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

Successful Transcatheter Arterial Embolization of Abdominal Wall Hematoma from the Left Deep Circumflex Iliac Artery after Abdominal Paracentesis in a Patient with Liver Cirrhosis: Case Report and Literature Review

The occurrence of an abdominal wall hematoma caused by abdominal paracentesis in patients with liver cirrhosis is rare. This paper presents a case of an abdominal wall hematoma caused by abdominal paracentesis in a 67-year-old woman with liver cirrhosis with a review of the relevant literature. Two days prior, the patient underwent abdominal paracentesis for symptom relief for refractory ascites at a local clinic. Upon admission, a physical examination revealed purpuric patches with swelling and mild tenderness in the left lower quadrant of the abdominal wall. Abdominal computed tomography revealed advanced liver cirrhosis with splenomegaly, tortuous dilatation of the para-umbilical vein, a large volume of ascites, and a large acute hematoma at the left lower quadrant of the abdominal wall. An external iliac artery angiogram showed the extravasation of contrast media from the left deep circumflex iliac artery. Embolization of the target arterial branches using N-butyl-2-cyanoacrylate was then performed, and the bleeding was stopped. The final diagnosis was an abdominal wall hematoma from the left deep circumflex iliac artery after abdominal paracentesis in a patient with liver cirrhosis.

Lights and Shadows of Paracentesis: Is an Ultrasound Guided Approach Enough to Prevent Bleeding Complications?

Paracentesis is a validated procedure for diagnosing and managing ascites. Although paracentesis is a safe procedure with a 1–2% risk of complications such as bleeding, it is necessary to inform the patient about the possible adverse events. We would like to share our experience with two cases of bleeding after paracentesis. In our unit, two major hemorrhagic complications occurred in 162 procedures performed over the year 2020 (frequency of bleeding complications: 1.2%). We report two clinical cases of post-paracentesis abdominal wall hematomas. Despite a similar clinical presentation, the management approach was different: in the first case, embolization of the epigastric artery supplying the hematoma was performed. In the second case, conservative treatment was adopted. Our report aims to provide food for thought about a potentially challenging hemorrhagic complication, even with the risk of adverse outcomes.

Transarterial embolization with n-butyl cyanoacrylate for the treatment of abdominal wall hemorrhage

PURPOSE

We aimed to evaluate the effectiveness and safety of n-butyl cyanoacrylate (n-BCA) in the context of the transarterial embolization (TAE) of abdominal wall hemorrhage in an urgent scenario.

METHODS

A retrospective study of cases admitted from January 2008 to December 2017 in the emergency unit of our institution revealed 11 patients with abdominal wall hemorrhage who underwent digital subtraction angiography and TAE with n-BCA. We analyzed the sex, age, hemorrhagic risk factors, etiology, embolized vessel, technical success (no rebleeding in the embolized area), clinical success (hemoglobin level control and hemodynamic stability after the procedure), complications inherent to the procedure, and clinical outcome (mortality in 30 days).

RESULTS

The mean age was 63.4 years (52-83 years), with a predominance of the female sex (64%). The majority (91%) of patients presented hemorrhagic risk factors (chronic hepatopathy and anticoagulation drug usage). Spontaneous hemorrhage was present in 18% of patients, and the other 82% had an iatrogenic etiology. Technical success was achieved in 100% of the patients, which required the embolization of inferior epigastric artery in 10 patients (91%), circumflex iliac artery in 2 (18%), and superior epigastric artery in 1 (9%). Five patients were hemodynamically unstable, and despite achieving technical success, 4 (36%) died in less than 30 days due to decompensation of their clinical comorbidities caused by the acute phase. There were no complications inherent to the procedures.

CONCLUSION

The present study concludes that TAE with n-BCA is a safe and effective treatment for abdominal wall hemorrhage in an urgent scenario, with high rates of technical and clinical success.

Superselective transcatheter arterial embolization of iatrogenic inferior epigastric artery after paracentesis: Unusual manifestation of hemoperitoneum

•

Hemoperitoneum is a rare complication in paracentesis.

•

Paracentesis should be guided by ultrasound.

•

Embolization of the lower epigastric artery is feasible and safe.

Introduction

Paracentesis is a safe procedure and can be performed as a therapy or diagnosis in cancer patients, liver cirrhosis, heart or liver failure.

Presentation of case

59-year-old man with alcoholic liver cirrhosis with ascites and coagulation abnormalities. After diagnostic paracentesis he presented hemodynamic instability with signs of hypovolemic shock and hemoperitoneum. Computed angiotomography with signs of active bleeding and pseudoaneurysm at the site of paracentesis.

Discussion

The interventional radiology unit was referred and submitted to arteriography, which demonstrated active bleeding from the left lower epigastric artery. It was successfully treated by transcatheter embolization with 100−300 μm PVA particles.

Conclusion

Transcatheter embolization with PVA particles is a fast, safe, minimally invasive, reliable method with a high technical success rate for the treatment of active bleeding resulting from injury to the lower epigastric artery.

Ultrasound-guided thrombin injection for treatment of superficial traumatic pseudoaneurysms and associated expanding hematomas: experience in five patients

Background

Angiography allows for excellent characterization and treatment of traumatic pseudoaneurysms. However, ultrasound-guided thrombin injection for pseudoaneurysm thrombosis allows for radiation-free treatment of superficial pseudoaneurysms and superficial expanding hematomas.

Methods

A retrospective review of 5 patient cases treated under this paradigm was performed following institutional review board approval. Outcomes following intervention were recorded and compared amongst the patient cohort.

Results

Ultrasound-guided closure of traumatic pseudoaneurysms allowed for reduced procedural times and procedural invasiveness.

Conclusions

As demonstrated by the following cases, ultrasound guided thrombin injection is a good method of primary treatment for superficial pseudoaneurysms, or as an alternative treatment in cases where transcatheter embolization fails.

Successful coil embolization of circumflex iliac artery pseudoaneurysms following paracentesis

Abdominal paracentesis complicated by perforation of a penetrating arterial branch is an extremely rare complication. We report 2 patients who presented with abdominal wall pseudoaneurysms following abdominal paracentesis for the evaluation and treatment of their hepatic dysfunction. We subsequently review the treatment modalities and interventions performed in each case.

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.