Case Study
Expanding extrapleural hematoma from rib fractures after cardiac surgery
Asian Cardiovascular & Thoracic Annals 21(3) 366–368 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454858 aan.sagepub.com
Marco Agrifoglio1, Stefano Zoli1, Marco Gennari1, Andrea Annoni2 and Gianluca Polvani1
Abstract A 79-year-old man underwent coronary artery bypass grafting and ascending aorta prosthetic replacement for aneurysm at our Institution. His postoperative course was characterized by rapid onset of hypotension and anemia. Re-exploration found no surgical source of bleeding. A chest computed tomography showed a huge extrapleural hematoma caused by rib fractures. Percutaneous chest drainage was effective, and the patient recovered quickly. Follow-up computed tomography confirmed a good result.
Keywords Aortic aneurysm, coronary artery bypass, hematoma, postoperative complications, rib fractures
Introduction Extrapleural hematoma is a quite uncommon condition. The clinical symptoms are ventilation disturbance, hypotension, and anemia. Rapid establishment of the diagnosis is mandatory to treat the condition quickly and effectively. There are only a few reports describing a very fast progression of an extrapleural hematoma over a period of hours.1,2 We report a case of rapidly expanding extrapleural hematoma after cardiac surgery, due to rib fractures.
Case report A 79-year-old man underwent ascending aorta prosthetic replacement for aneurysm and coronary artery bypass grafting (with a single saphenous vein graft to the posterior descending coronary artery), by median sternotomy at our Institution. A few hours after the operation, he experienced severe hypotension and rapid onset of anemia (hemoglobin dropped from 10.7 to 7.3 gdL 1). His coagulation status was within the normal range. A chest radiograph performed promptly in the intensive care unit showed an opacity in the left upper thorax (Figure 1(a)), suspected to be bleeding from sternal wires or an iatrogenic complication at the time of central venous catheterization
(puncture of the left internal jugular vein was suspected). Rapid hemodynamic deterioration required surgical re-exploration, but no surgical source of bleeding could be found. The patient received 4 units of fresh frozen plasma and 6 units of packed red blood cells, and his clinical status stabilized. On the next working day, thoracic computed tomography detected a huge extrapleural hematoma caused by rib fractures (Figure 1(a) and (b)). A chest drain was placed, with evacuation of 2500 mL of blood, partly clotted. During a 7-day stay in the intensive care unit, the patient recovered well, and computed tomography showed the effectiveness of the drainage. The patient was transferred to the ward on the 7th postoperative day, and discharged soon afterwards. After one month, a computed tomography showed good resolution of the hematoma 1 Department of Cardiovascular Sciences, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy 2 Department of Radiology, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
Corresponding author: Marco Gennari, MD, Department of Cardiovascular Disease, Cardiac Surgery Unit, Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, Italy. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
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Figure 1. (a) Postoperative chest radiography showed an opacity in the upper left thorax (arrows). (b) Chest computed tomography revealed 2 left rib fractures (arrow) and (c) a huge extrapleural hematoma (arrow). (d) Computed tomography after 1 month showed good resolution of the hematoma.
(Figure 1(d)). The patient is alive and well after 20 months of follow-up.
