Right ventricular lead perforation with iatrogenic injury to an intercostal artery causing haemothorax after pacemaker implant.

A woman in her 80s experienced a life-threatening complication of pacemaker implant consisting of subacute right ventricular lead perforation causing iatrogenic injury to an intercostal artery, resulting in a large haemothorax. A CT scan confirmed active bleeding from the fourth intercostal artery. The patient underwent cardiothoracic surgery via a median sternotomy approach, during which the source of the bleeding was sealed, a new epicardial lead was positioned, and the original lead was extracted. This case emphasises the potentially severe consequences of pacemaker lead perforation and secondary injury to adjacent structures. It underscores the importance of early recognition and timely intervention, preferably in a tertiary specialist unit equipped for cardiothoracic surgery and confirms the value of pacemaker interrogation and CT scans for diagnosis.

Thoracic Lavage for Traumatic Hemothorax.

This Surgical Innovation discusses thoracic lavage for traumatic hemothorax.

CT-based pleural effusion volume estimation formula demonstrates low accuracy and reproducibility for traumatic hemothorax.

PURPOSE: We aimed to evaluate the accuracy and reproducibility of the CT-based volume estimation formula V = d2 * h, where d and h represent the maximum depth and height of the effusion, for acute traumatic hemothorax. MATERIALS & METHODS: Prospectively identified patients with CT showing acute traumatic hemothorax were considered. Volumes were retrospectively estimated using d2 * h, then manually measured on axial images. Subgroup analysis was performed on borderline-sized hemothorax (200-400 mL). Measurements were repeated by three non-radiologists. Bland-Altman analysis was used to assess agreement between the two methods and agreement between raters for each method. RESULTS: A total of 46 patients (median age 34; 36 men) with hemothorax volume 23-1622 mL (median 191 mL, IQR 99-324 mL) were evaluated. Limits of agreement between estimates and measured volumes were -718 - +842 mL (± 202 mL). Borderline-sized hemothorax (n = 13) limits of agreement were -300 - +121 mL (± 114 mL). Of all hemothorax, 85 % (n = 39/46) were correctly stratified as over or under 300 mL, and of borderline-sized hemothorax, 54 % (n = 7/13). Inter-rater limits of agreement were -251 - +350, -694 - +1019, and -696 - +957 for the estimation formula, respectively, and -124 - +190, -97 - +111, and -96 - +46 for the measured volume. DISCUSSION: An estimation formula varies with actual hemothorax volume by hundreds of mL. There is low accuracy in stratifying hemothorax volumes close to 300 mL. Variability between raters was substantially higher with the estimation formula than with manual measurements.

Recurrence of pulmonary sarcomatoid carcinoma presenting as haemothorax: a case report.

Pulmonary sarcomatoid carcinoma (PSC) is a rare and highly invasive malignant tumour. It has similar clinical manifestations and imaging features to ordinary lung cancer. This current case report describes a 65-year-old male patient who had a mass in the apicoposterior segment of the left upper lobe with haemoptysis. Imaging studies revealed a central parenchymal mass surrounded by areas of ground-glass opacity, strongly indicating the presence of a pulmonary malignancy. Intraoperatively, the tumour was discovered to have invaded the chest wall and exhibited a significant propensity for bleeding. Consequently, a left upper lobe resection accompanied by extensive pleural debridement were performed. Subsequent postoperative histopathological examination confirmed the diagnosis of PSC. Unfortunately, 1 month after the surgery, the patient presented with left-sided haemothorax. Despite employing various haemostatic interventions, the patient eventually succumbed to haemorrhagic shock. This study provides a treatment strategy reference for patients with PSC presenting as haemothorax.

Efficacy and safety of transcatheter arterial embolization for hemodynamically unstable bleeding after percutaneous transthoracic needle biopsy.

