Pseudoaneurysm of the inferior epigastric artery. Pathogenesis, diagnosis, and treatment

Severe Intraperitoneal Hemorrhage from Pseudoaneurysm after a Large-volume Paracentesis, Successfully Treated with Microcoil Embolization

Large-volume paracentesis-induced intraperitoneal hemorrhage due to pseudoaneurysm formation is rarely reported. Here, we present a 56-year-old man with alcoholic liver cirrhosis admitted for massive ascites. Large-volume paracentesis was performed. Three days later, he became pale and complained of dyspnea and abdominal distention with hypotension. Percutaneous iliac angiography revealed contrast media leakage from a branch of the left circumflex iliac artery with pseudoaneurysm. He was successfully treated with microcoil embolization. Several days later, ascitic fluid increased and large-volume paracentesis was performed again. Two days later, his hemoglobin level suddenly decreased. An abdominal computed tomography scan showed new active bleeding at the left lower lateral peritoneal cavity, just anterior to the metalic coils. Percutaneous iliac angiography revealed contrast media extravasation from a branch of the left inferior epigastric artery with formation of collateral vessel. Percutaneous embolization was successfully performed again. After coil embolization, there were no further bleeding episodes.

Inferior epigastric artery pseudoaneurysms

INTRODUCTION

Inferior epigastric artery (IEA) pseudoaneurysms are recognised complications of abdominal wall procedures, and a variety of approaches including surgical excision and ligation, percutaneous procedures and conservative management have been employed in treating this rare complication.

METHODS

We describe a case of an IEA pseudoaneurysm diagnosed on computed tomography (CT) angiography, 14 days following a laparoscopic assisted low anterior resection, which was managed successfully with surgical excision and ligation. A review of the literature identified 32 reports of this complication since 1973 with 69% of cases occurring since 2000.

FINDINGS

The main aetiology of IEA pseudoaneurysm was abdominal surgery (n=20); 65% of cases were attributable to abdominal wound closure or laparoscopic surgery. Two-thirds (66%) of patients presented between 11 and 63 days, and all except 1 case presented with discomfort, abdominal mass or haemodynamic instability. Colour Doppler ultrasonography was the imaging modality of choice (n=18), either alone or in combination with computed tomography and/or angiography. Surgical ligation and excision and percutaneous coil embolisation formed the mainstay of attempted treatments (69%), particularly following treatment failure using an alternative technique.

CONCLUSIONS

The incidence of iatrogenic IEA pseudoaneurysms appears to be increasing. Awareness of this rare complication is of clinical importance to avoid excessive morbidity for affected individuals.

Inferior Epigastric Artery Pseudoaneurysm Following Paracentesis in a Liver Graft Recipient: A Case Report

Pseudoaneurysm happens when the artery wall is injured and the blood is contained by the surrounding tissues with eventual formation of a fibrous sac communicating with the artery. We report a case of a 39-year-old man with inferior epigastric artery (IEA) pseudoaneurysm after paracentesis. The pseudoaneurysm was diagnosed by Doppler ultrasound and treated by surgical intervention regarding the patient’s underlying comorbidity. IEA false aneurysm must be included in the differential diagnosis during investigation of the cause of any swelling after paracentesis. Cirrhotic patients may be more prone to this complication because of thin rectus muscle that could not confine the hematoma.

Hemorrhagic complications of paracentesis: a systematic review of the literature

Introduction. Large volume paracentesis is considered a safe procedure carrying minimal risk of complications and rarely causing morbidity or mortality. The most common complications of the procedure are ascitic fluid leakage, hemorrhage, infection, and perforation. The purpose of this study was to evaluate all hemorrhagic complications and their outcomes and to identify any common variables. Methods. A literature search for all reported hemorrhagic complications following paracentesis was conducted. A total of 61 patients were identified. Data of interest were extracted and analyzed. The primary outcome of the study was 30-day mortality, with secondary endpoints being achievement of hemostasis after intervention and mortality based on type of intervention. Results. 90% of the patients undergoing paracentesis had underlying cirrhosis. Three types of hemorrhagic complications were identified: abdominal wall hematomas (52%), hemoperitoneum (41%), and pseudoaneurysm (7%). Forty percent of the patients underwent either a surgical (35%) or an IR guided intervention (65%). Patients undergoing a surgical intervention had a significantly higher rate of mortality at day 30 compared to those undergoing IR intervention. Conclusion. Abdominal wall hematomas and hemoperitoneum are the most common hemorrhagic complications of paracentesis. Transcatheter coiling and embolization appear to be superior to both open and laparoscopic surgery in treatment of these complications.

A fatal complication of ultrasound-guided abdominal paracentesis

Ultrasound-guided abdominal paracentesis is a procedure that is frequently performed by radiologists for both diagnostic and therapeutic purposes. This procedure has been shown to be safe with few complications. We report the case of a patient who underwent an ultrasound-guided therapeutic abdominal paracentesis for refractory ascites complicated by intraperitoneal hemorrhage leading to death. This case suggests that ultrasound-guided paracentesis may need to become a more standardized procedure and that in the event of hemorrhage, alternative treatment options such as embolization or surgical intervention should be utilized when manual compression fails.

