Intercostal artery aneurysms are rare vascular abnormalities that are most often associated with aortic coarctation or neurofibromatosis type 1 (Tapping & Ettles, 2011; Dominguez et al., 2002). Aneurysm formation can also represent sequelae of vascular injury from systemic vasculitis, local infection, prior iatrogenic intervention, or previous trauma (Gonzalez et al., 2011; Bonne et al., 2015; Hernandez-Velasquez et al., 2016; Neuwirth & Singh, 2010). Patients with intercostal artery aneurysms are usually diagnosed following rupture, a potentially life-threatening complication (Arai et al., 2007; Kim et al., 2011). We describe a unique case of a patient who was incidentally found to have multiple unruptured intercostal artery aneurysms of indeterminate etiology. The clinical presentation, radiologic imaging, and endovascular management are discussed.
Case presentation
A 70-year-old male ex-smoker with hypertension, dyslipidemia, and newly diagnosed prostatic adenocarcinoma was undergoing staging prior to initiation of therapy. During this workup, a SPECT/CT scan noted vertebral body notching and multiple extrapleural nodules (Fig. 1). Further evaluation with CT angiography revealed multifocal saccular and fusiform aneurysms of the intercostal arteries (Fig. 2). No other aneurysms of the neck, chest, abdomen, or limbs were identified. It was decided to preventatively treat three large aneurysms of the right 7th intercostal artery with endovascular embolization.
Following conscious sedation with Fentanyl and Midazolam and local anesthesia with 2% Lidocaine, the right common femoral artery was punctured utilizing a single-wall technique. A 6-Fr sheath was introduced and 5-Fr C2 Cobra catheter (Boston Scientific, Cork, Ireland) advanced selectively into the right 6th through 8th intercostal arteries. Angiography confirmed the target aneurysms of the 7th intercostal artery (Fig. 3a) and that no spinal artery originated from them. The 6th and 8th intercostal arteries did not provide significant collateral supply to the 7th intercostal artery. A Renegade microcatheter (Boston Scientific, Cork, Ireland) was inserted and Interlock microcoils (2 of 2 mm × 6 mm × 8 cm, Boston Scientific, Cork, Ireland) were deployed starting distally (Fig. 3b). To maximize the occlusive effect, the aneurysms were then embolized with a Glubran 2 (GEM, Viareggio, Italy)/Lipiodol (Guerbert, Roissy-en-France, France) mixture (1:1). Proximally, Interlock microcoils (2 of 2 mm × 4 mm × 4.1 cm, Boston Scientific, Cork, Ireland) were placed and complete cessation of flow was achieved (Fig. 3c). There were no intraoperative complications. The patient was discharged home the following day and made an uneventful recovery. At six-month follow-up, the patient remained asymptomatic and will be monitored with yearly CT angiograms.