25% to 50% of the intercostal space, but also the presence of traversing collateral arteries. Herein, we discuss the potential benefit of vascular ultrasonography with color Doppler during thoracentesis, with the goal of avoiding vessel injury and hemorrhage.

Figures in this Article

Thoracentesis is a relatively safe, well-established procedure; however, hemorrhagic complication may be life-threatening. In this report, we describe a case of tension hemothorax and discuss the potential benefit of vascular ultrasonography to avoid vessel injury.

A 19-year-old woman with no history of coagulopathy developed right-sided pleural effusion in the setting of persistent fever. Thoracic ultrasonography with a phased-array transducer was used to locate the pleural effusion and mark the needle insertion site. The skin over the seventh intercostal space (ICS) at the midscapular line (approximately 8 cm laterally from the spinal midline) was anesthetized with 1% lidocaine, and a 5F needle was inserted over the superior aspect of the eighth rib. A total of 700 mL of amber-colored fluid was drained. One hour after procedure, the patient became hypotensive, tachycardic, and hypoxemic. Thoracic ultrasonography revealed a large right pleural effusion with atelectatic lung. Laboratory testing demonstrated a hemoglobin level of 5.5 g/mL. Massive transfusion protocol was initiated along with intubation and vasopressor infusion. Emergent chest tube placement drained 1,500 mL of blood from the right hemithorax. She was subsequently weaned off of vasopressors, confirming the diagnosis of tension hemothorax. Extubation occurred 2 days after transfusion and stabilization. Pleural fluid analysis was consistent with parapneumonic effusion, and she was treated with antibiotic therapy. Follow-up vascular ultrasonography with color Doppler demonstrated the intercostal artery (ICA) positioned near the center of ICS (Fig 1).

Figure Jump LinkFigure 1 –  Vascular ultrasonography with color Doppler demonstrating the intercostal artery positioned near the center of the intercostal space.Grahic Jump Location

This case illustrates a rare but possibly fatal complication of thoracentesis, in which ICA laceration led to tension hemothorax despite thoracic ultrasonography usage. Since the introduction of thoracic ultrasonography, the rate of pneumothorax has declined from 9.3% to 4.0%.1 However, it has been difficult to determine whether the rate of hemothorax has decreased with thoracic ultrasound usage, due to its relative infrequency.

Iatrogenic hemothorax due to thoracentesis has been reported in approximately 0.4% of the patients with mild coagulopathy and in 0.8% to 3.3% in patients who are mechanically ventilated.2,3 With chest tube insertion or video-assisted thoracoscopic surgery, hemothorax may occur in approximately 2% of cases.4,5 This low incidence of intragenic hemothorax may be confounded by the reality that mild intrathoracic hemorrhage ceases spontaneously and that it is often difficult to differentiate residual effusion from intrathoracic hemorrhage in the postprocedural films or ultrasonography. It is likely that only the severe cases complicated by respiratory distress or cardiopulmonary instability such as tension hemothorax have been clinically recognized, treated, and reported as such.2,6

Conventionally, proceduralists have been taught to insert the needle above the superior aspect of the rib in the ICS to avoid damaging the neurovascular bundle, which normally runs behind the inferior border.7 Hemothorax may occur despite following this precaution, due to the tortuous nature of the ICA and its collaterals traversing the ICS (Fig 2). Studies demonstrated that the ICA is positioned caudally to the inferior border of the rib when it is near the costovertebral junction, and as it runs laterally, becomes closer to or is hidden by the rib.8-10 Due to its tortuosity, the ICA may not be shielded by the rib within 12 cm from the spinal midline, spanning anywhere between 25% and 50% of the ICS, with a maximal tortuosity located at 6 to 9 cm laterally from midline.8-11 Elderly patients may have higher tortuosity, leading to wider exposure of the unshielded ICA.8,10,12 Furthermore, the collateral artery may branch at 4 to 5 cm lateral to the midline and traverse the ICS.10 An additional collateral branch is common and observed in approximately 80% of patients.10

Figure Jump LinkFigure 2 –  Anatomical illustration demonstrating the intercostal artery and its collaterals. (Reprinted with permission of the Mayo Foundation for Medical Education and Research.)Grahic Jump Location

