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Case Report
Intrahepatic Artery Pseudoaneurysm: A
Possible Complication of Blind Thoracentesis
Gianni Zironi, MD,1 Fabio Piscaglia, MD,2 Stefano Gaiani, MD,3 Livia Masi, MD,3 Luigi Bolondi, MD2
1
Division of Emergency Care, S. Orsola-Malpighi Hospital, Via Massarenti 9, Bologna 40138, Italy
Division of Internal Medicine, Marcello Malpighi Hospital, University of Bologna, Via Albertoni
15, Bologna 40138, Italy
3
Department of Internal Medicine and Gastroenterology, University of Bologna, Via Massarenti 9,
Bologna 40138, Italy
2
Received 13 April 1998; accepted 29 September 1998
ABSTRACT: We present a case of intrahepatic artery
pseudoaneurysm that developed after blind thoracentesis in a 67-year-old man. This unusual complication
demonstrates the value of sonographic guidance in
reducing the risk of complications of thoracentesis. © 1999 John Wiley & Sons, Inc. J Clin Ultrasound
27:151–155, 1999.
Keywords: thoracentesis; interventional procedures,
complication; pseudoaneurysm; ultrasonography
B
lind thoracentesis is a common procedure for
obtaining pleural fluid samples, with sonographic guidance used in the case of small pleural
effusions. One of the most common complications
of thoracentesis is pneumothorax,2 which occurs
in up to 7% of patients undergoing thoracentesis
even with sonographic guidance.1 A rare but serious complication is the incidental puncture of
blood vessels or abdominal organs during the procedure.3–6 We present a case of an intrahepatic
artery pseudoaneurysm that developed after
blind thoracentesis and was diagnosed by sonography. To our knowledge, this is the first such
case reported.
CASE REPORT
A 67-year-old man with a small-bowel obstruction
was referred to our hospital for sonographic examination of the upper abdomen. Sonography at
this time disclosed neither liver lesions nor abCorrespondence to: L. Bolondi
© 1999 John Wiley & Sons, Inc.
VOL. 27, NO. 3, MARCH/APRIL 1999
CCC 0091-2751/99/030151-05
dominal adenopathies. In the following days, the
patient underwent surgery to resect an intestinal
mass, which was subsequently pathologically diagnosed as a carcinoid tumor. A few days later,
the patient complained of chest discomfort and
increasing dyspnea. A chest radiograph revealed
a large, free-flowing, right-sided pleural effusion,
and the surgeon decided to perform a therapeutic
blind thoracentesis with an intercostal puncture
in the right median axillary line to relieve the
chest discomfort and dyspnea. When the puncture
with a fine needle yielded fluid too dense to be
drained easily, a larger (18-French) thoracic
drainage catheter (Vygon, Ecouen, France) was
inserted. A chest radiograph at the end of the procedure showed no sign of pneumothorax. Nevertheless, a few hours later, the patient complained
of increasing pain at the puncture site, and the
surgeon removed the catheter. The catheter had
drained about 500 ml of fluid from the pleural
cavity. No further drainage was attempted at this
time because the patient’s dyspnea had improved.
In the following days, the patient complained
of slight, persistent pain at his right shoulder and
at the puncture site. Laboratory investigations
demonstrated increased serum levels of aspartate
transaminase (186 U/l), alanine transaminase
(301 U/l),␥-glutamyltransferase (115 U/l), and alkaline phosphatase (836 U/l).
Abdominal sonography with an Esaote-Hitachi
AU 590 Asynchronous ultrasound scanner (Hitachi, Tokyo, Japan) showed an anechoic area of 3.5
× 1.9 cm in segment VII of the liver (Figure 1,
left). Color Doppler analysis showed turbulent
blood flow (Figure 1, right), and pulsed Doppler
151
ZIRONI ET AL
FIGURE 1. Gray-scale sonogram (left) shows an anechoic lesion (3.5 × 1.9 cm) in the right lobe of the liver that developed after a blind thoracentesis
performed with a thoracic drainage catheter. Color Doppler sonogram (right) shows intense color Doppler signals, suggesting that the lesion has
a vascular origin.
FIGURE 2. Pulsed Doppler sonogram with spectral analysis shows turbulent, pulsatile arterial flow within the intrahepatic anechoic area. Flow
velocities are so high that aliasing occurred even though a high pulse repetition frequency was used. The sampling gate is at the border of the
lesion (arrow).
152
JOURNAL OF CLINICAL ULTRASOUND
THORACENTESIS-RELATED HEPATIC PSEUDOANEURYSM
examination confirmed turbulent, pulsatile flow
within the anechoic area (Figure 2). The resistance index (RI) of the afferent artery to the lesion
was lower than that of a nearby artery (0.51 versus 0.60). Careful sonographic examination demonstrated no portal or hepatic venous drainage, so
a diagnosis of intrahepatic hepatic artery pseudoaneurysm was suggested.
Because of the paucity of symptoms and the
small size of the lesion, it was decided to perform
strict sonographic, clinical, and biochemical follow-up. In the subsequent days, the patient did
not have worsening symptoms or fever, and signs
or symptoms of hemobilia did not occur. However,
the aspartate transaminase, alanine transaminase, ␥-glutamyltransferase, and alkaline phosphatase values remained high. Sonography at
this time showed that the lesion had increased to
7.3 × 5.8 cm and maintained internal turbulent
flow. Selective hepatic angiography showed an intrahepatic lesion with ill-defined borders. Although the contrast medium filled the lesion, no
portal or hepatic venous branches were opacified
during the arterial phase, and no arteriovenous
fistula was detected. Successful embolization of
the injured artery was performed with Spongostan Standard (Ferrosan, Soeborg, Denmark).
