Transhepatic Tract Embolisation to Facilitate Retrieval of an Intercostal Chest Drain Sited in the Right Atrium

Abstract

Clinical History/Pre-treatment Imaging A 79-year-old female with atrial fibrillation, COPD, and chronic kidney disease was admitted for elective management of valvular heart disease. She underwent open aortic valve replacement and left atrial appendage closure under the cardiothoracic surgeons. On postoperative day six, a right-sided pleural effusion (6.5 cm) was identified on ultrasound, and a 12 Fr intercostal chest drain was placed under ultrasound guidance. Within 30 minutes, 1.2L of bloody fluid drained, followed by the patient experiencing hypotension. CT imaging confirmed the drain traversing the pleura, diaphragm, liver, and right hepatic vein, with the tip in the inferior vena cava. Treatment Options/Results The patient was resuscitated and transferred to interventional radiology. Angiography confirmed no active arterial extravasation but demonstrated communication between the drain tract and the hepatic vein. The drain was exchanged over a wire for an 11 Fr sheath. A 6 x l l mm Amplatzer II plug was deployed to occlude the distal hepatic vein, and gelfoam slurry was used to plug the tract. A new pigtail drain was inserted into the pleural space without further complications. Discussion Misplacement of intercostal chest drains into hepatic vascular structures is rare but potentially fatal. Immediate recognition and intervention are crucial. Endovascular management offers a minimally invasive alternative to surgery, reducing morbidity. Maintaining arterial and systemic venous access during the procedure allows rapid escalation if haemorrhage occurs. Take-home Points: - Misplaced chest drains require prompt imaging confirmation. - Large-volume drainage can cause haemodynamic instability. - Endovascular embolisation provides a safe, effective alternative to surgery.