Spontaneous Rupture of the Internal Thoracic Artery Causing a Mediastinal Hematoma in a Patient with Alcoholic Liver Cirrhosis: A Case Report

Abstract

Spontaneous arterial bleeding is uncommon, and a mediastinal hematoma caused by spontaneous rupture of the internal thoracic artery has not been reported previously. Patients with liver cirrhosis or heavy alcohol consumption have a higher risk of hemorrhage than those without cirrhosis or excessive alcohol consumption. We present the case of a 39-year-old female with a history of alcoholic liver cirrhosis, who presented with a large mediastinal hematoma attributable to spontaneous rupture of the internal thoracic artery.

Keywords: Embolization, Therapeutic; Hematoma; Liver Cirrhosis; Rupture, Spontaneous; Thoracic Artery.

Fig. 1. A 39-year-old female with alcoholic liver cirrhosis who presented with 2 weeks of jaundice.

A. Chest radiograph obtained on the 12th post-admission day shows massive left-sided pleural effusion. B. Contrast-enhanced chest CT scan obtained 4 days later shows a hematoma (8.7 cm × 6.6 cm × 9.0 cm) in the anterior mediastinum at the lateral aspect of the aortic arch. Contrast-enhanced images (upper images) showing internal linear vessel-like enhancing lesions (arrows), suggestive of active extravasation. The lesions appear hyperdense (61 Hounsfield units) on a non-enhanced scan (lower middle image). Enhancement is unclear in these images. Heterogeneous hepatic enhancement with hepatosplenomegaly is observed on an upper abdominal scan (lower left image); these findings are consistent with hepatopathy. C. Selective arteriography scan obtained the same day showing extravasation in the territory of the left anterior intercostal artery (arrow, left image). Image shows embolization of the left internal thoracic artery using Nester and Interlock coils (arrows, right image). D. Follow-up CT angiography scan obtained 4 days after embolization show an increase in the size of the mediastinal hematoma, which extends from the thoracic inlet to the cardiac border on a coronal scan (left image). Scans obtained in both arterial (middle image) and venous phases (right image) showing linear enhancing lesions (arrows), which were considered to represent active extravasation. E. Selective arteriography scan obtained the same day showing extravasation at the upper portion of the left internal thoracic artery, proximal to the site of previous coil embolization (arrow, left image). Embolization of the left internal thoracic artery was performed using a 1:4 glue-lipiodol mixture. Intraoperatively, the distal microcatheter was cast together with glue materials. Image showing the stent deployed into the left subclavian artery to prevent reflux of the catheter (right image). F. Follow-up chest radiograph obtained 2 months postoperatively showing near-complete resolution of the mediastinal hematoma and pleural effusion.