Inadvertent posterior intercostal artery puncture and haemorrhage after ultrasound-guided thoracic paravertebral block: a case report

BACKGROUND: This report describes one case of paravertebral haemorrhage after ultrasound-guided thoracic paravertebral block (TPVB) that may have been attributed to the inadvertent puncture of the posterior intercostal artery (PIA). This complication has never been reported in ultrasound-guided TPVB. Strategies to prevent this potentially serious complication are discussed. CASE PRESENTATION: A 52-year-old male underwent a video-assisted upper lobectomy. TPVB was performed under the guidance of ultrasound using the out-of-plane parasagittal approach. The transducer was placed 2.5 cm lateral to the midline area in a sagittal orientation. A needle was inserted at the lateral side of the transducer and advanced toward the T4 paravertebral space. During the final attempt, the needle tip was visualised in the middle area of the paravertebral space. Anterior displacement of the pleura was visualised upon injection of the saline. Aspiration of red blood was unfortunately identified. The block in this T4 level was discontinued. The patient was haemodynamically stable. When the chest cavity was entered, a bulging column-shaped haematoma was noted in the left paravertebral space extending from T1 to T12 with concomitant spread into the left T4–5 intercostal space. A postoperative neurological examination revealed intact sensory function in the T4 dermatome bilaterally. The patient fully recovered with no neurological sequelae. CONCLUSIONS: Ultrasound-guided TPVB still bears the potential risk of inadvertent PIA injury. We recommend colour Doppler imaging to identify PIA prior to the TPVB.