Successful coil embolization of a bleeding internal thoracic artery that caused severe hypotension immediately after permanent pacemaker placement

A 66-year-old male received a dual-chamber defibrillator (ICD) implant. Left subclavian artery (SCA) was inadvertently entered while attempting subclavian venous stick, and J-guidewire was passed into the vessel because the plan was to get the wire deep enough in the vessel that a sheath could be passed over the wire and then ICD lead passed through the sheath. The J-wire got stuck in the vessel and the wire was removed by pulling it back with minor difficulty. Subsequently, the ICD was implanted by sticking the vein, but the patient developed hypotension immediately after the procedure and an emergent chest CT scan was read as showing a large hematoma in left upper thorax. The bleeding source was suspected to be SCA at the stick site and the patient emergently came to the cardiac catheterization laboratory where an interventional cardiologist placed a Viabahn (Gore) covered stent in the SCA at the suspected site of bleeding. However, the active bleeding was soon identified to come from a large and free perforation in the proximal left internal thoracic artery (ITA) (Fig. 1, video 1). A 7-French guiding catheter was placed selectively in the ITA, and the ITA was successfully occluded with 3 cm × 5 cm and 4 cm × 10 cm AZUR (Terumo Interventional Systems, Somerset, New Jersey) coils (Fig. 2). There was no residual bleeding from the ITA. In retrospect, the CT scan showed the bleeding ITA (Fig. 3). This is the first reported case of hemodynamically significant ITA bleeding indirectly related to ICD placement.

Fig. 1.

Subclavian artery angiography showing ITA bleeding from the wire injury.

Fig. 2.

ITA is coiled successfully and the active bleeding has stopped on angiography.

Fig. 3.

Chest CT with a large thoracic hematoma and in retrospect, actively bleeding ITA.

Conflicts of interest

The authors have none to declare.

Appendix A. Supplementary data

The following are the Supplementary data to this article:

Video 1

Video of bleeding ITA.