Journal of Emergencies, Trauma, and Shock
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 Table of Contents    
Year : 2021  |  Volume : 14  |  Issue : 2  |  Page : 111-116
Role of intercostal artery embolization in management of traumatic hemothorax

1 Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Singapore 768828, Singapore
2 Department of Diagnostic Radiology, Woodlands Health Campus, Singapore 768024, Singapore
3 Department of General Surgery, Khoo Teck Puat Hospital, Singapore 768828, Singapore
4 Department of Diagnostic Radiology, Tan Tock Seng Hospital, Singapore 308433, Singapore

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Date of Submission31-Oct-2020
Date of Acceptance25-Feb-2021
Date of Web Publication27-Apr-2021


Intercostal artery bleeding from trauma can result in potentially fatal massive hemothorax. Traumatic hemothorax has traditionally been treated with tube thoracostomy, video-assisted thoracoscopic surgery, or thoracotomy. Transcatheter arterial embolization (TAE), a well-established treatment option for a variety of acute hemorrhage is not widely practiced for the management of traumatic hemothorax. We present 2 cases of delayed massive hemothorax following chest trauma which were successfully managed by transarterial embolization of intercostal arteries. The published studies are reviewed and a systematic approach to the selection of patients for TAE versus emergency thoracotomy is proposed.

Keywords: Chest trauma, hemothorax, intercostal artery, transarterial embolization

How to cite this article:
Lohan R, Leow KS, Ong MW, Goo TT, Punamiya S. Role of intercostal artery embolization in management of traumatic hemothorax. J Emerg Trauma Shock 2021;14:111-6

How to cite this URL:
Lohan R, Leow KS, Ong MW, Goo TT, Punamiya S. Role of intercostal artery embolization in management of traumatic hemothorax. J Emerg Trauma Shock [serial online] 2021 [cited 2022 Oct 1];14:111-6. Available from:

   Introduction Top

Massive hemothorax from intercostal artery bleeding is an infrequent but potentially life-threatening consequence of chest trauma. Exploratory thoracotomy has long been regarded as the therapeutic gold standard for further management of massive hemothorax.[1] Transcatheter arterial embolization (TAE), an effective and less invasive treatment alternative to surgery for hemorrhage control, is an established endovascular therapeutic option for a variety of indications including iatrogenic hemothorax and control of hemorrhage in abdominopelvic trauma. However, despite being described over three decades, the role of TAE in the management of traumatic hemothorax is not as well defined. We present two cases of successful intercostal artery embolization performed for delayed hemothorax secondary to trauma, and the review of the available literature. We discuss the indications, technical aspects, and clinical efficacy of TAE with regards to the management of traumatic hemothorax.

   Case Reports Top

Case 1

A 63-year-old male patient presented to the emergency department (ED), sustaining stab wound to the right lower chest wall. Upon arrival, he was mildly tachypneic with blood pressure of 146/100 mm Hg, heart rate of 90 beats/min, and oxygen saturation of 99%. Physical examination revealed a 1.5 cm stab wound and small chest wall hematoma. The chest radiograph showed no rib fracture nor any significant effusion. Contrast-enhanced computed tomography (CECT) demonstrated a small 7 mm pseudoaneurysm likely arising from the 6th anterior intercostal artery [Figure 1]a and [Figure 1]b. The patient was initially planned for percutaneous thrombin injection of the intercostal artery pseudoaneurysm to prevent further expansion of the chest wall hematoma. However, upon arrival to the angiography suite, the pseudoaneurysm had spontaneously thrombosed [Figure 1]c and [Figure 1]d. A pressure bandage was applied, and the patient was managed conservatively in the intensive care unit. After 24 h, the patient complained of severe right chest pain and became tachycardic. Hemoglobin showed a significant drop from 14.2 to 9.9 g/dl. The repeat chest radiograph revealed moderate right hemothorax [Figure 1]e, which was subsequently confirmed on a repeat CECT [Figure 1]f. A chest tube was inserted and 700 ml of blood was initially drained. Within 24 h, the amount of blood drained from the chest tube increased to 1.5 L, and a decision was made to proceed with angiography and trans-arterial embolization.
Figure 1: Stabbing injury. Arterial (a) and delayed phase (b) images from a CT demonstrate small pseudoaneurysm (white arrow) arising from the anterior intercostal artery. The pseudoaneurysm was also localized on ultrasound (c), however, after 2 h (d) it had spontaneously thrombosed. Follow up chest radiograph (e) and CT (f) obtained 24 h after the injury, show large right hemothorax. Selective angiography (g) of the anterior intercostal artery shows small focus of contrast extravasation. Angiographic image (h) following embolization with mixture of n butyl cyanoacrylate and lipiodol

