The University of Toledo Translation Journal of Medical Sciences 
Pulmonology Abstract, Department of Medicine Research Symposium UTJMS 2023 May 5; 11(1):e1-e1 

Spontaneous Second Intercostal Artery 
Bleeding Complicated with Massive 
Hemothorax after Lower Limb Angioplasty 
Procedure 
Harith Al-Ataby, MD1*, Mohamed Omballi, MD1 

1Division of Pulmonology and Critical Care Medicine, Department of Medicine, The 
University of Toledo, Toledo, OH 43614 

*Corresponding author: Harith.Al-Ataby@utoledo.edu

Published: 05 May 2023 

Introduction: This is an extremely rare case of left massive hemothorax secondary to a spontaneous 
rupture of an intercostal artery. Presenting with a combination of hypovolemic and obstructive shock. 

Case: A 42-year-old male with PMHx of polysubstance, and Buerger's disease presented with right 
lower limb ischemia. Patient underwent RLE angiogram and balloon angioplasty. Intraoperatively, he 
received 11,000 unit of heparin. In the PACU, he became unresponsive and went into a severe shock 
state, intubated and resuscitated with IV fluid and vasopressors. Examination showed absence breath 
sounds in the left lung. CTA chest showed large left hemothorax with linear contrast extending from the 
posterior second intercostal artery compatible with acute hemorrhage with right mediastinal shift. 
Massive transfusion protocol was initiated. Angiogram showed bleeding from the Lf posterior 2nd 
intercostal artery. Transthoracic arterial coil embolization was performed and successfully stopped the 
bleeding. Two left-sided chest tubes were placed and 1 L of frank blood was drained. Next day, his 
vitals were stable, and was extubated to room air.  

Discussion: Spontaneous intercostal artery bleeding is extremely rare and reported in patients with 
underlying disorders, such as neurofibromatosis type 1, SLE, coarctation of aorta, Kawasaki disease, or 
Ehler-Danlos. High blood pressure or physical can trigger intercostal artery bleeding. We believe that 
our patient is the first reported case of spontaneous second intercostal artery bleeding in absence of 
underlying disorders. Being fully anticoagulated with high-dose heparin during the angioplasty and 
being agitated with forceful movement directly after weaning off the sedation might have caused the 
spontaneous rupture. 

https://dx.doi.org/10.46570/utjms.vol11-2023-771 

https://dx.doi.org/10.46570/utjms.vol11-2023-771
mailto:Harith.Al-Ataby@utoledo.edu