Image-guided percutaneous biopsy is a commonly requested procedure for tissue diagnosis of mediastinal masses.[2
] It is a quick and well-tolerated procedure and does not commonly require general anesthesia. Core needle biopsy is the preferred choice compared with fine needle aspiration biopsy, as histopathology is more reliable to characterize the tumor, particularly lymphoma.[4
] For the radiologist, the central location of the mediastinal mass exposes the risk of pneumothorax, hemothorax, and pulmonary hemorrhage. It is known for lung or mediastinal biopsies to have a small and localized hemorrhage with or without hemoptysis. These are usually temporary and are remedied by normal fluid resuscitation and observation.
Despite careful maneuver of the biopsy needle and monitoring of the patient post biopsy, the patient developed a large hemothorax. The delay in symptoms was most likely due to the low-pressure pulmonary arterial system that ranges between 5 and 15 mm Hg. The CTA protocol prior to angiographic intervention has been a routine practice in the department for suspected hemorrhage and the multiphase study includes plain, arterial, and delayed phases.[5
] The location and the degree of the hemorrhage can be determined rather easily prior to therapeutic endovascular intervention. This will lessen the time spent on the angiographic table and secure the hemostasis faster. Based on the CT findings, right subclavian artery and its branches, relevant intercostal arteries, and right superior pulmonary artery territories were the main focus.
Transcatheter embolization is a well-known procedure for pulmonary artery embolization.[6
] There are many documented cases of pulmonary artery embolization, particularly when dealing with arteriovenous malformations in hereditary hemorrhagic telangiectasia[8
] and pseudoaneurysms.[9
] Coils or particles are chosen frequently as the embolic material.
In this case, the arterial bleeder originated from the terminal part of the apical branch of the right superior pulmonary artery. Distal or terminal arterial bleeders are suitable for transcatheter embolization using NBCA. NBCA or glue is known for endovascular management of arteriovenous malformations in the brain and spine. It is also known as the emerging embolic material of choice in gastrointestinal bleeds[10
] and can be used in bronchial artery embolization.[11
] The rapid polymerization of the NBCA giving faster occlusion of the bleeder point makes a rebleeding event less likely. Another advantage of endovascular embolization is the ability to distally occlude the bleeder reducing the area of pulmonary infarct.
Coils embolization is not chosen in this case, as the operator was able to achieve a distal cannulation. Coils embolization would have been the choice only if distal cannulation was not successful. The disadvantages of coil embolization are the time it takes to cease the bleed and should there be a rebleeding event, selective cannulation to the bleeding point may be technically difficult. In the case of intractable bleeding or failed endovascular embolization, a thoracotomy and surgical ligation has to be done.
In our experience, selective distal cannulation of the bleeder point with the right concentration of lipiodol-NBCA mixture and good injection control, cessation of a bleeder site can be achieved confidently. This case also illustrates that CT-guided mediastinal biopsy can occasionally presents a life-threatening complication and a good interventional radiology unit can help avoid mortality.