PURPOSE: To evaluate the safety and efficacy of transcatheter arterial embolization (TAE) in controlling hemodynamically unstable bleeding following a percutaneous transthoracic needle biopsy (PTNB). METHODS: A total of seven patients (four men and three women; mean age, 62 ± 12 years) who received TAE for post-PTNB bleeding between May 2007 and March 2022 were included. The observed types of bleeding were hemothorax (n = 3), hemoptysis (n = 2), and a combination of both (n = 2). In patients with active bleeding, the technical success of TAE was defined as superselective embolization of the target artery with no active bleeding visible on post-TAE angiography. Clinical success was defined as sustained cessation of bleeding without hemodynamic instability, requirement of repeat TAE, or the need for post-TAE hemostatic surgery during the initial admission. The metrics analyzed included technical and clinical success rates, complications, and 30-day mortality. RESULTS: All seven patients achieved technical success, with a clinical success rate of 86% (6/7). Six patients were discharged alive, while one patient died of respiratory failure accompanied by hemothorax 19 days post-biopsy. The angiographic findings associated with bleeding were contrast media extravasation or pseudoaneurysm (n = 3) and vascular hypertrophy with tortuosity (n = 2). The implicated bleeding arteries included the intercostal artery (n = 2), bronchial artery (n = 2), and internal thoracic artery (n = 1). In two cases, no clear bleeding foci were identified; nonetheless, prophylactic embolization was performed on the right intercostal artery (n = 1) and right intercostobronchial trunk (n = 1). The embolic agents utilized included microcoils (n = 1), gelatin sponge particles (n = 2), polyvinyl alcohol (PVA) with gelatin sponge particles (n = 1), PVA with microcoils (n = 1), microcoils with gelatin sponge particles (n = 1), and microcoils with n-butyl-2-cyanoacrylate and gelatin sponge particles (n = 1). The 30-day mortality rate was 14% (1/7). No ischemic complications related to TAE were observed. CONCLUSION: The study suggests that TAE is safe and effective for controlling hemodynamically unstable bleeding following a PTNB.

Spontaneous large volume hemothorax managed with a small-bore chest tube.

A 67-year-old male with metastatic lung cancer presented with acute shortness of breath and increasing oxygen requirements. He had a decreasing hemoglobin for which he required red blood cell transfusions. His chest X-ray showed near complete white-out of the left lung. Bedside ultrasound (Handheld Sonostar C4PL) showed a large pleural effusion with swirling echogenic material suggestive of plankton sign. The pleural effusion was aspirated and showed frank blood, after which a small-bore chest tube (SBCT) was inserted. A total of 3200 mL of blood was drained with the SBCT. There was complete clearance of the pleural space, and no further blood product transfusions were needed. This case highlights that conservative management can be considered in patients with spontaneous hemothorax due to metastatic disease.

[Chest Tube in Thoracic Trauma - Recommendations of the Interdisciplinary Thoracic Trauma Task Group of the German Society for Thoracic Surgery (DGT) and the German Trauma Society (DGU)]. / Thoraxdrainage beim Thoraxtrauma ­ Empfehlungen der interdisziplinären Arbeitsgemeinschaft Thoraxtrauma der Deutschen Gesellschaft für Thoraxchirurgie (DGT) und der Deutschen Gesellschaft für Unfallchirurgie (DGU).

For unstable patients with chest trauma, the chest tube is the method of choice for the treatment of a relevant pneumothorax or haemothorax. In the case of a tension pneumothorax, needle decompression with a cannula of at least 5 cm length should be performed, directly followed by the insertion of a chest tube. The evaluation of the patient should be performed primarily with a clinical examination, a chest X-ray and sonography, but the gold standard of diagnostic testing is computed tomography (CT).A small-bore chest tube (e.g. 14 French) should be used in stable patients, while unstable patients should receive a large-bore drain (24 French or larger). Insertion of chest drains has a high complication rate of between 5% and 25%, and incorrect positioning of the tube is the most common complication. However, incorrect positioning can usually only be reliably detected or ruled out with a CT scan, and chest X-rays proofed to be insufficient to answer this question. Therapy should be carried out with mild suction of approximately 20 cmH2O, and clamping the chest tube before removal showed no beneficial effect. The removal of drains can be safely performed, either at the end of inspiration or at the end of expiration. In order to reduce the high complication rate, in the future the focus should be more on the education and training of medical staff members.

[Massive Hemorrhage from the Delayed Diaphragmatic Injury due to the Rib Fracture after the Blunt Chest Trauma:Report of a Case].

We report a case of delayed diaphragmatic injury caused by lower rib fractures. A 56-year-old male was referred to our hospital due to the fractures of right lower ribs. Chest X-ray revealed pneumothorax, and the patient was hospitalized for follow-up. On the sixth day after the injury, the patient suddenly complained of chest pain and respiratory distress, and then shock status developed. Chest computed tomography (CT) revealed massive pleural effusion. An emergency operation was performed. The injury of the diaphragm was found. Fracture of the lower rib can cause diaphragmatic injury leading to massive hemorrhage.

A pilot study of deep learning-based CT volumetry for traumatic hemothorax.