Inferior epigastric artery pseudoaneurysm in a kidney transplant recipient

Pseudoaneurysm of inferior epigastric artery (IEA) is a very rare clinical entity. We reported a case of combined kidney transplant and pseudoaneurysmectomy in a young HBV-HCV-HIV recipient. This case emphasizes the possibility of planning a safe and correct surgical treatment and the best timing to treat IEA pseudoaneurysm. An exhaustive preoperative radiological study in all patients candidate to kidney transplant could identify the possible aortoiliac disease both stenotic or dilatative even if it is rare and helps to define the best treatment options.

Referred pain in right arm from abdominal wall pseudoaneurysm

Pseudoaneurysm of the abdominal wall is a possible but very rare clinical entity. It is a known complication of surgery, trauma, or arterial puncture, but it is rarely spontaneous. Even though it can usually present with a wide range of local symptoms, it can cause referred pain via spinal cord, which is cross-excited with afferent sympathetic nervous system. We report a case of right arm pain which was referred from a small abdominal pseudoaneurysm like a referred pain from gall bladder. This rare entity should be considered in the differential for pain management in case that the pain does not resolve with medication or interventional pain management.

Transcatheter arterial embolisation for haemorrhage from the inferior epigastric artery after acupuncture: a case report

We report a rare case of haemorrhage from the inferior epigastric artery, which was injured after acupuncture. The haemorrhage was successfully controlled by transcatheter arterial embolisation. To the best of our knowledge, this is the first report describing the use of transcatheter arterial embolisation for inferior epigastric artery haemorrhage following acupuncture.

Transcatheter coil embolization of the inferior epigastric artery in a huge abdominal wall hematoma caused by paracentesis in a patient with liver cirrhosis

Therapeutic paracentesis is considered to be a relatively safe procedure and is performed commonly for the control of massive ascites in patients with liver cirrhosis. The commonest puncture site, approximately 4 or 5 cm medial of left anterior superior iliac spine, can be located across the route of the inferior epigastric artery, which is one of the sites of potential massive bleeding. In a 46-year-old woman with liver cirrhosis and refractory ascites, a huge abdominal wall hematoma developed after therapeutic paracentesis. The patient was not stabilized by conservative treatment, and inferior epigastric artery injury was confirmed on angiography. Angiographic coil embolization of the inferior epigastric artery was conducted, after which the bleeding ceased and the hematoma stopped growing. This case indicates that physicians performing paracentesis should be aware of the possibility of inferior epigastric artery injury and consider early angiographic coil embolization when a life-threatening abdominal wall hematoma develops.

Transcatheter arterial embolization for hemoperitoneum: unusual manifestation of iatrogenic injury to abdominal muscular arteries

PURPOSE

To evaluate the etiology of unusual manifestation of hemoperitoneum and the efficacy of transcatheter arterial embolization (TAE).

MATERIALS AND METHODS

A retrospective review of patients at three hospitals was performed. A total of 12 patients (M:F = 5:7, mean age: 48) had massive hemoperitoneum without evidence of an intramuscular hematoma on CT (n = 10) or US (n = 2) after injury to the abdominal wall. The patients underwent TAE. The etiology of iatrogenic injury to the abdominal muscular arteries and the effectiveness of embolization were evaluated.

RESULTS

Among 12 patients, 11 patients had injuries to the inferior epigastric artery (IEA) and one patient had an injury to the deep circumflex iliac artery (DCIA). The causes of the injuries were: paracentesis (n = 6), open laparotomy (n = 4), removal of a CAPD catheter (n = 1), and surgical drain (n = 1). The TAE was successfully performed in all patients. Over 10 days of follow-up after the embolization, all patients were stabilized hemodynamically.

CONCLUSION

Injury to the IEA or DCIA should be considered as a possible source of hemoperitoneum even in patients with no evidence of an intramuscular hematoma after injury to the superficial arteries of the abdominal wall. In addition, such injuries can be treated successfully using TAE.

Spontaneous inferior epigastric artery pseudoaneurysm

A case of spontaneous pseudoaneurysm of the inferior epigastric artery-diagnosed on Doppler sonography-is presented. A 19-year-old boy presented with a lump in the anterior abdominal wall. Clinically a smooth, nontender, and noncompressible mass was present above umbilicus to the right of midline. A bruit was heard over the swelling. Doppler sonography demonstrated an oval hypoechoic structure in the right rectus sheath with turbulent flow. The pseudoaneurysm could be traced to the inferior epigastric artery. Surgical excision of pseudoaneurysm was performed. Histopathology showed myxoid changes in the wall of the pseudoaneurysm with no inflammatory changes.