Discussion An extrapleural hematoma is a collection of blood in the space between the parietal pleura and the endothoracic fascia. This can develop when the parietal pleura is still intact and the blood cannot escape into the pleural cavity. There are several causes of extrapleural hematoma, such as chest trauma, rupture of an aneurysm of the thoracic aorta, pleural biopsy, or iatrogenic complications of any medical or surgical procedure on the chest. The condition described in this report is uncommon after cardiac surgery.3 In this case, an iatrogenic rib fracture caused by the use of a sternal retractor is the most plausible etiology. The main challenge is to quickly establish the right diagnosis and initiate adequate treatment. Chest radiography may be useful to obtain the diagnosis; however, computed tomography is the most effective imaging tool available.4 The treatment is often conservative. Current guidelines suggest medical therapy if the hematoma is small with few clinical symptoms. It is sometimes necessary perform an
invasive intervention in the case of a larger hematoma causing respiratory or hemodynamic deterioration. 5 In the light of our experience, we recommend to take into account a diagnosis of extrapleural hematoma after cardiac surgery, when the clinical picture is characterized by rapid onset of hypotension, anemia, and respiratory problems, especially with evidence of a new opacity on a chest radiograph. In this case, aggressive management by surgical re-exploration was useless. Effective collaboration among surgeons, anesthetists, and radiologists is essential. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Igai H, Okumura N, Ohata K, Matsuoka T, Kameyama K and Nakagawa T. Rapidly expanding extrapleural hematoma [Review]. Gen Thorac Cardiovasc Surg 2008; 56: 515–517.
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
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Asian Cardiovascular & Thoracic Annals 21(3)
2. Tayyareci Y, Tas¸ tan CP, Bayazit P, Akar H, Yilmaz U, Ozalp T, et al. Extrapleural hematoma, a rare post-operative complication of coronary bypass grafting with left internal mammary artery. Anadolu Kardiyol Derg 2008; 8: E6. 3. Sumida H, Ono N and Terada Y. Huge extrapleural hematoma in an anticoagulated patient. Gen Thorac Cardiovasc Surg 2007; 55: 174–176.
4. Konen O, Hertz M, Klein HO, Konen E and Zissin R. Extrapleural hematoma as an unexpected finding on a follow-up chest X-ray after coronary surgery. Eur J Radiol 2002; 44: 225–227. 5. Poyraz AS, Kilic D, Gultekin B, Ozulku M and Hatipoglu A. Extrapleural hematoma: when is surgery indicated? Monaldi Arch Chest Dis 2005; 63: 166–169.
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
Expanding extrapleural hematoma from rib fractures after cardiac surgery
Asian Cardiovascular & Thoracic Annals 21(3) 366–368 ß The Author(s) 2012 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492312454858 aan.sagepub.com
Marco Agrifoglio1, Stefano Zoli1, Marco Gennari1, Andrea Annoni2 and Gianluca Polvani1
Abstract A 79-year-old man underwent coronary artery bypass grafting and ascending aorta prosthetic replacement for aneurysm at our Institution. His postoperative course was characterized by rapid onset of hypotension and anemia. Re-exploration found no surgical source of bleeding. A chest computed tomography showed a huge extrapleural hematoma caused by rib fractures. Percutaneous chest drainage was effective, and the patient recovered quickly. Follow-up computed tomography confirmed a good result.
Keywords Aortic aneurysm, coronary artery bypass, hematoma, postoperative complications, rib fractures
Introduction Extrapleural hematoma is a quite uncommon condition. The clinical symptoms are ventilation disturbance, hypotension, and anemia. Rapid establishment of the diagnosis is mandatory to treat the condition quickly and effectively. There are only a few reports describing a very fast progression of an extrapleural hematoma over a period of hours.1,2 We report a case of rapidly expanding extrapleural hematoma after cardiac surgery, due to rib fractures.
