Percutaneous Arterial Embolization in the Management of ... - AJR

Rimola et al. Embolization of Rectus Sheath Hematoma

Inter ventional Radiolog y • Clinical Obser vations

Percutaneous Arterial Embolization in the Management of Rectus Sheath Hematoma Jordi Rimola1,2 Joan Perendreu1 Joan Falcó1 José R. Fortuño1 Anna Massuet1 Jordi Branera1 Rimola J, Perendreu J, Falcó J, Fortuño JR, Massuet A, Branera J

Keywords: abdomen, digital subtraction angiography, embolization, interventional radiology DOI:10.2214/AJR.06.0861 Received June 30, 2006; accepted after revision October 31, 2006. 1Department of Radiology, UDIAT-CD, Corporació Sanitaria

Parc Taulí, Sabadell, Barcelona, Spain. 2Present address: Department of Radiology, Hospital Clinic,

C/Villaroel 170, Barcelona, Spain 08036. Address correspondence to J. Rimola. WEB This is a Web exclusive article. AJR 2007; 188:W497–W502 0361–803X/07/1886–W497 © American Roentgen Ray Society

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OBJECTIVE. Spontaneous rectus sheath hematoma can become clinically relevant and necessitate hemostatic intervention. The aim of this study was to describe the efficacy of percutaneous arterial embolization in the management of this condition. CONCLUSION. Selective transcatheter embolization is effective hemostatic treatment of patients with large, clinically relevant rectus sheath hematoma. pontaneous nontraumatic rectus sheath hematoma usually is not a severe condition. In some patients, however, it can be a complication due to massive or persisting bleeding or be a diagnostic error in confusion with intraabdominal problems, particularly in pregnant women [1]. Deaths have been reported [2–4]. The most frequent cause of spontaneous rectus sheath hematoma is anticoagulation therapy [5, 6]. The number of patients undergoing anticoagulation therapy is increasing because of the benefits of anticoagulation in the management of a variety of conditions, such as atrial fibrillation, and in prophylaxis against deep venous thrombosis. Spontaneous abdominal rectus sheath hematoma, usually resulting from rupture of the inferior epigastric artery and in some cases the deep circumflex iliac artery, is an uncommon but well-known complication of anticoagulation therapy [7–11]. Symptoms range from slight abdominal pain to hypovolemic shock. The natural course of most rectus sheath hematomas is typically self-limited as the bleeding tamponades itself, and management usually is conservative [5, 12–17]. Nevertheless, a large hematoma can develop and cause marked hypovolemia, necessitating prompt and accurate diagnosis, reversal of anticoagulation status, fluid resuscitation or transfusion, and hemostatic treatment [16, 17]. In some patients, persistence of bleeding despite adequate reversal of anticoagulation necessitates hemostatic intervention [3, 16, 18]. Although surgical evacuation of hematoma and ligation of bleeding vessels are the hemostatic procedures most commonly indicated for severe rectus sheath hematoma [12, 18, 19],

S

percutaneous management by selective transcatheter arterial embolization may be a therapeutic option. A few anecdotal reports [20–22] have described percutaneous embolization in patients with rectus sheath hematoma. Our series, although small, included more patients than described in those reports. Materials and Methods We retrospectively reviewed the charts and radiologic images of all patients with rectus sheath hematoma consecutively registered at our institution between January 2001 and March 2005. The inclusion criteria were as follows: development of rectus sheath hematoma during anticoagulation therapy; spontaneous origin of rectus sheath hematoma without apparent trauma or penetrating injury to the abdominal wall; and rectus sheath hematoma considered clinically relevant, that is, associated with arterial hypotension necessitating fluid resuscitation or with persistent bleeding despite reversal of anticoagulation status. A total of 19 patients met all the criteria. Twelve of the 19 patients were transferred to our interventional radiology section, and these patients constitute the study group. Clinical and laboratory data on the 12 patients (four men and eight women; mean age ± SD, 69 ± 8 years) are detailed in Table 1. Ten patients presented with lower abdominal pain, abdominal wall mass, or both. Five patients were in a state of hypovolemic shock, and seven had persistent bleeding. In all patients, imaging findings confirmed the clinical suspicion of rectus sheath hematoma. In 11 cases, the diagnosis was confirmed with emergency abdominal CT (Asteion single-detector scanner, Toshiba, or Sensation 16-MDCT system, Siemens Medical Solutions). The twelfth hematoma was confirmed with abdominal sonography (Applio 3.5

W497

10

55

F

Oral anticoagulation

4.6

5

Systemic lupus

69

80/50

120/90

Yes

Yes

3, PRBCs

1, PRBCs 11

72

M


4.2

1.2

Atrial fibrillation

67

90/50

155/85

No

Yes

4, PRBCs

None F

LMWHb

2.1

2

Prophylaxis of deep venous thrombosis

72

100/55

130/75

No

Yes

2, PRBCs

None 73 12

After Embolization Patient No.

