Life-threatening hemothorax after radiofrequency ablation for subcapsular hepatocellular carcinoma in a patient with previous rib injury

Radiofrequency ablation is a well-established treatment for early-stage hepatocellular carcinoma. Although generally safe, serious complications may occur, particularly when an intercostal approach is required. We report a rare case of life-threatening hemothorax caused by intercostal artery injury following radiofrequency ablation for a subcapsular hepatocellular carcinoma in a patient with a prior rib fracture. Approximately 1 hour after the procedure, the patient developed acute chest symptoms and hemodynamic instability. Contrast-enhanced computed tomography revealed a massive right-sided hemothorax with active extravasation from the right eighth intercostal artery. Emergent thoracoscopic surgery confirmed arterial injury adjacent to a callus-related tent-like deformity from the old rib fracture. This case highlights the potential vulnerability of intercostal vessels in patients with altered chest wall anatomy and underscores the importance of obtaining a history of prior chest trauma, reviewing available chest wall imaging when feasible, and promptly recognizing severe postablation complications.