intercostal artery pseudoaneurysm is an extremely rare phenomenon with only a few cases described so far . we describe a case of corrosive poisoning induced intercostal artery pseudoaneurysm , presenting with massive hematemesis and shock which was treated by glue embolisation . to the author 's belief and to the best of their knowledge , this is the first reported case of non - traumatic intercostal artery pseudoaneurysm caused by acid ingestion and presenting with hematemesis . a 32 year old male with history of suicidal intent corrosive acid consumption , 5 weeks ago , was referred to our hospital with complaint of massive hematemesis . the patient initially presented , 4 weeks after corrosive consumption , to another hospital with two episodes of massive hematemesis where the patient was managed conservatively with blood transfusion . an upper gastrointestinal endoscopy revealed grade 3 corrosive injury involving esophagus , gastroesophageal junction and stomach . at the time of admission , patient was pale with pulse rate of 98/min and blood pressure of 90/58 mm of hg . laboratory investigations revealed haemoglobin level of 6.3 g / dl , rbc count of 2.03 millions / mm and 1.32 inr . ct angiogram was performed to delineate the exact cause and site of bleed which revealed hematoma in and around the upper thoracic oesophagus on non - contrast enhanced scan [ figure 1 ] . on contrast - enhanced study , a small pseudoaneurysm of right third intercostal artery , posterior to thoracic esophagus at level of d4-d5 intervertebral disc was noticed [ figure 2 ] . his blood pressure dropped to 60/35 mm of hg , haemoglobin level to 3.1 g / dl . multiple units of fresh frozen plasma , blood and intravenous fluids were administered and patient was taken for emergency embolisation of pseudoaneurysm . selective cannulation of right third intercostal artery via right femoral artery puncture was performed with a 4 fr cobra catheter . pseudoaneurysm was cannulated with 0.017  headway microcatheter ( microvention ) with the help of 0.014  micro guide wire . 0.5ml of n - butyl cyanoacrylate ( nbca ) glue ( histoacryl ) was thoroughly mixed with 2 ml of lipiodol ( guerbet ) to make 20% nbca solution . about 1.0 ml of this solution was carefully injected under guidance in the right third intercostal artery after flushing the microcatheter with 5% dextrose solution , checking that there was no reflux into non - target vessels [ figure 4 ] . there was extravasation of glue - lipiodol mixture into the intercostal space due to active leak . axial non - enhanced ct chest showing hyperdense hematoma in and around the esophagus ( arrow ) reconstructed ct angiogram maximum intensity projection image showing the right 3rd intercostal artery pseudoaneurysm ( arrow ) ( a ) axial ( b ) swirled lateral ( c ) 3d reconstructed selective right intercostal artery dsa using road - map technique shows the pseudoaneurysm ( arrow ) with active contrast leak ( arrowheads ) image showing radio - opaque glue in the pseudoaneurysm ( arrow ) with micro - catheter in situ ( arrowhead ) . note local perianeurysmal glue leak post - embolisation check angiogram showing complete cut - off of the aneurysm from circulation ( arrow ) the patient 's hematemesis stopped immediately after the procedure and after active resuscitation , his vital parameters became stable . hemoglobin was 9.3 g / dl on the next day of the procedure with no fresh episode of hematemesis . etiology described in all the published cases was trauma , either iatrogenic or otherwise and the presentation was in the form of hemothorax , retroperitoneal hematoma or pulsatile swelling . this was a complicated case because of massive hematemesis , continuous on - going blood loss and circulatory shock . doppler ultrasound , ct angiography and digital substraction angiography ( dsa ) are the investigations commonly used to diagnose pseudoaneurysm . accurate diagnosis of aneurysm can be achieved by utilising the multi - planar reformation ( mpr ) and maximum intensity projection ( mip ) feature of ct . dsa is not only diagnostic but also has the advantage of endovascular treatment in the same setting . coil embolisation , glue embolisation , thrombin injection and surgery are the various treatment options available . stenting of non - bleeding pseudoaneurysm and conservative management of asymptomatic cases has also been described . surgical treatment is usually reserved for failed embolisation or where embolisation could not be accomplished . the choice of embolic material in vascular interventional procedures depends on anatomy , pathology , flow characteristics and personal preference of the interventional radiologist . the main advantage of nbca is that it is capable of conforming within the vessel and occludes the vessel lumen rapidly besides being cheap . lipiodol is mixed with nbca to make it radio - opaque and to dilute it so as to delay it 's time of polymerisation . nbca quickly solidifies by exothermic reaction when it comes in contact with an ionic solution of alkaline ph such as blood . to prevent early solidification within the delivery system itself , the catheter is primed with low ph non - ionic 5% dextrose solution prior to injection of glue bolus . spinal cord ischemia , a serious complication which can arise due to embolisation needs special mention . detailed knowledge of spinal cord blood supply , anatomy of radiculo - medullary arteries , the artery of adamkiewicz and expertise of interventional radiologist are the determining factors of outcome of embolisation procedure . esophageal and gastric burns , perforation , mediastinitis , early fatal outcome , esophageal and pyloric stenosis and carcinoma formation are the various complications of corrosive ingestion . this case emphasizes the consideration of pseudoaneurysm , as a possible complication of corrosive poisoning , in patients presenting with hematemesis . pseudoaneurysm of intercostal artery can cause massive rapid blood loss and can be life threatening . clinical suspicion , accurate diagnosis and early timely intervention can be lifesaving in such a situation .
pseudoaneurysms of intercostal artery are very rare . 
 all the published cases have been caused by trauma , either iatrogenic or otherwise . 
 they can cause hemothorax , retroperitoneal hemorrhage or can present as pulsatile chest mass . 
 doppler ultrasound , contrast - enhanced ct and conventional angiogram can accurately diagnose this condition . 
 all the reported cases have been treated by embolisation , stenting or surgery . 
 we report an unusual case of intercostal artery pseudoaneurysm arising as a complication of corrosive poisoning presenting with hematemesis and treated by glue embolisation . 
 the authors believe this to be the first case of intercostal artery pseudoaneurysm that is non - traumatic , complicating corrosive poisoning and presenting with hematemesis .