Percutaneous Transthoracic Embolization for Hemothorax Due to Suspected Secondary Rupture After Chimney TEVAR

Purpose To describe a bailout percutaneous transthoracic embolization for the management of life-threatening hemothorax caused by suspected secondary aortic rupture following chimney thoracic endovascular aortic repair (ch-TEVAR), in a patient unsuitable for open surgical conversion. Materials and Methods A patient previously treated with ch-TEVAR for complex aortic pathology presented with acute hemodynamic instability and large left hemothorax on CTA, with imaging findings suspicious for contained secondary rupture and active bleeding adjacent to the excluded aortic segment. Due to prohibitive surgical risk and unfavorable anatomy for conventional endovascular re-intervention, a percutaneous transthoracic approach was planned. Under cone-beam CT and fluoroscopic guidance, direct puncture of the hemothorax was performed, allowing selective catheterization of the bleeding site. Embolization was achieved using a combination of embolic agents until complete angiographic exclusion of the contrast extravasation was obtained. Technical success, hemodynamic stabilization, and imaging follow-up were assessed. Results The transthoracic approach enabled rapid control of active bleeding with immediate hemodynamic improvement. Final angiography and post-procedural cone-beam CT demonstrated complete embolization of the rupture site with no residual extravasation. No procedure-related complications occurred. Follow-up CT confirmed persistent exclusion of the bleeding source and progressive reduction of the hemothorax. Conclusion Percutaneous transthoracic embolization represents a feasible and lifesaving minimally invasive bailout technique for the treatment of hemothorax due to suspected secondary rupture after ch-TEVAR in selected high-risk patients. Advanced intraprocedural imaging guidance is essential to ensure accurate targeting and to expand the therapeutic options when conventional surgical or endovascular strategies are not viable.