Ultrasonography can be used not only to visualize the lung and pleural effusion, but also to locate the ICA and its collaterals. Studies have demonstrated that the ICA can be imaged with a linear transducer via color Doppler ultrasound in the majority of patients.13,14 As demonstrated in this case, a linear vascular transducer with a frequency range of 6 to 13 MHz should be placed over the inferior edge of the rib or the targeted ICS using color Doppler function. We recommend using a Nyquist limit (aliasing velocity) below 15 to 20 cm/s with proper color gain that eliminates random color speckles from nonmoving regions. It is important to align the insertion needle with the ultrasound plane. Surface landmarks may be difficult to delineate in patients with obesity or subcutaneous edema, therefore, slight needle angulation may cause vessel injury (Fig 3).

Figure Jump LinkFigure 3 –  Illustration demonstrating appropriate and inappropriate needle angulation (pathway A and B, respectively) from the same needle insertion site. (Reprinted with permission of the Mayo Foundation for Medical Education and Research.)Grahic Jump Location

A current guideline suggests that ultrasound may not reduce the incidence of ICA laceration as the artery is not well visualized on thoracic ultrasound.7 We suggest there is a potential benefit for patient safety through the use of both phased-array (thoracic) and linear (vascular) transducers, with the goal of avoiding pneumothorax, subdiaphragmatic organ injury, and arterial laceration. Similarly, the use of vascular ultrasonography to visualize the inferior epigastric artery has been suggested to make paracentesis safer.15

In conclusion, it is essential to understand the anatomic course and tortuosity of the ICA and its collaterals. Although it may not be necessary in all thoracentesis procedures, the elderly or those in whom thoracentesis is obtained closer to the costovertebral junction may potentially benefit from vascular ultrasonography with color Doppler, in addition to thoracic ultrasonography.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

ICA

intercostal artery

ICS

intercostal space

Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339. [CrossRef] [PubMed]
 
Hibbert RM, Atwell TD, Lekah A, et al. Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest. 2013;144(2):456-463. [CrossRef] [PubMed]
 
Goligher EC, Leis JA, Fowler RA, Pinto R, Adhikari NK, Ferguson ND. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care. 2011;15(1):R46. [CrossRef] [PubMed]
 
Aylwin CJ, Brohi K, Davies GD, Walsh MS. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl. 2008;90(1):54-57. [CrossRef] [PubMed]
 
Imperatori A, Rotolo N, Gatti M, et al. Peri-operative complications of video-assisted thoracoscopic surgery (VATS). Int J Surg. 2008;6(suppl 1):S78-S81. [CrossRef] [PubMed]
 
Yacovone ML, Kartan R, Bautista M. Intercostal artery laceration following thoracentesis. Respir Care. 2010;55(11):1495-1498. [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Choi S, Trieu J, Ridley L. Radiological review of intercostal artery: anatomical considerations when performing procedures via intercostal space. J Med Imaging Radiat Oncol. 2010;54(4):302-306. [CrossRef] [PubMed]
 
Helm EJ, Rahman NM, Talakoub O, Fox DL, Gleeson FV. Course and variation of the intercostal artery by CT scan. Chest. 2013;143(3):634-639. [CrossRef] [PubMed]
 
Shurtleff E, Olinger A. Posterior intercostal artery tortuosity and collateral branch points: a cadaveric study. Folia Morphol (Warsz). 2012;71(4):245-251. [PubMed]
 
Yoneyama H, Arahata M, Temaru R, Ishizaka S, Minami S. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med. 2010;49(4):289-292. [CrossRef] [PubMed]
 
Carney M, Ravin CE. Intercostal artery laceration during thoracocentesis: increased risk in elderly patients. Chest. 1979;75(4):520-522. [CrossRef] [PubMed]
 
Koyanagi T, Kawaharada N, Kurimoto Y, et al. Examination of intercostal arteries with transthoracic Doppler sonography. Echocardiography. 2010;27(1):17-20. [CrossRef] [PubMed]
 
Salamonsen M, Ellis S, Paul E, et al. Thoracic ultrasound demonstrates variable location of the intercostal artery. Respiration. 2012;83(4):323-329. [CrossRef] [PubMed]
 