PURPOSE: We employ nnU-Net, a state-of-the-art self-configuring deep learning-based semantic segmentation method for quantitative visualization of hemothorax (HTX) in trauma patients, and assess performance using a combination of overlap and volume-based metrics. The accuracy of hemothorax volumes for predicting a composite of hemorrhage-related outcomes - massive transfusion (MT) and in-hospital mortality (IHM) not related to traumatic brain injury - is assessed and compared to subjective expert consensus grading by an experienced chest and emergency radiologist. MATERIALS AND METHODS: The study included manually labeled admission chest CTs from 77 consecutive adult patients with non-negligible (≥ 50 mL) traumatic HTX between 2016 and 2018 from one trauma center. DL results of ensembled nnU-Net were determined from fivefold cross-validation and compared to individual 2D, 3D, and cascaded 3D nnU-Net results using the Dice similarity coefficient (DSC) and volume similarity index. Pearson's r, intraclass correlation coefficient (ICC), and mean bias were also determined for the best performing model. Manual and automated hemothorax volumes and subjective hemothorax volume grades were analyzed as predictors of MT and IHM using AUC comparison. Volume cut-offs yielding sensitivity or specificity ≥ 90% were determined from ROC analysis. RESULTS: Ensembled nnU-Net achieved a mean DSC of 0.75 (SD: ± 0.12), and mean volume similarity of 0.91 (SD: ± 0.10), Pearson r of 0.93, and ICC of 0.92. Mean overmeasurement bias was only 1.7 mL despite a range of manual HTX volumes from 35 to 1503 mL (median: 178 mL). AUC of automated volumes for the composite outcome was 0.74 (95%CI: 0.58-0.91), compared to 0.76 (95%CI: 0.58-0.93) for manual volumes, and 0.76 (95%CI: 0.62-0.90) for consensus expert grading (p = 0.93). Automated volume cut-offs of 77 mL and 334 mL predicted the outcome with 93% sensitivity and 90% specificity respectively. CONCLUSION: Automated HTX volumetry had high method validity, yielded interpretable visual results, and had similar performance for the hemorrhage-related outcomes assessed compared to manual volumes and expert consensus grading. The results suggest promising avenues for automated HTX volumetry in research and clinical care.

Detection of incidental schwannoma by traumatic hemothorax.

A case of hemothorax caused by traumatic rupture of schwannoma is rarely reported. We present a case of thorax injury of an 18-year-old woman who had fallen from a high place with a Glasgow Coma Score 13. Chest X-ray showed a left-sided massive pleural effusion. Chest tomography revealed a 105×80 mm formation in the left lung basal region. The patient underwent an emergency thoracotomy after 2000 cc blood drainage with intercostal tube placement. Tumor's pathologic diagnosis was schwannoma (neurilemmoma). In this case study, we would like to present a traumatic hemothorax for the previously unknown mediastinal mass with the relevant literature.

Recurrent Massive Hemothorax of Unknown Etiology in an 85-Year-Old Man.

CASE PRESENTATION: An 85-year-old Japanese man, who was taking aspirin and edoxaban for previous myocardial infarction and atrial fibrillation, came to our hospital with a chief complaint of dyspnea for 3 weeks. Chest radiography showed a massive left pleural effusion (Fig 1A). Analysis of pleural fluid showed an elevated hematocrit level at 32.8% (blood hematocrit level, 32.0%), and he was diagnosed with hemothorax. However, he had neither coagulation disorder nor thrombocytopenia, and the pleural effusion was negative for atypical cells. These findings suggested that the antithrombotic and anticoagulant medications might have induced the hemothorax.

Acute Presentation of a High-Grade Myxofibrosarcoma Originating in the Thoracic Wall: A Case Report.

We report the first case of a patient with myxofibrosarcoma (MFS) who presented acutely with a rib fracture and developed a rapidly expanding loculated hemothorax after chest trauma. The patient was taken to the operating room for evacuation of hemothorax, and samples and biopsy specimens were taken for cytologic and pathologic examination. Final report with immunohistochemical staining showed a high-grade MFS. After the procedure, there was clinical and radiological improvement, and the patient was followed up as an outpatient. Myxofibrosarcoma is a very rare and aggressive connective tissue neoplasm with variable presentations. Surgical resection is the preferred treatment. Prompt diagnosis and adequate management of these tumors are important to reduce their high local recurrence and distant metastasis rates. Therefore, it is important to be aware of its common and uncommon presentations.

Mediastinal Ancient Schwannoma Causing Intrathoracic Bleeding.

