PMC9296063_01
(A) Clinical photograph showing bulge in the right mammary and infraclavicular areas; (B) Right internal thoracic artery (RITA) aneurysm showing bidirectional blood flow with characteristic yin yang sign; (C and D) Pre-coiling CT: CT angiography images show presence of ruptured aneurysm sac (arrow) arising from the RITA (arrowheads) with surrounding large hematoma (dashed arrows) causing contour bulge along anterior chest wall on right side.
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Examination revealed an ill-defined soft tender swelling arising from the intermuscular plane in the right infraclavicular and mammary region (Figure 1A). Doppler ultrasound showed a large hyperechoic area with eccentric hypoechoic region and bidirectional flow with the characteristic Yin-Yang sign (Figure 1B) along the right anterior chest wall. Computed tomography angiography (CTA) (Figure 1C) showed presence of an aneurysm arising from the RITA, surrounded by large hematoma suggestive of contained rupture.
Selective RITA injection from RFA access (A) Coronary 018 wire into the aneurysm (B) Microcatheter injection showing microleak (C) Wire/microcatheter induced dissection in the distal part of the RITA (D) Coronary wire parked in the right superior epigastric artery from right brachial access (E) Injection through microcatheter showing flow in the right superior epigastric artery (F) Micro coils deployed distal and proximal to the aneurysm (G and H) Selective RITA injection demonstrating RITA occlusion (I).
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Selective injection of the RITA with a Judkins right diagnostic catheter from right femoral access showed leakage from the distal part of the RITA (Figure 2A). As a dissection was noted in the RITA proximal to the aneurysm during manipulation of catheter and wires (Figure 2D), we shifted to brachial access for ease of hardware manipulation. A 0.018 Coronary wire was parked in the right superior epigastric artery and a microcatheter was traversed over it (Figure 2E). Final selective RITA injection demonstrated RITA occlusion with insignificant flow of blood into the aneurysm (Figure 2H).
Post-coiling CT: CT images (A and B) following coil embolization show no residual filling of the sac with coil mass in situ (arrow) and resolving residual hematoma (dashed arrows).
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Post intervention CTA confirmed sealing of the ruptured aneurysm with no residual filling of the sac (Figure 3) with resolving residual hematoma.