Sekiguchi H, Suzuki J, Daniels CE. Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication. Chest. 2013;143(4):1136-1139. [CrossRef] [PubMed]
 

Figures

Figure Jump LinkFigure 1 –  Vascular ultrasonography with color Doppler demonstrating the intercostal artery positioned near the center of the intercostal space.Grahic Jump Location
Figure Jump LinkFigure 2 –  Anatomical illustration demonstrating the intercostal artery and its collaterals. (Reprinted with permission of the Mayo Foundation for Medical Education and Research.)Grahic Jump Location
Figure Jump LinkFigure 3 –  Illustration demonstrating appropriate and inappropriate needle angulation (pathway A and B, respectively) from the same needle insertion site. (Reprinted with permission of the Mayo Foundation for Medical Education and Research.)Grahic Jump Location

Tables

References

Gordon CE, Feller-Kopman D, Balk EM, Smetana GW. Pneumothorax following thoracentesis: a systematic review and meta-analysis. Arch Intern Med. 2010;170(4):332-339. [CrossRef] [PubMed]
 
Hibbert RM, Atwell TD, Lekah A, et al. Safety of ultrasound-guided thoracentesis in patients with abnormal preprocedural coagulation parameters. Chest. 2013;144(2):456-463. [CrossRef] [PubMed]
 
Goligher EC, Leis JA, Fowler RA, Pinto R, Adhikari NK, Ferguson ND. Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis. Crit Care. 2011;15(1):R46. [CrossRef] [PubMed]
 
Aylwin CJ, Brohi K, Davies GD, Walsh MS. Pre-hospital and in-hospital thoracostomy: indications and complications. Ann R Coll Surg Engl. 2008;90(1):54-57. [CrossRef] [PubMed]
 
Imperatori A, Rotolo N, Gatti M, et al. Peri-operative complications of video-assisted thoracoscopic surgery (VATS). Int J Surg. 2008;6(suppl 1):S78-S81. [CrossRef] [PubMed]
 
Yacovone ML, Kartan R, Bautista M. Intercostal artery laceration following thoracentesis. Respir Care. 2010;55(11):1495-1498. [PubMed]
 
Havelock T, Teoh R, Laws D, Gleeson F; BTS Pleural Disease Guideline Group. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Thorax. 2010;65(suppl 2):ii61-ii76. [CrossRef] [PubMed]
 
Choi S, Trieu J, Ridley L. Radiological review of intercostal artery: anatomical considerations when performing procedures via intercostal space. J Med Imaging Radiat Oncol. 2010;54(4):302-306. [CrossRef] [PubMed]
 
Helm EJ, Rahman NM, Talakoub O, Fox DL, Gleeson FV. Course and variation of the intercostal artery by CT scan. Chest. 2013;143(3):634-639. [CrossRef] [PubMed]
 
Shurtleff E, Olinger A. Posterior intercostal artery tortuosity and collateral branch points: a cadaveric study. Folia Morphol (Warsz). 2012;71(4):245-251. [PubMed]
 
Yoneyama H, Arahata M, Temaru R, Ishizaka S, Minami S. Evaluation of the risk of intercostal artery laceration during thoracentesis in elderly patients by using 3D-CT angiography. Intern Med. 2010;49(4):289-292. [CrossRef] [PubMed]
 
Carney M, Ravin CE. Intercostal artery laceration during thoracocentesis: increased risk in elderly patients. Chest. 1979;75(4):520-522. [CrossRef] [PubMed]
 
Koyanagi T, Kawaharada N, Kurimoto Y, et al. Examination of intercostal arteries with transthoracic Doppler sonography. Echocardiography. 2010;27(1):17-20. [CrossRef] [PubMed]
 
Salamonsen M, Ellis S, Paul E, et al. Thoracic ultrasound demonstrates variable location of the intercostal artery. Respiration. 2012;83(4):323-329. [CrossRef] [PubMed]
 
Sekiguchi H, Suzuki J, Daniels CE. Making paracentesis safer: a proposal for the use of bedside abdominal and vascular ultrasonography to prevent a fatal complication. Chest. 2013;143(4):1136-1139. [CrossRef] [PubMed]
 
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