Right inferior phrenic artery injury as a complication of needle aspiration: a case report

To the best of the author’s knowledge, inferior phrenic artery injury was not documented in the literature as a complication of chest tube insertion or needle aspiration, and our case was the first to be mentioned in literature. Traumatic injury to the inferior phrenic artery is extremely rare. It was reported to be injured by blunt trauma such as motorcar accident and may be associated with another organ injury. The present case represents an unexpected event of inferior phrenic artery injury due to iatrogenic chest aspiration. Despite the safe maneuver we have approached in our center using a blunt dissection technique rather than the trocar technique, an unexpected complication occurred. The right inferior phrenic artery was injured with subsequent intra-abdominal bleeding and shock. It was treated successfully by endovascular embolization of the bleeding artery. This complication might add a further morbidity and mortality and raising the responsibility of the surgeon to one of the most common daily surgeon’s practices.


Background
Traumatic injury to the inferior phrenic artery is extremely rare. It was reported to be injured by blunt trauma such as motorcar accident [1] and may be associated with another organ injury [2]. The present case represents an unexpected event of inferior phrenic artery injury due to iatrogenic chest aspiration. This complication might add a further morbidity and mortality and raising the responsibility of the surgeon to one of the most common daily surgeon's practices.

Case presentation
A female patient 21 years old was diagnosed by transthoracic echocardiography and computed tomography angiography (CTA) as Fallot's tetralogy with absent pulmonary valve. She underwent surgical reconstruction of the pulmonary valve with a tissue valve and Fallot repair. After an uneventful recovery, she returned to our department at the 55th day after the operation with high grade fever. Diagnosis of infective endocarditis based on echocardiographic finding of a big mass (3.4 × 1.7 cm) attached to pulmonary tissue valve resulting in severe pulmonary stenosis (PG = 77.1 mmHg) and leukocytosis on blood picture. Therefore, the patient underwent a second operation on the second day after presentation with insertion of a valved Dacron graft on the infundibulum of right ventricular outflow tract.
Three days postoperatively, the patient developed extensive pneumonia that was treated by an extensive course of broad-spectrum antibiotics. Four days after surgery, we notice a blunt angle on the right side of the chest x-ray. Chest aspiration was done to detect the exact site of effusion, and then right intercostal tube was inserted using the blunt dissection technique.
Three hours after aspiration and insertion of a chest tube, we noticed continuous trickling of blood from chest drain, and the patient became hemodynamically unstable with hemoglobin level dropping from 10.5 to 7 mg/dl. Urgent bedside sonar revealed a significant amount of collection in the right anterior and posterior subphrenic spaces. The patient underwent contrastenhanced computed tomography (CE-CT) of the abdomen which revealed large subcapsular hepatic and sub-phrenic hematomas with extravasation of contrast media within the hematoma ( Fig. 1) raising the possibility of traumatic active arterial bleeding.
After that, we prepared the patient for angioembolization after consultation of the Interventional Radiology team. Endovascular procedure started by insertion of 5 French (Fr) arterial sheath in the right femoral artery. A 5 Fr Cobra catheter was used to catheterize the hepatic artery, searching for injury through puncture of the       hepatic parenchyma. The hepatic angiogram was normal as we could not identify any contrast extravasation. Then we catheterized the right inferior phrenic artery that showed extravasation from its lateral branch. A 2.4 Fr microcatheter (Renegade, Boston Scientific, USA) was introduced through the cobra catheter towards the injured branch and used to deliver polyvinyl alcohol particles (PVA) distally, then the main trunk was permanently embolized using N-Butyl cyanoacrylate (NBCA) lipiodol mixture (50%) (Fig. 1). Two hours after the angioembolization, the amount of bleeding in the right chest drain dramatically decreased, and she became hemodynamically stable, with no further drop of the hemoglobin concentration. The patient underwent daily bedside sonar that showed decreasing the amount of the intra-abdominal collection. The patient was successfully extubated after 2 days of embolization, but the pneumonia was not improving, so alternating vent and continuous positive airway pressure (CPAP) mask were putted on.
Despite the successful surgery and successful management of complications, the patient died 5 days later from respiratory muscle fatigue due to extensive pneumonia despite meticulous observation and management.

Discussion
Between the 12th thoracic vertebrae and 2nd lumbar vertebrae, the inferior phrenic artery usually originates. The right and left branches may arise from the celiac trunk, aorta, renal artery, and left gastric or hepatic artery proper. The inferior phrenic artery gives rise to about eight branches: ascending artery, descending artery, inferior vena cava, esophageal branch, diaphragmatic hiatal, superior or middle suprarenal, and accessory splenic [3]. Until the present moment, only seven cases of inferior phrenic artery injury (excluding our case) were reported, and each case has a different clinical scenario and condition (Table 1) [1,2,[4][5][6]. Hemothorax due to inferior phrenic artery injury rarely occurs, and only two cases were previously reported in the literature [1,5], and our case may be the third one. The mechanism here explained by injury of right inferior phrenic artery led to hemorrhage in the mediastinum, which opened from a previous cardiac operation with subsequent rupture in right pleural sac, causing hemothorax and continuous trickling from the intercostal tube after insertion.
Transcatheter arterial embolization (TAE) is considered the appropriate management for inferior phrenic artery injury, if the injury was not associated with diaphragmatic rupture or herniation of the stomach. It can abolish the prerequisites for laparotomy and thoracotomy that were only needed in one case [2,4].
To the best of the author's knowledge, it is the first documented case in the literature caused by iatrogenic percutaneous chest aspiration of pleural effusion. It was unbelievable except after evident CT and angiographic examination.

Conclusion
Inferior phrenic artery injury should be kept in mind in any case with chest aspiration and drain insertion. The surgeon should have a low threshold to this complication if there are intra-peritoneal collection, hemothorax, and hemodynamic instability.