Posterior intercostal artery tortuosity and collateral branch points: a cadaveric study

Publications report observing tortuosity in the posterior intercostal arteries of elderly patients. Studies also describe the size and course of the collateral intercostal arteries. This information is clinically significant when performing thoracentesis and video-assisted thorascopic surgery. To the best of our knowledge, no studies have examined arterial tortuosity or described collateral artery origins relative to bony landmarks. The purpose of this study was to define a safe surgical zone for thoracic access using palpable external bony landmarks. A total of 348 intercostal spaces (3rd-8th) of 29 male and female embalmed cadavers were dissected from the vertebral body to the mid-axillary line to observe the posterior intercostal artery and its collateral branch. The origins of the collateral intercostal arteries relative to the midline of thoracic spinous processes were measured. Mild to moderate tortuosity (arterial curves covering 25- -50% of the intercostal space) was observed in at least one posterior intercostal artery in the majority of cadavers. The origins of the collateral intercostal arteries were variable relative to the midline. Additional collateral intercostal arteries distal to the primary collateral branch were observed, most commonly in the 5th intercostal space, which is used in video-assisted thorascopic surgery and thoracentesis. Tortuosity is common in the 3rd to the 8th posterior intercostal arteries, especially in individuals over the age of 60 years. Given the findings of this study, we recommend that any procedure involving placement of a surgical instrument into these intercostal spaces does so at least 120 mm lateral to the midline of the spinous processes. We also recommend pre-procedure ultrasound (intercostal scan) of the posterior and collateral intercostal arteries when performing non-emergent thoracentesis and video-assisted thorascopic surgery, particularly in patients over 60 years of age.