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Through the right femoral access, the right internal mammary artery was cannulated. Selective arteriography showed contrast extravasation from the right 6th anterior intercostal artery [Figure 1]g. Superselective embolization of the 6th intercostal artery was performed with n-butyl-2-cyanoacrylate (NBCA) glue (Histoacryl®) [Figure 1]h. The intercostal arteries above (5th) and below (7th) this level were embolized with gelfoam slurry. Postprocedure, the drain output reduced to 70 ml (at 3-h postprocedure). The hemoglobin level stabilized at 12.0 g/dl with two units of packed red blood cell transfusion. Follow-up radiograph 48 h later showed complete resolution of hemothorax. The chest drain was removed, and he was discharged on the third postprocedural day.

Case 2

A 90-year-old male patient presented to ED with left chest pain and tenderness following an accidental fall at home. He had a past medical history of hypertension, diabetes mellitus, ischemic heart disease, old stroke, epilepsy, and chronic thrombocytopenic purpura. His blood pressure was 136/84 mm Hg, with a heart rate of 84 beats/min. The chest radiograph did not show any significant pleural effusion or pneumothorax [Figure 2]a. He was treated symptomatically and discharged home after overnight observation. He presented 9 days later to ED with severe dyspnea. The oxygen saturation was 66% and repeat radiograph showed complete whiteout of the left hemithorax [Figure 2]b. A tube thoracostomy was performed and 1500 ml of blood was drained. He became drowsy and blood gas analysis revealed severe metabolic acidosis. Hemoglobin dropped from a baseline of 12 g/dl to 7.3 g/dl. He was intubated and a contrast-enhanced CT study was performed.
Figure 2: Delayed hemothorax following fall. Initial chest radiograph (a) did not show any pleural fluid. Chest radiograph (b) obtained 9 days later, shows almost complete white out of the left hemithorax from large hemothorax. Contrast-enhanced CT images (c and d) demonstrate contrast extravasation from the posterior intercostal artery and multiple displaced rib fractures. Selective angiography images before (e) and after (f) embolization with n-butyl cyanoacrylate -lipiodol mixture

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Urgent CECT demonstrated displaced left 9th to 11th rib fractures and identified contrast extravasation from left 10th posterior intercostal artery as cause of massive hemothorax [Figure 2]c and [Figure 2]d. In view of the underlying comorbidities and CECT findings, a primary TAE of the culprit intercostal artery was performed. Via right femoral access, the origin of the left 10th posterior intercostal artery was cannulated with a reverse curve catheter and a 2.2F microcatheter was advanced into the intercostal artery. Selective arteriography of the intercostal artery re-demonstrated the contrast extravasation [Figure 2]e. Super-selective embolization was performed using NBCA glue (Histoacryl®) [Figure 2]f. The drain output gradually reduced, and no additional procedures were required for bleeding control. The drain was removed on day 7. His hospital stay was complicated by urinary tract infection and renal impairment. On day 15, the patient was transferred to a step-down rehabilitation center for further care.

