Spontaneous Refractory Intercostal Artery Hemorrhage in a Patient With Decompensated Liver Cirrhosis

Intercostal artery hemorrhage (ICAH) is an uncommon occurrence that may lead to significant clinical complications if not promptly addressed. We present the case of a 39-year-old man with a history of liver cirrhosis who was waitlisted for liver transplantation (LT). He presented with acute, severe left shoulder pain without any recent trauma. Contrast-enhanced computed tomography revealed a left posterolateral chest wall intramuscular hematoma with active contrast extravasation originating from the left sixth intercostal artery. Interventional radiology angiography confirmed the extravasation, and embolization was successfully performed to achieve hemostasis. Despite the embolization, the patient required blood transfusions due to a gradually decreasing hemoglobin level. Five days after the initial procedure, CT angiography identified additional multifocal small arterial hemorrhages. Subsequently, the patient developed acute-on-chronic liver failure. Fortunately, a deceased donor LT was performed eight days after admission. Postoperatively, his coagulation status normalized, and no further bleeding was observed. His recovery was uneventful, with no recurrence of ICAH, and he was discharged on postoperative day 9. This case highlights an acutely decompensated cirrhotic patient who developed spontaneous ICAH due to coagulopathy, successfully treated with LT. Given the potential severity of ICAH in high-risk patients, prompt and intensive initial management is essential.