Treatment for esophageal cancer usually consists of surgery combined with perioperative chemical (radio) therapy . The incidence of AL after McKeown esophagectomy remains relatively high, which may be related to tube gastric perfusion, anastomotic tension, construction of the anastomosis [1, 2]. The Esophageal Complications Consensus (ECCG) classified AL into three types, typ I: local defect requiring no change in therapy or treated medically or with dietary modification; typ II: localized defect requiring interventional (not surgical) therapy, for example, drain placement or stenting; typ III: localized defect necessitates surgical therapy . Measures for prevention of anastomotic leak include reducing the tension of the anastomosis, avoiding damage to the vascular arch, strengthening the anastomosis and wrapping anastomosis with omentum .
Intrathoracic hemorrhage is a common clinical emergency and requires a significant health and economic burden, the source of which varies . Early postoperative intrathoracic bleeding after esophagectomy, especially with intrathoracic anastomosis, resulting from mechanical anastomotic failure or vascular injury . In this case, the branch vessels of the subclavian artery may be damaged during esophagectomy. The physiological response of these small blood vessels to tearing is post-traumatic contraction and thrombosis secondary to hemostasis. However, owing to AL, the combination of the long-term erosion of pus and the shedding of necrotic tissue are the presumed initiating factors of the pathological cascade of delayed recurrent intrathoracic hemorrhage.
In most patients, traditionally, an additional thoracotomy is considered the firstline therapeutic option to control the blood loss. However, in our case, a re-thoracotomy to control bleeding can be difficult and tedious, owing to severe infection, the anatomic inaccessibility caused by extensive adhesion and limited exposure of the thoracic roof. On the contrary, TAE is minimally invasive, facilitates the identification of bleeding sources (extravasation or irregular arterial walls) through angiography, and can effectively achieve hemostasis . Moore C et al. had extended this technique to the thoracic cavity by using selective thoracic aortography with transcatheter embolization of intercostal artery, providing a minimally invasive auxiliary method for the treatment of refractory intrathoracic hemorrhage . Apart from the direct sign of contrast extravasation on angiography, irregular blood vessels, cut off blood vessels, arteriovenous shunts, pseudoaneurysms, increased new blood vessels and dilated arterioles were also considered signs of bleeding indicating embolization . In this case, a selective angiography can visualize a curved, irregular blood vessel originated from the right subclavian artery, and the microcatheter was used to embolize the bleeding artery as distal as possible. If the source of bleeding cannot be identified angiographically, empiric embolization or blind embolization can be considered. Empiric embolization technique has been shown no difference in clinical outcome when compared with embolization of an identifiable source of bleeding . Microcoils, polyvinyl alcohol particles, NBCA, vascular plugs, and gelatin sponges are used as embolic agents. Interventional radiologists should fully consider the unique characteristics and embolization mechanism of each embolic agent, and select the appropriate embolic agent based on collateral network, vascular lesions, cost and operator skills .