   Discussion Top

The chest radiograph is often inadequate for the evaluation of hemothorax. CECT should be performed if the radiograph demonstrates displaced rib fractures and the initial chest drainage confirms hemothorax. Hagiwara et al. found that the patients with >200 ml/h of hemothorax and greater parallel displacement of rib fractures on chest radiograph demonstrated contrast extravasation on CECT.[2] The threshold for CECT examination should be even lower in cases of penetrating injuries and elderly patients with co-morbidities. In patients with significantly displaced rib fractures and persistent bleeding, where a definitive diagnosis of intercostal artery injury represented by contrast extravasation or pseudoaneurysm on CECT can be made, TAE should be considered primarily.[2] In contrast, if the CECT demonstrates parenchymal lacerations, aortic rupture, or pulmonary arterial injuries to be the source of hemothorax, TAE may unnecessarily delay the thoracotomy. Besides imaging findings, the clinical symptoms and laboratory findings play an important role in decision-making. TAE should be considered in settings of significant hemoglobin drop (>2 g/dl) or signs of shock with hypotension or tachycardia.[3] Persistent bleeding from posterior intercostal arteries close to the spine can be difficult to control at thoracotomy. The limited exposure at the posterior rib space makes hemostasis challenging.[4] Transarterial embolization provides a minimally invasive adjunct to surgical methods in such difficult-to-control intrathoracic hemorrhage.[4] A systematic approach to the selection of patients for TAE is outlined in the algorithm [Figure 3].
Figure 3: Previously published case reports and studies on transarterial embolization of intercostal artery(ies) for traumatic hemothorax

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A clear understanding of the anatomy of anterior and posterior intercostal arteries and collateral circulation is crucial to technical success.[5] Wherever feasible “frontdoor–backdoor” technique of embolization should be applied to achieve adequate hemostasis.[6] Only front door embolization with gelfoam or particles may result in pseudoaneurysm at the arterial injury site and manifest as delayed hemothorax.[7] Various embolic materials as gelfoam, Polyvinyl-alcohol particles, NBCA glue, and coils have been used. No one embolic agent has been shown to be superior to the rest. No major immediate procedure-related complication has been reported. Nonetheless, inadvertent spinal artery embolization is always a concern during the embolization of the intercostal arteries. When liquid or particulate embolic materials are to be used in the posterior intercostal arteries, the angiograms should be scrutinized for opacification of the artery of Adamkiewicz [Figure 4]. Microcoils are the most used embolic agents and should be favored if the angiograms demonstrate classic hairpin appearance of spinal artery feeders on angiography and the bleeding source is close to the origin of the radicular arteries.[3],[8],[9]
Figure 4: Ar tery of Adamkiewicz. Posterior intercostal ar tery angiogram (from case 2) demonstrates the characteristic hairpin turn (arrow) at its junction with the anterior spinal artery

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The largest case series that described the role of TAE in massive hemothorax reported a technical success rate of 87%.[10] Most other studies with five or more patients have also reported similar results, with higher success rate in traumatic cases. The published case studies are summarized in [Table 1]. Tamburini et al. found that patients with a single bleeding artery showed a better outcome in terms of bleeding control compared to two or more arteries.[10] Despite the high technical success rate, up to 60% of patients would require additional surgical intervention to remove the clotted hemothorax or manage incontrollable bleeding. Most of these additional surgical procedures are nonurgent video-assisted thoracoscopic surgery (VATS) for retained hemothorax.[10] The average rate of clinical failure (defined as patients requiring further surgeries i.e., VATS or thoracotomy) after TAE to control the bleeding is about 20%.[6] The possible predictors of clinical failure are incomplete embolization (e.g. two or more intercostal arterial injuries),[10] presence of collateral pathways (e.g. internal mammary arteries, inferior phrenic arteries, musculophrenic arteries, etc.),[5],[19] abnormal clotting process (due to severe initial bleeding, chronic liver disease) and failure to recognize alternate sources of bleeding like pulmonary parenchymal lacerations, pulmonary arterial injuries[17] or diaphragmatic rupture.[18]
Table 1: Previously published case reports and studies on transarterial embolization of intercostal artery (ies) for traumatic hemothorax