The procedure was well tolerated. The patient’s
symptoms progressively disappeared, and the increased serum chemistry levels returned to normal. Color and pulsed Doppler examinations performed 5 and 12 days after embolization showed
the interruption of flow in the injured artery and
an increased RI in the afferent artery (0.66). No
flow was seen within the pseudoaneurysm, but
the size of the lesion remained unchanged (Figure
3). Six months after discharge, the patient had no
symptoms, and the anechoic area had almost
completely disappeared.
DISCUSSION
Thoracentesis was reported as a diagnostic procedure as early as 1852,7 but studies dealing with
the clinical usefulness and complications of the
procedure are far more recent.2,8,9 The most common complications of thoracentesis are pneumothorax, local pain, dry taps, and subcutaneous hematoma. A less common complication is the
incidental puncture of an abdominal organ
(spleen, liver, or kidney), which can have serious
consequences.3–6,10,11 For instance, an incidental
puncture of the liver could lead to hematomas,
vascular intrahepatic lesions with or without hemobilia, and peritoneal hemorrhage.
Hepatic artery pseudoaneurysm typically re-
FIGURE 3. Color Doppler sonogram 5 days after transarterial embolization shows that the size of the pseudoaneurysm has not changed but that
there is no flow in it.
VOL. 27, NO. 3, MARCH/APRIL 1999
153
ZIRONI ET AL
sults from hepatic trauma or percutaneous diagnostic or therapeutic procedures on the hepatobiliary system. Hepatic artery pseudoaneurysm
seems to develop from an intrahepatic collection
of blood and bile, that accumulates as bile lyses
clotted blood from small injured arteries, while
blood continues to fill them. Under the force of
arterial pressure, an intrahepatic cavity develops,
resulting in necrosis of the surrounding liver tissue.12 Hemobilia can occur if the blood-filled cavity erodes into a branch of the biliary tree. These
hepatic complications are not uncommon in patients who have undergone liver biopsy or percutaneous biliary drainage, but only a small percentage of patients with these complications show
symptoms from the injury and/or have hepatic
problems that require intervention. To our knowledge, intrahepatic artery pseudoaneurysm, with
or without hemobilia, has never been described as
a complication of thoracentesis.
In the case presented here, several factors
probably contributed to the complication. The
presence of a large pleural effusion and the fluid
obtained with the fine-needle puncture convinced
the surgeon that imaging guidance for the thoracentesis was unnecessary. Because the fluid obtained with the fine-needle puncture appeared too
viscous for easy drainage, a larger drainage catheter was inserted. It is conceivable that a needle
misdirection resulted in an incidental puncture of
the liver parenchyma during the insertion of the
thoracic drainage catheter and that the presence
of pleural fluid prevented puncture of the lung
parenchyma, explaining why pneumothorax did
not develop. Furthermore, the relatively large diameter of the catheter facilitated the complication; the incidence of complications of percutaneous liver procedures is directly related to the
diameter of the needle used.13,14
The sonographic examination following thoracentesis depicted the intrahepatic lesion as an anechoic area, suggesting it contained fluid. The
lack of any abnormality in the liver’s echotexture
before surgery ruled out the possibility of a preexisting liver lesion. Color and pulsed Doppler sonography revealed the lesion’s internal turbulent
and pulsatile flow, indicating that the lesion had
a vascular origin.
Because the RI reflects downstream impedance,15 it is conceivable that the resistance to flow
of the normal liver parenchyma is higher than
that of an intrahepatic cavity in which blood can
freely collect. On the other hand, the resistance to
flow should increase in the afferent artery if an
arterial occlusion is produced. These considerations may explain the reduced RI initially seen
154
in the afferent artery, the enlargement of the lesion, and the increased RI in the afferent artery
after embolization. However, the reduced RI initially seen in the afferent artery could also indicate high velocities and low resistances, which are
findings consistent with a more complicated lesion such as a pseudoaneurysm with a venous fistula or an aneurysmal arteriovenous fistula. Because no communication was seen between the
lesion and the portal or hepatic venous system
during subsequent angiography or the several follow-up gray-scale and Doppler sonographic examinations, the diagnosis of complicated pseudoaneurysm was considered unlikely.
The expansion of the pseudoaneurysm accounted for both the increased serum chemistry
values and the pain in the right shoulder and at
the puncture site. The expansion also influenced
the therapeutic decision: small pseudoaneurysms
without sepsis are generally treated with arterial
embolization,16 even though surgical intervention
or observation alone has also been reported.17,18
We preferred embolization because the pseudoaneurysm met the above criteria, the procedure is
less traumatic than surgical intervention, and
even if embolization is insufficient for occlusion, it
would reduce the operative risk during a possible
subsequent surgical resection.
The case presented demonstrates possible adverse effects of blind thoracentesis. The fact that
such complications could occur even when thoracentesis is performed by an experienced operator
supports a greater use of sonography for both diagnostic and therapeutic thoracentesis.2,19
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