Pleural interventions are commonly performed in both elective and emergency settings. They include simple thoracocentesis, closed pleural biopsy (with or without image guidance), intercostal drain (ICD) insertion, in-dwelling pleural catheter insertion and medical thoracoscopy. Complications of pleural procedures are common but their incidence is often under-recognised. Higher operator experience and the use of image guidance are key factors demonstrated to significantly reduce the frequency of complications.1

Injury to the intercostal artery (ICA) is an infrequent but potentially life-threatening complication of all pleural interventions. Pleural haemorrhage is reported to occur in up to 2% of thoracocenteses, up to 13% of ICD insertions and up to 4% of thoracoscopies.2 The true incidence of ICA laceration and consequent pleural haemorrhage is likely to be higher due to under-reporting of complications seen in retrospective case series.

The British Thoracic Society has published guidelines for the insertion of ICDs,1 aiming to reduce the potential harm of ICD insertion. Although these recommendations are likely to reduce certain complications such as drain insertion into abdominal or thoracic viscera, they do not specifically address the possibility of ICA injury. Proper site selection for pleural interventions is important as this minimises the likelihood of ICA laceration. In a recent large study, Helm et al3 identified that ICA is exposed within the intercostal space in the first 6 cm lateral to the spine using CT pulmonary angiograph and mapping of the ICA course. The variability of ICA is greater in older people and in more cephalad rib spaces and decreases with lateral distance from the spinous process. Additionally, another important parameter is the management protocol for intrapleural haemorrhage. This should be in place prior to any pleural interventions to avoid life-threatening delays.

We present three cases of iatrogenic ICA injury in different clinical circumstances, from three different …