MANAGEMENT OF INTERNAL MAMMARY ARTERY INJURIES ASSOCIATED WITH THE NUSS PROCEDURE: A CASE SERIES

Objectives: The minimally invasive repair of pectus excavatum (MIRPE), or Nuss procedure, is regarded as the gold standard technique. MIRPE is regarded as a low-risk operation with a reported life-threatening complication rate estimated at around 0.1%. Direct cardiac injury represents the vast majority of published complications; however, other major adverse events may arise. Here, we present three cases of right internal mammary artery injury (RIMA) after MIRPE resulting in massive hemorrhage and subsequent management strategies.
Patient 1 was an 18-year-old male who underwent MIRPE and was found to have large right hemothorax on postoperative day one. A thoracoscopic intervention allowed for ligation of the RIMA. The patient required subsequent bar adjustment for malpositioning but experienced ongoing hemostasis. Patient 2 was also an 18-year-old male who was found, on postoperative day three, to have a right hemothorax. Again, exploratory thoracoscopic surgery was utilized but did not allow for bleeding point identification. Therefore, the patient underwent angiography, and the RIMA was embolized which achieved hemostasis. Patient 3 was a 14-year-old male who experienced a delayed internal mammary artery injury two years after MIRPE while exercising. In this case, embolization by interventional radiology was again utilized with good success.
Hemorrhagic complications following MIRPE are rare but do occur, most commonly secondary to internal mammary artery injury. Prompt recognition and expedient response are both paramount to patient outcomes. Here we described two management strategies, exploratory thoracoscopy and angioembolization, which achieved prompt hemostasis and allowed for complete patient recovery.

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