Journal Reading
Herman Syah Putra Nasution
Divisi Bedah Thoraks Kardiak & Vaskular
Departemen Ilmu Bedah Fakultas Kedokteran Universitas Hasanuddin
Makassar 2020
Background
• Bleeding of the subclavian artery is a fatal condition.
• Bleeding may be controlled by either open repair (median
sternotomy, lateral thoracotomy) or endovascular repair.
• Adhesion between the pleura and staple line may develop after
surgical treatment of pneumothorax. In such cases, collateral arteries
often develop from the subclavian artery toward the adhesion at the
lung apex
• We herein report a case of atraumatic subclavian artery bleeding that
was suspected to be associated with surgical treatment of
pneumothorax performed 20 years previously
Case presentation
• A 70-year-old man had experienced left chest pain for half a day.
• He had a history of atrial fibrillation and had taken an anticoagulant for many
years.
• He had undergone VATS bullectomy for pneumothorax 20 years previously
and the period of post-operative chest tube drainage had been long because
of refractory air leakage.
• Plueodesis had not been performed. No history of hereditary diseases such as
von Recklinghausen disease.
• Chest CT-Scan showed a giant tumor in the apex of the lung and staple line of
the pneumothorax surgery, however, he came home because his vital sign was
stable.
• He returned to the hospital the next day because his left chest pain had worsened.
Contrast-enhanced chest CT-Scan showed left hemothorax in addition to the
superior sulcus tumor and staple line of the pneumothorax surgery
Case presentation
• The huge tumor in the apex of the lung was suspected to be an extrapleural huge
hematoma, and it ruptured into the pleural cavity.
• He was raced to our hospital and a chest tube was inserted into the left pleural
cavity, resulting a large volume of bloody fluid. The patient shock, and a massive
blood transfusion was started.
• Bleeding from the left subclavian artery was suspected, and emergency
angiography via the right femoral artery was performed. Angiography showed
some collateral arteries from the left subclavian artery to the apex of the left
lung.
• Distal and proximal bleeding points were identified. The distal bleeding point was
embolized using coils.
• The proximal bleeding point (Fig. 2a, b) was blown out, and 8.0- × 50-mm stent
grafts were placed in the left subclavian artery with careful attention to
occlusion of the vertebral artery (Fig. 2c).
• The shock and bleeding continued during the angiography, and the massive
blood transfusion was continued. After placement of the stents, the patient’s
vital signs stabilized. The amount of bleeding was 2000 ml. The chest tube was
removed 4 days after treatment, and he was discharged.
Discussion
• Atraumatic bleeding from the subclavian artery to the extrapleural or
thoracic cavity is rare; however, it is a critical situation that requires
rapid bleeding control.
• We successfully stopped the bleeding by emergency angiography via
the right femoral artery and percutaneous stent placement.
• Our patient’s bleeding was strongly suspected to be associated with
the pneumothorax surgery performed 20 years previously.
Discussion
• The collateral arteries from the subclavian artery could have
developed secondary to pneumothoraxinduced inflammation; these
vessels ruptured and bled into the extrapleural cavity, the pleura
became compromised and hemothorax developed.
• Santin et al. reported subclavian artery rupture in a patient with von
Recklinghausen disease. They successfully stopped the bleeding using
an 8- mm × 5-cm endoprosthesis stent graft via the brachial sheath.
• Tennyson et al. reported traumatic subclavian artery rupture that was
successfully repaired by thoracotomy and direct suturing.
Discussion
• Angiography showed collateral arteries from the left subclavian artery to the left
apical portion of the lung.
• The collateral circulation from the subclavian artery could have developed because
of postpneumothorax inflammation, eventually rupturing and bleeding into the
extrapleural space.
• We considered that these adhesions and collateral arteries had been ruptured by
coughing or similar stimulation, and administration of anticoagulant therapy
promoted the bleeding.
• Terada et al. reported a case of intractable hemoptysis by the branches of the right
subclavian artery caused by an aspergilloma, and the patient was successfully
treated with arterial coil embolization. The authors considered that these abnormal
branches were caused by pleural adhesion to the aspergilloma.
Conclusion
• This report described an important case of atraumatic subclavian
artery bleeding considered to have been caused by surgical treatment
of pneumothorax 20 years previously.
• Emergency angiography and percutaneous stent placement or coil
embolization should be considered first in such cases.
