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Superior epigastric artery pseudoaneurysm- a rare complication of chest drain insertion in coronary artery bypass grafting
© Sadat et al; licensee BioMed Central Ltd. 2007
Received: 09 December 2006
Accepted: 25 April 2007
Published: 25 April 2007
Although chest drain insertion during coronary artery bypass grafting is a fairly standard procedure, however it may result in extremely rare complications.
This is the first case being reported that demonstrates a pseudoaneurysm of superior epigastric artery resulting from chest drain insertion following coronary artery bypass grafting.
Adequate caution should be used along with good understanding of the anatomical landmarks during apparently simple and standard operative procedures.
This is the first case being reported that demonstrates a pseudoaneurysm of superior epigastric artery resulting from chest drain insertion in a patient undergoing coronary artery bypass grafting. Adequate caution should be used along with good understanding of the anatomical landmarks during such operative procedures.
Pseudoaneurysms result from injury to the blood vessel wall; the leaking blood later becomes walled off by surrounding tissue, the communication with the vessel making them pulsatile. Common causative factors include iatrogenic injury , trauma , infection (mycotic), vasculitic disease  etc.
Although investigative tools for pseudoaneurysms include doppler ultrasound scan or angiograms (digital subtraction angiogram or CT/MR angiograms), in this case the diagnosis was entirely clinical with confirmation by duplex scan. Invasive angiograms are usually performed when there is intent to treat the pseudoaneurysm with embolization. Pseudoaneurysms have a tendency to thrombose on their own, but mostly they require either surgical or radiological intervention. The latter involves ultrasound compression of the pseudoaneurysm, thrombin injection into the neck of the pseudoaneurysm or coil embolization. However, in large pseudoaneurysms presenting with shock, open surgical repair is done after initial resuscitation as in this case.
Literature search using medline search engine shows that it is the first case to be reported of superior epigastric artery pseudoaneurysm after chest drain insertion following coronary artery bypass graft. Other complications include damage to the lung parenchyma, injury to the pulmonary artery, blockage of the drain etc. Chest drains after CABG can be placed either in the intercostal region and/or the subxyphoid region. The latter has been shown to be less painful and associated with better post op chest physiotherapy .
To avoid such uncommon complications adequate anatomical knowledge is required during chest drain insertions. As insertion of chest drain is under direct vision; hence the risk of injury vessels is low. This case report appears to be an unfortunate and isolated case, which should not affect the surgeon's choice of the chest drain's site. Perhaps, it reminds us that Murphy's law is very much alive: anything that can go wrong, will. Hence, it may be added to the pre-op counselling of patients that the apparently innocuous chest drain can give trouble. In addition, as an added precaution, a check can be made to ensure that the drain is well away from the superior epigastric artery prior to closing the chest.
Conflict of interests
The author(s) declare that they have no competing interests.
Written consent was obtained from the patient for publication of case report.
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