Spontaneous hemothorax caused by the rupture of a benign schwannoma has rarely been reported. Herein, we present the successful excision of an extremely rare case of mediastinal ancient schwannoma causing intrathoracic bleeding. A 27-year-old man was admitted to our emergency department because of back pain and dyspnea. Computed tomography revealed massive pleural effusion with a posterior mediastinal tumor. We performed a resection of the tumor which had ruptured, and the tumor was diagnosed as an ancient schwannoma.

Managing tube thoracostomy with thoracic ultrasound: results from a randomized pilot study.

PURPOSE: Tube thoracostomy (TT) is a simple and a life-saving procedure; nevertheless, it carries morbidity, even after its removal. Currently, TT is managed and removed by chest X-ray (CXR) evaluation. There are limitations and these are directly linked to complications. The use of thoracic ultrasound (US) has already been established in the diagnosis of pneumothorax (PTX) and hemothorax (HTX); its use, in substitution of CXR can lead to improvement in care. Our aim is to evaluate the efficiency and safety of US in the management of TT. METHODS: Prospective and randomized study with patients requiring TT. They were divided in groups according to their thoracic injuries (PTX and HTX) and randomized into two groups according to TT management: US and CXR. Data collected included gender, age, mechanism of injury, days to TT removal, complications after TT removal and presence of mechanical ventilation. RESULTS: Sixty-one patients were randomized, of which 68.8% were male. The most frequent diagnosis was PTX, present in 37 cases. Median time for TT removal was 2.5 days in the US group and 4.9 in the control group (p = 0.009). The complication rate was 6.6%, with no morbidity in the US group. TT removal in patients with mechanical ventilation did not increase the incidence of complications. CONCLUSIONS: The use of US in the management is efficient and safe. It allows early TT removal regardless the cause of the thoracic injury.

[Traumatic Right Atrial Rupture with Left Hemothorax but without Hemopericardium:Report of a Case].

Traumatic cardiac rupture is mostly accompanied by tamponade and/or hemopericardium. We experienced a rare case of traumatic right atrial rupture with left hemothorax, but without hemopericardium. A 36-year-old male had a traffic accident, and was transported to our hospital. He was in a state of shock caused by massive hemothorax. He underwent emergency operation through median sternotomy. No blood was seen in the pericardium nor injury of any major vessels or lungs. When the heart was exposed, massive bleeding occurred. A tear of 30 mm in length was found in the right atrium at the junction of the superior vena cava. The tear was repaired under cardiopulumonary bypass. Even after surgery, however, he remained unconscious.

Massive hemothorax in a pregnant patient with neurofibromatosis type 1.

BACKGROUND: Reports of spontaneous hemothorax in patients with neurofibromatosis type 1 are scarce despite the severe complication. We herein present the first case of hemothorax in a neurofibromatosis type 1 patient during pregnancy and discuss the difficulty associated with its diagnosis and treatment. CASE PRESENTATION: A 39-year-old female at 34 weeks gestation presented with sudden left back pain and dyspnea. Chest radiography revealed massive left pleural effusion. Computed tomography showed bleeding from the intercostal artery. Although the patient appeared hemodynamically stable, the fetus was in a critical condition. Emergency caesarean section was performed within 1 hour. Subsequently, we performed endovascular coil embolization of the intercostal artery. While this intensive treatment saved the patient, her fetus could not be rescued. CONCLUSIONS: Patients with neurofibromatosis type 1 may develop massive hemothorax without gross lesions. In late pregnancy, sufficient infusion and quick hemostasis are essential and can be lifesaving.

Delayed massive haemothorax following thoracic trauma. / Forsinket pleuraeffusjon etter thoraxtraume.

BACKGROUND: Most cases of thoracic injury are the result of minor trauma, treated out of hospital. Approximately 10 % of patients with minor thoracic trauma develop delayed haemothorax, with risk of fibrosis and empyema. Traumatic diaphragmatic injury following blunt trauma can be difficult to diagnose, and is a rare condition associated with high-energy trauma. CASE PRESENTATION: A 63-year-old man with multiple rib fractures following a traffic accident was readmitted for chest tube drainage 19 days after trauma, due to delayed haemothorax. Four days later, the patient developed massive haemothorax due to pleural fibrinolysis. Video-assisted thoracic surgery confirmed lacerated diaphragm with protruding, bleeding omentum. INTERPRETATION: This case report describes an atypical presentation of a common complication following thoracic trauma. Identification and control of patients at risk of developing delayed haemothorax is of clinical importance to reduce the risk of long-term complications.