Hattori Masashi, Matsumura Yu, Yamaki Fumitaka
Department of Cardiovascular Surgery, Nagano Chuo Hospital, 1570 Nishi-tsurugamachi, Nagano, Nagano, 3800814, Japan.
J Cardiothorac Surg. 2021 Nov 21;16(1):335. doi: 10.1186/s13019-021-01718-1.
Median sternotomy remains the most common approach in cardiovascular surgery. Recently, minimally invasive procedures, such as minimally invasive cardiac surgery, robot surgery, and catheter therapy have been developed in cardiovascular surgery. However, all these surgeries cannot be performed by minimally invasive approaches. Several complications associated with median sternotomy have been reported, although post-sternotomy hemorrhage from the posterior intercostal artery is extremely rare.
We present a case of posterior intercostal artery bleeding following lower partial sternotomy. A 79-year-old man underwent aortic valve replacement using lower partial median inverted L-shaped sternotomy that cut into the right second intercostal space. A postoperative chest radiograph indicated a hematoma in the right upper chest wall and pleural effusion. Hence, we inserted a drainage tube immediately. Approximately 2 hours after the surgery, his blood pressure gradually decreased. Blood drainage was observed from the tube, and the amount of blood drainage was not large. Contrast-enhanced computed tomography revealed a huge hematoma and hemorrhage from the fourth right posterior intercostal artery. Immediately, we performed emergency surgery. The lower partial sternotomy was repeated. We detected the origin of the bleeding that was identified in the right fourth posterior intercostal artery, and the bleeding was stopped. The postoperative course was uneventful.
This case highlights the possibility of intraoperative bleeding from the intercostal artery, even in the absence of clearly rib fracture. In our case, we did not identify the cause of bleeding, although we suggest the inhomogeneous stress on the posterior ribs upon attaching the sternal retractor for lower partial sternotomy may have affected the posterior intercostal artery.
正中胸骨切开术仍是心血管外科最常用的手术入路。近年来，心血管外科已开展了一些微创手术，如微创心脏手术、机器人手术和导管治疗。然而，并非所有这些手术都能通过微创方法进行。虽然胸骨切开术后肋间后动脉出血极为罕见，但已有数种与正中胸骨切开术相关的并发症报道。
我们报告一例低位部分胸骨切开术后肋间后动脉出血的病例。一名79岁男性接受了主动脉瓣置换术，采用低位部分正中倒L形胸骨切开术，切口延伸至右侧第二肋间间隙。术后胸部X线片显示右上胸壁血肿及胸腔积液。因此，我们立即插入了引流管。术后约2小时，他的血压逐渐下降。观察到引流管有血液引出，引流量不大。增强CT显示巨大血肿及右侧第四肋间后动脉出血。我们立即进行了急诊手术。再次行低位部分胸骨切开术。我们找到了出血来源，确定为右侧第四肋间后动脉出血，并止住了血。术后病程顺利。
本病例突出了即使没有明显肋骨骨折，肋间动脉术中也可能出血的可能性。在我们的病例中，虽然我们推测在低位部分胸骨切开术安装胸骨牵开器时后肋受力不均可能影响了肋间后动脉，但我们并未明确出血原因。