Case report A 79-year-old man underwent ascending aorta prosthetic replacement for aneurysm and coronary artery bypass grafting (with a single saphenous vein graft to the posterior descending coronary artery), by median sternotomy at our Institution. A few hours after the operation, he experienced severe hypotension and rapid onset of anemia (hemoglobin dropped from 10.7 to 7.3 gdL 1). His coagulation status was within the normal range. A chest radiograph performed promptly in the intensive care unit showed an opacity in the left upper thorax (Figure 1(a)), suspected to be bleeding from sternal wires or an iatrogenic complication at the time of central venous catheterization
(puncture of the left internal jugular vein was suspected). Rapid hemodynamic deterioration required surgical re-exploration, but no surgical source of bleeding could be found. The patient received 4 units of fresh frozen plasma and 6 units of packed red blood cells, and his clinical status stabilized. On the next working day, thoracic computed tomography detected a huge extrapleural hematoma caused by rib fractures (Figure 1(a) and (b)). A chest drain was placed, with evacuation of 2500 mL of blood, partly clotted. During a 7-day stay in the intensive care unit, the patient recovered well, and computed tomography showed the effectiveness of the drainage. The patient was transferred to the ward on the 7th postoperative day, and discharged soon afterwards. After one month, a computed tomography showed good resolution of the hematoma 1 Department of Cardiovascular Sciences, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy 2 Department of Radiology, University of Milan, Centro Cardiologico Monzino, IRCCS, Milan, Italy
Corresponding author: Marco Gennari, MD, Department of Cardiovascular Disease, Cardiac Surgery Unit, Centro Cardiologico Monzino, IRCCS, Via Parea 4, Milan, Italy. Email: [email protected]
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
Agrifoglio et al.
367
Figure 1. (a) Postoperative chest radiography showed an opacity in the upper left thorax (arrows). (b) Chest computed tomography revealed 2 left rib fractures (arrow) and (c) a huge extrapleural hematoma (arrow). (d) Computed tomography after 1 month showed good resolution of the hematoma.
(Figure 1(d)). The patient is alive and well after 20 months of follow-up.
Discussion An extrapleural hematoma is a collection of blood in the space between the parietal pleura and the endothoracic fascia. This can develop when the parietal pleura is still intact and the blood cannot escape into the pleural cavity. There are several causes of extrapleural hematoma, such as chest trauma, rupture of an aneurysm of the thoracic aorta, pleural biopsy, or iatrogenic complications of any medical or surgical procedure on the chest. The condition described in this report is uncommon after cardiac surgery.3 In this case, an iatrogenic rib fracture caused by the use of a sternal retractor is the most plausible etiology. The main challenge is to quickly establish the right diagnosis and initiate adequate treatment. Chest radiography may be useful to obtain the diagnosis; however, computed tomography is the most effective imaging tool available.4 The treatment is often conservative. Current guidelines suggest medical therapy if the hematoma is small with few clinical symptoms. It is sometimes necessary perform an
invasive intervention in the case of a larger hematoma causing respiratory or hemodynamic deterioration. 5 In the light of our experience, we recommend to take into account a diagnosis of extrapleural hematoma after cardiac surgery, when the clinical picture is characterized by rapid onset of hypotension, anemia, and respiratory problems, especially with evidence of a new opacity on a chest radiograph. In this case, aggressive management by surgical re-exploration was useless. Effective collaboration among surgeons, anesthetists, and radiologists is essential. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Conflicts of interest statement None declared.
References 1. Igai H, Okumura N, Ohata K, Matsuoka T, Kameyama K and Nakagawa T. Rapidly expanding extrapleural hematoma [Review]. Gen Thorac Cardiovasc Surg 2008; 56: 515–517.
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
368
Asian Cardiovascular & Thoracic Annals 21(3)
2. Tayyareci Y, Tas¸ tan CP, Bayazit P, Akar H, Yilmaz U, Ozalp T, et al. Extrapleural hematoma, a rare post-operative complication of coronary bypass grafting with left internal mammary artery. Anadolu Kardiyol Derg 2008; 8: E6. 3. Sumida H, Ono N and Terada Y. Huge extrapleural hematoma in an anticoagulated patient. Gen Thorac Cardiovasc Surg 2007; 55: 174–176.
4. Konen O, Hertz M, Klein HO, Konen E and Zissin R. Extrapleural hematoma as an unexpected finding on a follow-up chest X-ray after coronary surgery. Eur J Radiol 2002; 44: 225–227. 5. Poyraz AS, Kilic D, Gultekin B, Ozulku M and Hatipoglu A. Extrapleural hematoma: when is surgery indicated? Monaldi Arch Chest Dis 2005; 63: 166–169.
Downloaded from aan.sagepub.com at UNIV OF MICHIGAN on June 25, 2015
