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Clinical Observations |
1 Department of Radiology, UDIAT-CD, Corporació Sanitaria Parc
Taulí, Sabadell, Barcelona, Spain.
2 Present address: Department of Radiology, Hospital Clinic, C/Villaroel 170,
Barcelona, Spain 08036.
Received June 30, 2006;
accepted after revision October 31, 2006.
Address correspondence to J. Rimola.
Abstract
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CONCLUSION. Selective transcatheter embolization is effective hemostatic treatment of patients with large, clinically relevant rectus sheath hematoma.
Keywords: abdomen • digital subtraction angiography • embolization • interventional radiology
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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], 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.
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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 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. 1A, 1B, 1C). 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.
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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. 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.
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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].
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, contrast-enhanced 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.
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 first-option 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.
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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