Age (y)

Sex 1

73

F

LMWHb

2.3

2.2

Atrial fibrillation

66

70/50

130/70

Yes

No

4, PRBCs

2, PRBCs 2

67

M

Oral anticoagulationc

4.9

1.54

Atrial fibrillation

90

110/60

130/70

No

Yes

3, FFP

None 3

54

F

LMWHb

1.7

1.79

Pulmonary embolism

81

90/50

110/60

No

Yes

4, PRBCs

None 4

70

F


3.7

1.2

Atrial fibrillation

65

110/50

150/75

No

Yes

2, FFP

None 5

69

F


6.1

1.89

Atrial fibrillation

50

80/35

120/75

Yes

Yes

3, PRBCs

None 6

68

F

LMWHd

2.5

1.92

Myocardial infarction

84

90/50

125/70

No

Yes

2, PRBCs

2 PRBCs 7

77

M


4.7

1.49

Atrial fibrillation

76

80/50

110/60

Yes

Yes

2, PRBCs

2, FFP 8

83

M


4.1

1.15

Atrial fibrillation

90

90/50

115/65

No

Yes

3, FFP

None 9

68

F


3.3

1.25

Atrial flutter

58

60/40

95/50

Yes

No

2, PRBCs

1, PRBCs; 1, FFP

Hemoglobin Before After Hypovolemic Abdominal Before Level (g/L)a Embolization Embolization Shock Mass and Pain Embolization Indication for Anticoagulation Anticoagulation

INR

aPTT Ratio

No. of Transfusions Clinical Presentation Blood Pressure (mm Hg)

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TABLE 1: Clinical and Laboratory Data on Patients with Large Rectus Sheath Hematoma

Rimola et al.

Note—INR = international normalized ratio, aPTT = activated partial thromboplastin time, LMWH = low-molecular-weight heparin (enoxaparin in all cases), PRBCs = packed RBCs, FFP = fresh frozen plasma. a Lowest hemoglobin concentration before embolization. b In patients 1, 3, and 12, LMWH had been started a few days or weeks before the development of rectus sheath hematoma. c Oral anticoagulation in all cases consisted of long-term administration of acenocoumarol. d Patient 6 was undergoing long-term acenocoumarol therapy, but this medication was changed to LMWH 5 days before the development of rectus sheath hematoma.

MHz probe, Toshiba). All abdominal CT images were obtained after IV injection of 120 mL of iodinated contrast material. All 12 patients were referred to our vascular and interventional radiology section for diagnostic angiography and possible intervention at the bleeding site. The indications were hemodynamic instability (n = 5) or persistence of active bleeding in a large rectus sheath hematoma (n = 7) despite initial conservative management with fresh frozen plasma, blood transfusion, and reversal of the anticoagulation profile. At referral, seven patients were hospitalized in the intensive care unit, three in the department of medicine, one in the department of cardiology, and one in the department of surgery. Digital subtraction angiography (FA Axiom Artis, Siemens Medical Solutions) was performed through the common femoral artery after administration of local anesthetic (lidocaine) on the side contralateral to the hematoma. Vascular access was obtained by placement of a 5-French sheath (Terumo Europe). Digital subtraction angiography of the pelvic vessels after selective catheterization of the external iliac artery depicted the vascular anatomic features. The choice of catheter (Cobra-II 5 French or Simmons-I 5 French, both Terumo Europe) for use with a hydrophilic 0.035-inch guidewire depended on the morphologic features of the aortic bifurcation. Supraselective catheterization of the affected artery through a 3-French coaxial microcatheter system was used to embolize the distal artery. The embolization material used to occlude the arterial bleeding sites included platinum microcoils and absorbable gelatin sponge pledgets. The choice of embolic agent for each patient was based on the anatomic location and size of the blood vessel. The absence of contrast extravasation at the bleeding site on repeated supraselective digital subtraction angiography was considered technically successful embolization (Fig. 1). The contrast injection rate was 2 mL/s. We also repeated digital subtraction angiography through the ipsilateral and contralateral external iliac arteries at a contrast injection rate of 3 mL/s to ensure there was no arterial bleeding from the collateral pathways. We did not routinely check the internal mammary artery unless there was evidence that hemorrhage had not stopped after embolization. Clinical success was considered improvement in hemodynamic values and hemoglobin concentration. Table 2 shows the main CT, sonographic, and angiographic findings. After embolization, all patients were transferred to the intensive care unit.

