{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T09:27:20Z","timestamp":1787045240193,"version":"build-2736575974"},"reference-count":18,"publisher":"MDPI AG","issue":"8","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Children"],"abstract":"<jats:p>Background\/Objectives: The minimally invasive repair of pectus excavatum (MIRPE) and its modifications represent the gold standard for surgical repair of chest wall deformities. Severe complications during or after MIRPE are rare but likely underreported in the literature. Methods\/Results: We report the case of a 14-year-old adolescent who underwent an uneventful repair of an asymmetric pectus excavatum. Six weeks postoperatively, the patient presented with shortness of breath and dizziness. Clinical examination and imaging revealed a spontaneous massive right-sided hemothorax. Following chest tube placement, an initial 600 mL of bloody pleural fluid was drained. CT angiography demonstrated no active bleeding but raised suspicion of an injury to the right-sided internal mammary artery. After a total drainage of 1600 mL, the patient remained hemodynamically stable, and the chest tube was removed within 24 h. During 32 months of follow-up, the further clinical course was uneventful, and imaging demonstrated no secondary displacement of the implants. Discussion\/Conclusions: Accidental injury to the internal mammary or intercostal vessels during pectus surgery is a rare but potentially life-threatening complication. Only a few cases of delayed hemorrhage following MIRPE have been reported, and in many a clear source of bleeding could not be identified. Pectus surgeons should be aware of this rare complication and should report such cases to improve understanding of its incidence and management.<\/jats:p>","DOI":"10.3390\/children13081093","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T16:35:08Z","timestamp":1786984508000},"page":"1093","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Another Source of Near-Fatal Bleeding\u2014Late-Onset Hemothorax Six Weeks After Uneventful Minimally Invasive Repair of Pectus Excavatum"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8426-5011","authenticated-orcid":false,"given":"Frank-Martin","family":"Haecker","sequence":"first","affiliation":[{"name":"Chest Wall Unit, Departement of Pediatric Surgery, Children\u2019s Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland"},{"name":"Faculty of Medicine, University of Basel, 4001 Basel, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kai-Uwe","family":"Kleitsch","sequence":"additional","affiliation":[{"name":"Chest Wall Unit, Departement of Pediatric Surgery, Children\u2019s Hospital of Eastern Switzerland, 9006 St. Gallen, Switzerland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Haecker, F.-M., Krebs, T.F., and Kleitsch, K.U. (2022). Current Development of Minimally Invasive Repair of Pectus Excavatum (MIRPE). Children, 9.","DOI":"10.3390\/children9040478"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"133","DOI":"10.1053\/j.sempedsurg.2018.05.004","article-title":"Modifications to the Nuss procedure for pectus excavatum: A 20-year review","volume":"27","author":"Notrica","year":"2018","journal-title":"Semin Pediatr. Surg."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"993","DOI":"10.1016\/j.athoracsur.2016.03.105","article-title":"Success of Minimally Invasive Pectus Excavatum Procedures (Modified Nuss) in Adult Patients (>\/=30 Years)","volume":"102","author":"Jaroszewski","year":"2016","journal-title":"Ann. Thorac. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"422","DOI":"10.21037\/acs.2016.08.05","article-title":"Nuss bar procedure: Past, present and future","volume":"5","author":"Nuss","year":"2016","journal-title":"Ann. Cardiothorac. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"640","DOI":"10.1016\/j.jpedsurg.2023.12.012","article-title":"Recent advancements in Pectus surgery: Crane lifting, multiple-bar approach, bridge stabilization, and Sandwich technique","volume":"59","author":"Park","year":"2024","journal-title":"J. Pediatr. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"728","DOI":"10.1016\/j.jpedsurg.2017.07.020","article-title":"Life-threatening complications and mortality of minimally invasive pectus surgery","volume":"53","author":"Hebra","year":"2018","journal-title":"J. Pediatr. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"757","DOI":"10.1089\/lap.2011.0035","article-title":"Pectus excavatum repair according to Nuss: Is it safe to place a retrosternal bar by a transpleural approach under thoracoscopic vision?","volume":"8","author":"Becmeur","year":"2011","journal-title":"J. Laparoendosc. Adv. Surg. Tech."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"540","DOI":"10.1016\/j.jpedsurg.2020.11.001","article-title":"Pectus bar Removal\u2014Why, when, where and how","volume":"56","author":"Haecker","year":"2021","journal-title":"J. Pediatr. Surg."},{"key":"ref_9","first-page":"1","article-title":"Life-threatening cardiovascular adverse events related to pectus excavatum surgery","volume":"4","author":"Loobuyck","year":"2019","journal-title":"Cardiovasc Disord. Med."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"320","DOI":"10.1055\/s-0038-1670690","article-title":"Minor and Major Complications Related to Minimally Invasive Repair of Pectus Excavatum","volume":"28","author":"Hebra","year":"2018","journal-title":"Eur. J. Pediatr. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"497","DOI":"10.1093\/icvts\/ivz142","article-title":"Sternal elevation techniques during the minimally invasive repair of pectus excavatum","volume":"29","author":"Haecker","year":"2019","journal-title":"Interact. CardioVasc Thorac. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"649","DOI":"10.1016\/j.jpedsurg.2020.07.005","article-title":"Selective use of sternal elevation before substernal dissection in more than 2000 Nuss repairs at a single institution","volume":"56","author":"Obermeyer","year":"2021","journal-title":"J. Pediatr. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"571","DOI":"10.1093\/icvts\/ivt255","article-title":"Do Nuss bars compromise the blood flow of the internal mammary arteries?","volume":"17","author":"Bostanci","year":"2013","journal-title":"Interact. Cardiovasc. Thorac. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"2518","DOI":"10.1111\/jocs.15576","article-title":"Does the Nuss procedure for treating pectus excavatum compromise the long term internal mammary artey flow? A systemic review","volume":"36","author":"Elsayed","year":"2021","journal-title":"J. Card. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"e50","DOI":"10.1055\/a-2349-9668","article-title":"Bilateral Lung Injury with Delayed Pneumothorax following Preoperative Cryoanalgesia for Pectus Excavatum Repair in a 13-year-old Boy","volume":"12","author":"Massaguer","year":"2024","journal-title":"Eur. J. Pediatr. Surg. Rep."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e5","DOI":"10.1016\/j.jpedsurg.2005.07.038","article-title":"Delayed near-fatal hemorrhage after Nuss bar displacement","volume":"40","author":"Barsness","year":"2005","journal-title":"J. Pediatr. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"394","DOI":"10.1016\/j.jpedsurg.2007.10.002","article-title":"Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum","volume":"43","author":"Adam","year":"2008","journal-title":"J. Pediatr. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e22","DOI":"10.1136\/hrt.2003.029983","article-title":"Haemopericardium causing cardiac tamponade: A late complication of pectus excavatum repair","volume":"90","author":"Barakat","year":"2004","journal-title":"Heart"}],"container-title":["Children"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/8\/1093\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,18]],"date-time":"2026-08-18T08:41:59Z","timestamp":1787042519000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2227-9067\/13\/8\/1093"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":18,"journal-issue":{"issue":"8","published-online":{"date-parts":[[2026,8]]}},"alternative-id":["children13081093"],"URL":"https:\/\/doi.org\/10.3390\/children13081093","relation":{},"ISSN":["2227-9067"],"issn-type":[{"value":"2227-9067","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]}}}