CTICasesIatrogenic Hemothorax from Intercostal Artery Injury After Pleural Drain Removal
Imaging findings
An elderly patient with a pleural effusion drain placed that morning had a normal-appearing portable radiograph, but became progressively short of breath after the drain was pulled that afternoon; a repeat radiograph showed a new pleural effusion with displacement of the heart, mediastinum, and hilar structures indicating a space-occupying process rather than simple rotation. CT confirmed a heterogeneous dense pleural fluid collection (hemothorax) with active contrast extravasation/blush at the chest wall corresponding to an intercostal artery, and delayed imaging showed pooling blood in the pleural space; angiography localized and embolized the bleeding tortuous intercostal artery, which was noted to dip unusually low into the intercostal space, a feature more common with age-related vessel tortuosity and systemic hypertension.
Key takeaways
A rapidly developing pleural effusion after a chest tube or pleural drain manipulation should be presumed to be blood (hemothorax) rather than serous fluid until proven otherwise, particularly in older, hypertensive patients whose intercostal arteries can become markedly tortuous and dip lower within the intercostal space, increasing the risk of injury during needle or drain placement or removal; anterior approaches are safer for pleural interventions because intercostal arteries are much smaller and less consistently visible anteriorly than posteriorly, and active bleeding from such an injury can be managed with angiographic embolization.
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