Results CT, sonography, or both showed large rectus sheath hematoma in all cases. Contrast-enhanced CT images disclosed active bleeding

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Embolization of Rectus Sheath Hematoma

A

B

C

Fig. 1—69-year-old woman with large rectus sheath hematoma associated with anticoagulant therapy. A, Helical CT scan after administration of contrast material shows hyperdense hematoma enlarging left side of rectus sheath. Extravasation of contrast material (arrow) within collection indicates active bleeding. B, Angiogram during selective catheterization of left inferior epigastric artery shows multiple active bleeding foci (arrowheads). C, Angiogram after embolization shows proximal embolization of inferior epigastric artery (arrowhead) with complete exclusion of bleeding segment without further contrast extravasation.

in seven patients because extravasation of high-density contrast material was seen. This finding was seen as a jet in six patients and layering on a fluid–fluid level within the hematoma in the seventh patient. Selective catheterization was possible in all 12 patients. Selective digital subtraction angiography showed active bleeding points in all patients, the site corresponding well with CT findings in the seven cases in which bleeding was detected on CT. The inferior epigastric artery was the primary source of bleeding in all 12 patients. Eight patients had only one bleeding vessel contributing to the rectus sheath hematoma, and the other four had multiple vessels involved. Secondary collateral supply from the superior epigastric artery was found in two patients. The other two patients had concomitant bleeding from the ipsilateral deep circumflex iliac artery. Embolization of the contralateral inferior epigastric artery also was performed in one patient because of hyperemia in the distal branches, although there was no evidence of active bleeding. Vascular embolization was technically successful in all cases because no active bleeding was detected on angiography immediately after the procedure. Only one percutaneous embolization procedure was necessary in all 12 patients. After the embolization procedure, patients underwent follow-up for 19 ± 18 days.

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During this period, there was no clinical evidence of rebleeding, and hemodynamic values returned to normal. Mean arterial pressure after percutaneous embolization (86 ± 13 mm Hg) was significantly higher (p = 0.001, paired Student’s t test) than that before intervention (60 ± 8 mm Hg). Four patients needed additional transfusion of packed RBCs for correction of residual anemia, and one patient needed additional transfusion of fresh frozen plasma after embolization for reversal of anticoagulation status. No patient needed surgical intervention. No complications related to embolization were found during or after the procedure. Three patients died during the hospital stay (12 hours and 2 and 8 days after the procedure). Causes of death were multiple organ failure as a result of hemodynamic complications related to rectus sheath hematoma in the two first patients and acute renal failure related to hypovolemic shock secondary to rectus sheath hematoma combined with chronic cardiac failure in the third. A fourth patient died of nosocomial pneumonia 1 month after embolization. The other eight patients had an uneventful course after embolization and were discharged from the hospital in good condition. None of these eight patients was readmitted to the hospital for problems related to rectus sheath hematoma or the vascular intervention.

Discussion Bleeding is a major complication of anticoagulation therapy. The main determinants of bleeding induced by oral anticoagulants are the intensity of the anticoagulant effect, underlying patient characteristics, and the length of therapy. A similar risk of bleeding is associated with treatment with IV or low-molecular-weight heparin [5, 10]. Hemorrhage into the rectus muscle sheath is a well-recognized but relatively uncommon complication of anticoagulant therapy. Bleeding at this location can produce painful, tender swelling mimicking an intraperitoneal mass with features of acute abdomen. The clinical history, physical examination, and abdominal sonographic or CT findings are used to establish the definitive diagnosis [14, 18, 23, 24]. The pathogenesis of anticoagulation-associated rectus sheath hematoma is unknown. A diffuse microvascular origin has been postulated, either as a result of preexisting diffuse small-vessel arteriosclerosis or heparin-induced microangiopathy. Minor or unrecognized trauma, such as coughing fits, twisting, rapid change in position, and Valsalva maneuvers, have been reported to be precipitating factors that may have a role in the development of rectus sheath hematoma [6, 7, 10, 12, 16, 25].

