Thoracic Ultrasound Demonstrates Variable Location of the Intercostal Artery

Abstract

Background: Ultrasound (US) guidance is advocated to reduce complications from thoracocentesis or intercostal catheter (ICC) insertion. Although imaging of the intercostal artery (ICA) with Doppler US has been reported, current thoracic guidelines do not advocate this, and bleeding from a lacerated ICA continues to be a rare but serious complication of thoracocentesis or ICC insertion. Objectives: It was the aim of this study to describe a method to visualise the ICA at routine US-guided thoracocentesis and map its course across the posterior chest wall. Method: The ICA was imaged in 22 patients undergoing US-guided thoracocentesis, at 4 positions across the back to the axilla. Its location, relative to the overlying rib, was calculated as the fraction of the intercostal space (ICS) below the inferior border of that rib. Results: An ICA was identified in 74 of 88 positions examined. The ICA migrated from a central ‘vulnerable’ location within the ICS near the spine (0.28, range 0.21–0.38; p < 0.001) towards the overlying rib (0.08, range 0.05–0.11; p < 0.001) in the axilla. Conclusions: The ICA can be visualised with US and is more exposed centrally within the ICS in more posterior positions; however, there is a marked variation between individuals, such that the ICA may lie exposed in the ICS even as far lateral as the axilla. Future studies need to identify which patients are at risk for a ‘low-lying’ ICA to further define the role of US imaging of the ICA during thoracocentesis or ICC insertion.

The efficacy of bedside chest ultrasound: from accuracy to outcomes

“…SALAMONSEN et al [101] visualised intercostal arteries using colour Doppler and confirmed significant variation in their course. In a subsequently contrast CT-validated study, ultrasound had excellent sensitivity (86%) but poor specificity (30%) for detecting such vulnerable intercostal vessels [102].…”

Diagnostic approach to pleural diseases: new tricks for an old trade

“…While most physicians use ultrasound merely to mark the site for needle insertion before setting up for the procedure, real-time ultrasound using a sterile sleeve allows sampling of previously unreachable small loculated effusions and occasionally allows parietal pleural biopsies. Furthermore, recent evidence suggests that pre-procedural identification of the intercostal artery, the course of which can be unpredictable, is easily achieved with a high-frequency probe and could help avoid rare but potentially fatal bleeding complications 20– 22 . Ultrasound examination immediately after the procedure can indirectly suggest the occurrence of pneumothorax by the disappearance of the typical “sliding” sign, representing the sliding of visceral and parietal pleura over each other.…”

Percutaneous Ultrasonography as Imaging Modality and Sampling Guide for Pulmonologists

“…US enables visualization of the course of an aberrant or intercostal vessel which is advantageous to determine the best location for drain insertion. It is well known that more vulnerable intercostal arteries are found near the spine, disappearing gradually behind the overlying rib in the axillar plane [25]. A sensitivity of 86% for US to detect vessels within the intercostal space was demonstrated in a study in 50 patients [26].…”