We present a case of a 70-year-old patient with hepatocellular carcinoma treated with RFA. The lesion was located in segment II under the ribs. During RFA pleural effusion is presented. After the procedure a dual phase CT revealed haemothorax and extravasation of the contrast medium from the intercostal vessels.
Percutaneous radiofrequency ablation is used for treatment of hepatocellular carcinoma and it can be performed with a variety of imaging modalities ultrasound, computed tomography, magnetic resonance imaging, and fluoroscopy. Severe complications can happen like intraperitoneal bleeding, pneumothorax, hemothorax, liver abscess, and bile duct injury. In our department RFA is performed under CT guidance and complications can be detected with accuracy. In our case we present a case of a female patient with HCC who complicated with pleural effusion detected with CT. Intravenous contrast medium administration revealed a jet-like extravasation from the intercostal vessels which is evolved to hemothorax.
A 70-year-old woman with two lesions of hepatocellular carcinoma was treated in our department. The first large lesion, located in segment V, was ablated several times the previous years. A new lesion appeared in segment II, located under the ribs (Figure
A 70-year-old woman with two lesions of hepatocellular carcinoma. Contrast-enhanced CT scan shows two hepatocellular masses in segment V (treated before with RFA) and II, under the ribs.
Prior to therapy the patient had underwent laboratory examinations: hematocrit, white blood cell count, blood coagulation tests, values for hepatic, function and a-fetoprotein levels. Platelet (PLT) count value was 60,000/mL and international normalized ratio (INR) was 1,2. Forty-five minutes before the procedure the patient received analgesic and antidepressant treatment consisting of one pill of 3 mg bromazepam per os and 75 mg d-propoxyphene hydrochloride intramuscularly. CT-guided RFA started by placing the patient in the supine position. The shortest, most vertical, and safest path should be chosen. The front path just over the lesion was chosen. The skin at the needle entry site was prepared with povidone iodine 10% solution. A 22 G needle for syringe use was inserted into the skin, and three contiguous CT images were obtained to ensure that the chosen point was the appropriate one. Local anaesthetic (2% lidocaine hydrochloride) was then instilled through this needle for skin and subcutaneous tissue anaesthetization. The needle was removed and an incision with a surgical blade was made to facilitate electrode cannula insertion. Ablation was carried out with a MIRAS triple spiral 15 G electrode.
The tip of the electrode was positioned in the correct position and it was deployed slowly (Figure
The front path just over the lesion was chosen. The tip of the electrode was positioned in the correct position and it was deployed slowly.
A few minutes before RFA, CT scan showed pleural effusion, and right after the ablation of the lesion was completed, low pulsed RF energy was applied for the ablation of the track to avoid tumor seeding and ablate the source of the bleeding. A dual-phase dynamic contrast-enhanced CT was performed which revealed a jet-like extravasation from the intercostal vessels (Figure
A dual-phase dynamic contrast-enhanced CT was performed just after the RFA procedure which revealed a jet-like extravasation from the intercostal vessels.
A chest CT was performed immediately which revealed a right pleural effusion with a distinct fluid level.
According to a study Hyunchul Rhim et al. [
Goto et al. [
In their opinion, once hemothorax occurs, the respiratory condition may deteriorate rapidly. Acute respiratory distress syndrome may occur and the resulting thrombocytopenia can aggravate the hemorrhage. In addition to stabilizing the circulation by using infusion and transfusion, thoracic drainage is often required to stabilize the respiratory condition and prevent subsequent acute respiratory distress syndrome. If the estimated blood loss was <300 to 400 mL, they performed thoracentesis, whereas if the estimated loss exceeded 500 mL, they performed a tube thoracostomy.
Akahane et al. [
Livraghi et al. [
Sugihara et al. [
Using contrast-enhanced ultrasonography (CEUS), a jet-like extravasation of contrast medium was revealed and pooling of microbubbles in the pleural cavity. It was an active bleeding in the pleural cavity, from a branch of the inferior phrenic artery, which was confirmed by angiography. They embolized the branch using a gelatin sponge with a particle size of 1 mm.
Our treatment in this complication was not so aggressive. Positioning a drainage we monitored the blood loss. It was a self-limited hemorrhage and drainage was withdrawn after a couple of days.
The authors declare that they have no conflict of interests.