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• W4387248857 abstract "SESSION TITLE: Common Procedures, Unintended Consequences SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/11/2023 09:40 am - 10:25 am INTRODUCTION: Tube thoracostomy (TT) is a commonly performed procedure for patients with clinically significant pleural effusions. It can result in several serious complications including vascular injury and a resultant hemothorax (1). Massive hemoptysis is a less expected complication. We present a case of a 73-year-old man who underwent TT for management of an empyema which was complicated by intercostal artery (ICA) injury upon removal followed by massive hemoptysis in the setting of a suspected bronchopleural fistula (BPF). CASE PRESENTATION: A 71-year-old male with a history of squamous cell carcinoma of the lung, for which he had received prior chemotherapy and radiation, presented with increased cough and chest pain after an outpatient thoracentesis for a recurrent pleural effusion. CT imaging revealed a large hydropneumothorax concerning for a necrotizing infection. Prior imaging had demonstrated a small foci of gas in the same area but this had been attributed to prior thoracenteses as opposed to an overt bronchopleural fistula. TT was subsequently performed at the 8th-9th intercostal space in the posterior axillary line with placement of a 14 French catheter and successful removal of clear yellow fluid, which ultimately grew alpha-hemolytic streptococcus. Intrapleural tissue plasminogen activator and dornase alfa were then intermittently administered through the chest tube. As pleural fluid output decreased and no air leak was noted, the chest tube was removed. During its removal, however, significant arterial bleeding at the thoracostomy site developed requiring both manual pressure and packing with SURGICEL. Shortly thereafter, the patient experienced the onset of massive hemoptysis and ultimately devolved into cardiac arrest. ACLS was promptly initiated, blood products were transfused, and one gram of tranexamic acid was administered via the endotracheal tube. Upon return of spontaneous circulation, bronchoscopy was performed without identification of active bleeding. The leading differential for the cause of his massive hemoptysis was the transmission of blood from an intercostal artery injury through a pre-existing BPF. CT angiography of the chest showed active extravasation from the ICA under the 9th rib without bronchial artery bleeding (Figure 1). The patient underwent successful coil and gel-foam embolization of the 8th, 9th, and 10th intercostal arteries (Figure 2). His course stabilized and he was able to tolerate washout of his pleural space followed by extubation and ultimately, discharge home. DISCUSSION: Intercostal artery injury and subsequent hemothorax are potential complications of tube thoracostomy as well as thoracentesis and typically occur at rates between 0.4%-3% (2) Arterial injury, however, is usually apparent during placement rather than removal of the chest tube, as was seen here. A bronchopleural fistula can arise from a number of causes and in this case, was likely present due to prior radiation treatments as noted by the foci of gas on prior imaging. CONCLUSIONS: Massive hemoptysis due to the presence of a bronchopleural fistula following tube thoracostomy is a less common event and has not been well described in the literature (3). We present such a case here. Careful consideration for underlying pleural pathology should be undertaken prior to TT performance. REFERENCE #1: Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S, Tulman D, Latchana N, Papadimos TJ, Cook CH, Stawicki SP. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci. 2014 Apr;4(2):143-55. doi: 10.4103/2229-5151.134182. PMID: 25024942; PMCID: PMC4093965. REFERENCE #2: Yacovone ML, Kartan R, Bautista M. Intercostal artery laceration following thoracentesis. Respir Care. 2010 Nov;55(11):1495-8. PMID: 20979678. REFERENCE #3: Vujic I, Pyle R, Parker E, Mithoefer J. Control of massive hemoptysis by embolization of intercostal arteries. Radiology. 1980;137(3):617-620. doi:10.1148/radiology.137.3.7444046 DISCLOSURES: No relevant relationships by William Bender No relevant relationships by Niraj Gowda No relevant relationships by Anjali Patel No relevant relationships by Alejandro Sardi" @default.
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• W4387248857 date "2023-10-01" @default.
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• W4387248857 title "MASSIVE HEMOPTYSIS IN THE SETTING OF A BRONCHOPLEURAL FISTULA FOLLOWING TUBE THOROACOSTOMY" @default.
• W4387248857 doi "https://doi.org/10.1016/j.chest.2023.07.3483" @default.
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