Coil embolization of inferior epigastric artery pseudoaneurysm after percutaneous thrombin injection failure: a case report

We report a case of a 71-year old woman with right inferior epigastric artery pseudoaneurysm following laceration by a computed tomography-guided 18G biopsy needle. The laceration was initially treated with placement of retained sutures; however the patient turned hemodynamically unstable 41 days later. Percutaneous ultrasound-guided injection of 1500 U of thrombin solution resulted in almost complete thrombosis of the pseudoaneurysm; however 24 hour control ultrasound revealed refilling of the pseudoaneurysm. Definite treatment was achieved by transcatheter coil embolization. Inferior epigastric artery pseudoaneurysm with underlying laceration may not respond to percutaneous thrombin injection, whereas coil embolization is shown to be effective.

Transcatheter embolization of a pseudoaneurysm of the inferior epigastric artery with N-butyl cyanoacrylate

A 41-year-old man presented with alcoholic liver cirrhosis with ascites and clotting abnormality. After therapeutic paracentesis, haemoperitoneum ensued without colour Doppler ultrasound or CT evidence of pseudoaneurysm or haematoma at the site of paracentesis. However, an angiogram of the inferior epigastric artery revealed an obvious small pseudoaneurysm arising from its small muscular branch, and this pseudoaneurysm was successfully treated by transcatheter embolization with N-butyl cyanoacrylate. Transcatheter embolization with N-butyl cyanoacrylate is useful treatment for pseudoaneurysms arising from the small muscular branch of the inferior epigastric artery, which cannot be catheterized superselectively close to the pseudoaneurysm.

The rare case of a symptomatic atherosclerotic aneurysm of the superior epigastric artery mimicking an acute cholecystitis

True aneurysms of the epigastric artery are rare. We report a case of a 65-year-old female who was admitted for increasing upper abdominal pain. A leukocytosis, pyrexia, breathing stop on inspiration, and a palpable mass next to the right costal arch with severe local pain were suspicious for acute cholecystitis. Surprisingly, sonography and CT scan revealed a 5 x 4 cm structure limited to the abdominal wall directly above the gallbladder, which showed an arterial flow in the duplex scan. After resection and an uneventful postoperative course, the histological findings confirmed the diagnosis of a symptomatic true atherosclerotic aneurysm.

Inferior epigastric artery false aneurysms: review of the literature and case report

A case report is presented of a IEA false aneurysm successfully embolized in a 50-year old man following a blunt abdominal injury. A literature review revealed another 15 cases. Most cases were iatrogenic (13/16) complicating abdominal wall procedures. Treatment options included open surgery (8 cases), percutaneous coil embolization (6), ultrasound guided thrombin injection or ultrasound guided compression (2). The selected treatment (surgical or non-surgical) was not affected by the size of the aneurysm (p=0.6) and was successful in all patients. However two of the non-surgically removed lesions (25%) remained unchanged in size for a long time causing discomfort. IEA false aneurysms represent an uncommon entity. Open surgery for IEA false aneurysms is easy and cheap. Endovascular approaches can lead to a long delay in resolution of the problem.

Pseudoaneurysm in children: diagnosis and interventional management

Pseudoaneurysms (PAn) are uncommon in adults and even less common in children. They are most often encountered after iatrogenic arterial injury. Presentation may be substantially delayed after the iatrogenic event, and diagnosis can be difficult, especially when the PAn occurs in an unexpected location. Treatment of PAn has evolved during the last two decades from a reliance on surgical resection to US-guided compression, coil embolization, covered stents, and stent-graft exclusion. More recently, direct percutaneous US-guided thrombin injection has been used in the treatment of PAn. We present three cases of successful PAn thrombosis by US-guided percutaneous thrombin injection in children, one of the epigastric artery and two of the femoral artery.

Inferior epigastric artery pseudoaneurysm: ultrasound diagnosis and treatment with percutaneous thrombin

A case of a pseudoaneurysm arising from the inferior epigastric artery in a patient presenting with a rectus sheath haematoma is reported. The pseudoaneurysm was successfully treated by percutaneous injection of human thrombin.

Inferior epigastric artery pseudoaneurysm: a complication of paracentesis

Two patients had inferior epigastric artery pseudoaneurysms after therapeutic paracentesis for ascites caused by portal hypertension. The first patient, a 62-year-old man, had a two-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. A left inferior epigastric artery pseudoaneurysm measuring 10 cm in diameter and 20 cm in length was diagnosed by means of Duplex ultrasound and arteriography. The patient was treated with percutaneous embolization, with successful thrombosis of the pseudoaneurysm. The second patient, a 33-year-old woman, had a six-week history of left lower quadrant pain, tenderness, and nonpulsatile mass after a paracentesis for ascites. Computerized tomography and arteriography showed a left inferior epigastric artery pseudoaneurysm, measuring 7 cm in diameter and 9 cm in length. The patient was treated with percutaneous embolization with successful thrombosis of the pseudoaneurysm. Both patients were discharged in good condition 2 days after embolization. Inferior epigastric artery pseudoaneurysm is a complication of paracentesis, and percutaneous embolization may be preferable to surgical repair in patients with chronic liver failure and portal hypertension.