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   Conclusion Top

TAE provides an effective and less invasive therapeutic option in the management of traumatic hemothorax in a selected group of patients. Despite a remarkably high technical success and almost no major complication, the decision for TAE versus surgery as a primary treatment is dependent on the identification of the origin of bleeding. Primary TAE is recommended for isolated intercostal artery injuries; while emergency thoracotomy should be performed in unstable patients with pulmonary lacerations, hilar vessel injuries, or diaphragmatic rupture. Adjunct TAE should be considered in cases whereby surgical control of hemorrhage is expected to be tedious and difficult.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (http:// guidelines, notably the CARE guideline, during the conduct of this report.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patients has given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Mowery NT, Gunter OL, Collier BR, Diaz JJ Jr., Haut E, Hildreth A, et al. Practice management guidelines for management of hemothorax and occult pneumothorax. J Trauma 2011;70:510-8.  Back to cited text no. 1
Hagiwara A, Yanagawa Y, Kaneko N, Takasu A, Hatanaka K, Sakamoto T, et al. Indications for transcatheter arterial embolization in persistent hemothorax caused by blunt trauma. J Trauma 2008;65:589-94.  Back to cited text no. 2
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;49:1505-13.  Back to cited text no. 3
Moore C, Kwayisi G, Esiobu P, Bashan-Gilzenrat KA, Matthews LR, Nguyen J, et al. Successful treatment of massive hemothorax with class IV shock using aortography with transcatheter embolization of actively bleeding posterior left intercostal arteries after penetrating left chest trauma: A case for the hybrid OR. Int J Surg Case Rep 2018;48:109-12.  Back to cited text no. 4
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Nemoto C, Ikegami Y, Suzuki T, Tsukada Y, Abe Y, Shimada J, et al. Repeated embolization of intercostal arteries after blunt chest injury. Gen Thorac Cardiovasc Surg 2014;62:696-9.  Back to cited text no. 7
Vujic I, Pyle R, Parker E, Mithoefer J. Control of massive hemoptysis by embolization of intercostal arteries. Radiology 1980;137:617-20.  Back to cited text no. 8
Casper KP, Sanchirico PJ, Pfeiffer DC. Intercostal artery pseudoaneurysm following thoracentesis: Multi-modal imaging and treatment. BMC Med Imaging 2019;19:31.  Back to cited text no. 9
Tamburini N, Carriel N, Cavallesco G, Molins L, Galeotti R, Guzmán R, et al. Technical results, clinical efficacy and predictors of outcome of intercostal arteries embolization for hemothorax: A two-institutions' experience. J Thorac Dis 2019;11:4693-9.  Back to cited text no. 10
Carrillo EH, Heniford BT, 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;64:1142-8.  Back to cited text no. 11
Matsumoto H, Suzuki M, Kamata T, Kanno M. Intercostal artery injuries treated by angiographic embolization: Case report. J Trauma 1998;44:392-3.  Back to cited text no. 12
Nishizuka K, Hirota K, Nuriya E, Furuki I, Matsumoto Y, Yoshida Y. A case of unspeculated massive hemothorax during emergency operation in a patient with multiple trauma. Hokuriku J Anesthesiol 1999;33:39-41.  Back to cited text no. 13
Kessel B, Alfici R, Ashkenazi I, Risin E, Moisseev E, Soimu U, et al. Massive hemothorax caused by intercostal artery bleeding: Selective embolization may be an alternative to thoracotomy in selected patients. Thorac Cardiovasc Surg 2004;52:234-6.  Back to cited text no. 14
Hagiwara A, Iwamoto S. Usefulness of transcatheter arterial embolization for intercostal arterial bleeding in a patient with burst fractures of the thoracic vertebrae. Emerg Radiol 2009;16:489-91.  Back to cited text no. 15
Behera RR, Gouda B, Kulkarni A, Udwadia ZF, Bhandarkar DS. Thoracoscopic and endovascular management of retained haemothoarx associated with an intercostal artery pseudoaneurysm. Indian J Chest Dis Allied Sci 2014;56:37-9.  Back to cited text no. 16
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Ota K, Fumimoto S, Iida R, Kataoka T, Ota K, Taniguchi K, et al. Massive hemothorax due to two bleeding sources with minor injury mechanism: A case report. J Med Case Rep 2018;12:291.  Back to cited text no. 18
Loukas M, Hullett J, Wagner T. Clinical anatomy of the inferior phrenic artery. Clin Anat 2005;18:357-65.  Back to cited text no. 19

Correspondence Address:
Rahul Lohan
Department of Diagnostic Radiology, Khoo Teck Puat Hospital, 90 Yishun Central, Singapore 768828
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JETS.JETS_157_20

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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