Internal mammary artery pseudoaneurysms complicating chest wall infection in children Diagnosis and endovascular therapy Hemant Deshmukh a , Srinivasa R. Prasad b, *, Tufail Patankar a , Madhavi Zankar a a Department of Radiology, King Edward Memorial Hospital, Bombay, India b Department of Abdominal Imaging, 9th Floor, Mallinckrodt Institute of Radiology, St. Louis, MO 63110, USA Received 3 April 2001; accepted 2 June 2001 Abstract Mycotic internal mammary artery (IMA) pseudoaneurysms are sparsely reported in medical literature. We report imaging findings of IMA pseudoaneurysms secondary to chest wall abscesses (staphylococcal and tuberculous) in two children. Both children were successfully treated by endovascular method thus obviating the need for surgery. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Abscess; Internal mammary artery; Pseudoaneurysm; Embolization 1. Introduction Internal mammary artery (IMA) aneurysms are extremely rare. Postoperative [1], posttraumatic, mycotic [2], and atherosclerotic aneurysms of the IMA are described in the literature. IMA may be a source of significant mediastinal hemorrhage with possible catastrophic consequences espe- cially in patients with blunt or penetrating trauma [3]. Angiographic demonstration of an aneurysm is critical in establishing specific diagnosis and detects the source of hemorrhage to enable timely institution of endovascular treatment. We report two cases of bleeding IMA pseudoa- neurysms in children (staphylococcal and tuberculous pseu- doaneurysms) that were successfully embolized using coils. 2. Case reports 2.1. Case 1 A 5-year-old boy developed fever and a large, left-sided anterior chest wall abscess 1 week following an accidental fall from a treetop. Incision and drainage of this abscess in a peripheral hospital had yielded blood admixed with pus and had resulted in considerable hemorrhage. The pus had grown Staphylococcus aureus and the patient was put on antistaphylococcal antibiotics. The patient was referred to our hospital following two episodes of massive hemoptysis. Clinical examination revealed a large, anterior chest wall abscess. Contrast-enhanced CT scan of the chest demon- strated a large, partially thrombosed pseudoaneurysm; how- ever, its precise arterial origin could not be ascertained (Fig 1). In addition, there was a lenticular-shaped hemo- thorax. Arch aortogram, bronchial, and intercostal angio- grams were normal. Selective left subclavian angiogram showed a large pseudoaneurysm arising from the IMA just distal to its origin (Fig. 2a). Complete occlusion of the IMA at its origin with obliteration of the pseudoaneurysm was achieved using 4-mm diameter, 3-cm-long steel coil (Cook, Bloomington, US) placed through a 4F head hunter (Cook) (Fig. 2b). A follow-up CT scan at 2 weeks showed marked diminution in the size of the pseudoaneurysm. The patient was discharged after 2 weeks following an uneventful course in the hospital. 2.2. Case 2 An 11-year-old girl presented with low-grade fever and a right-sided anterior chest wall cold abscess. An incision and drainage was attempted in a peripheral hospital resulting in 0899-7071/01/$ – see front matter D 2001 Elsevier Science Inc. All rights reserved. PII:S0899-7071(01)00325-4 * Corresponding author. E-mail address: sprasad@partners.org (S.R. Prasad). Journal of Clinical Imaging 25 (2001) 396 – 399