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Patient No.

NP

Left rectus sheath hematoma 12 × 6 × 3 cm Left inferior epigastric artery and DCIA; hyperemia right inferior epigastric artery

Coils

12 h

Death 2

Right rectus sheath hematoma 20 × 11 × 5.5 cm with intraperitoneal rupture; active bleeding

NP

Gelatin

14 d

Survival 3

Right rectus sheath hematoma 15 × 12 × 7 cm

NP

Right inferior and superior epigastric arteries Coils

13 d

Survival 4

Left rectus sheath hematoma 9 × 7 × 4 cm; active bleeding NP

Left inferior epigastric artery

Gelatin + coils

19 d

Survival 5

Right rectus sheath hematoma 14 × 13 × 7.5 cm with intraperitoneal rupture; active bleeding

Right inferior epigastric artery

Gelatin + coils

70 d

Survival 6

Right rectus sheath hematoma 15 × 14 × 6 cm

NP

Right inferior and superior epigastric arteries Gelatin + coils

30 d

Survival 7

Right rectus sheath hematoma 10 × 10 × 11 cm with intraperitoneal rupture; active bleeding

NP

Right inferior epigastric artery and DCIA

Gelatin + coils

2d

Death 8

Right rectus sheath hematoma 20 × 7.7 × 3.4 cm

NP


Gelatin + coils

16 d

Survival 9

Left rectus sheath hematoma 22 × 1 × 11 cm with intraperitoneal rupture; active bleeding

NP

Left inferior epigastric artery

Gelatin + coils

8d

Death 10

Right rectus sheath hematoma 12 × 8 × 6.5 cm with intraperitoneal rupture

NP


Gelatin

30 d

Deatha 11

Right rectus sheath hematoma 25 × 12 × 7 cm; active bleeding

NP


Gelatin + coils

14 d

Survival 12

Right rectus sheath hematoma 10 × 8.5 × 3 cm; active bleeding

NP


Coils

12 d

Survival Note—NP = not performed, DCIA = deep circumflex iliac arteries. a Death from nosocomial pneumonia, unrelated to hemorrhagic event.

Rimola et al.

1

Right rectus sheath hematoma 10 × 10 × 5 cm with intraperitoneal fluid


Outcome CT Finding Before Angiography

Sonographic Finding Before Angiography

Bleeding Site

Embolization Material

FollowUp Period W500

TABLE 2: Radiologic and Embolization Data

Rectus sheath hematoma is most commonly found in the lower abdomen. The epigastric vessels lie between the rectus abdominis muscle and the posterior leaf of the rectus sheath. Above the arcuate line, the muscle is supported in the posterior aspect by strong aponeurotic sheaths. Below the arcuate line, only the transverse fascia and the peritoneum support the rectus abdominis muscle. Thus hematomas in this region can enlarge easily, cross the midline to the opposite side, and dissect down into the prevesical space of Retzius [26, 27]. In cases of large rectus sheath hematoma, as occurred in our patients, standard imaging techniques, mainly CT and sonography, are commonly used to confirm the existence of the hematoma. Sonography can reveal patterns ranging from solid masses to cystic masses with septa. Sonographic findings are nonspecific in some cases and can mimic abdominal wall tumors and inflammatory diseases. Information about the rectus abdominis muscle itself, perimuscular tissue, and peritoneal cavity is best obtained with CT. In addition, contrastenhanced CT can provide information about signs of active bleeding. Active bleeding can be seen as a jet of contrast material within the hematoma on images obtained in the arterial phase and as layering of contrast material inside the hematoma in the delayed phase [15, 18, 24]. Digital subtraction angiography is the most useful imaging technique for identifying active bleeding. It also provides information such as the number of bleeding sites and their exact location [28–30]. In our series, digital subtraction angiography depicted active bleeding in all cases. Contrast-enhanced CT showed active bleeding in only seven cases. Conservative management is the most common therapy for rectus sheath hematoma because the lesion usually is self-limited. The coagulation profile of patients taking anticoagulation medications can be corrected by withdrawal of these medications and administration of vitamin K and fresh frozen plasma or, in patients being treated with heparin, protamine sulfate. The decision to perform a transfusion depends on the hemodynamic status and presence of comorbid conditions such as active coronary ischemia and severe anemia [12, 13, 17]. Surgical ligation of the bleeding epigastric vessels is commonly considered the only option in the management of uncontrolled bleeding, although this technique can be limited by inability to localize and ligate the bleeding vessel [12, 18, 19]. Surgery has the advantage of evacuation of very large rectus sheath hematomas.

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Embolization of Rectus Sheath Hematoma Arterial embolization is a therapeutic option for bleeding from a variety of sources, mainly in the abdomen and pelvis [14, 28, 29, 31, 32]. Embolization through a coaxial microcatheter to enable selective or supraselective distal embolization of small-vessel bleeding points at various sites has been described in the management of rectus sheath hematoma [22, 30]. In our patients, indications for angiography and further embolization were persistent bleeding and hemodynamic instability despite reversal of anticoagulation and conservative management with fluids, fresh frozen plasma, or RBC transfusion. Rectus sheath hematoma is sometimes multifocal and involves collateral pathways. Vessels collateral to the inferior epigastric artery can arise from the superior epigastric artery [26, 27]. For this reason, we performed embolization of the inferior epigastric artery supply to the rectus sheath, although embolization of the superior epigastric artery also was necessary in two patients in whom the hemorrhage did not stop. The inferior epigastric artery was embolized at sites proximal and distal to the site of active bleeding. In our patients, absorbable gelatin sponge pledgets were used to embolize distal and small vessels, and coils were favored for occlusion of proximal vessels. Our experience was similar to that reported in the literature in isolated cases of embolization of spontaneous extraperitoneal hemorrhage with marked hemodynamic alterations [14, 28, 29, 31, 32]. After embolization, the hemorrhage ceased in all of our patients, and clinical success, that is, favorable course with hospital discharge, was achieved in 75% of the patients. This 100% rate of hemostasis after embolization may suggest that this radiologic procedure should be considered firstoption therapy for clinically relevant rectus sheath hematoma that cannot be controlled by conservative management. Twenty-five percent of our patients died after embolization. Most of the deaths were related to complications of hemodynamic disturbances secondary to rectus sheath hematoma. No death was related to the radiologic procedure. This finding suggests that earlier diagnosis and intervention might have been associated with better clinical results. Therefore, in the care of patients with rectus sheath hematoma not rapidly controlled by conservative treatment, it may be appropriate to recommend early referral to an interventional radiology service. This recommendation may be especially important in the cases of patients with comorbid conditions that can lead to an adverse outcome.

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The role of surgery in the management of rectus sheath hematoma is difficult to ascertain owing to the scarcity of data in the literature. The largest series on this topic was described in 1972 by Titone et al. [2], and more recent reports have involved isolated patients [3, 4, 7]. In these studies, death occurred after surgery (for example, an 18% mortality rate in the study by Titone et al.). However, little or no information was provided on hemodynamic status and cause of death. Furthermore, in a number of patients, surgery was performed for incorrect diagnoses, mainly after confusion of rectus sheath hematoma with intraabdominal problems. Published results and our results therefore are insufficient for comparison of embolization and surgery in terms of efficacy and safety. Nevertheless, because percutaneous embolization and surgical treatment are not mutually exclusive, it can be suggested that surgery be reserved for patients with embolization failure or need for evacuation of a very large rectus sheath hematoma because of infection or marked impairment of breathing or mobility [2, 4]. Although to our knowledge our series of percutaneous embolization procedures in the management of rectus sheath hematoma is the largest thus far reported, the number of patients is small. Therefore, our suggestions should be taken cautiously. Further studies involving larger series of patients are necessary to confirm our results. In conclusion, digital subtraction angiography with arterial embolization is an effective and safe procedure for detecting and controlling the arterial bleeding sources in cases of large rectus sheath hematoma when conservative management is unsuccessful in stabilizing hemodynamic status. Although a few case reports have been published, to our knowledge our evaluation of the efficacy and safety of this procedure was conducted with the largest series of patients described thus far.

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