Spontaneous retroperitoneal hematoma associated with iliac vein rupture

Spontaneous Extraperitoneal Hematoma Related to May-Thurner Syndrome

In this report, we describe a rare case: deep vein thrombosis due to May-Thurner syndrome with a spontaneous pelvic extraperitoneal hematoma. This unique challenge highlights balancing thrombosis treatment and bleeding risk. Endovascular treatment with delayed anticoagulation may be an alternative to surgery for stable retroperitoneal hematoma in May-Thurner syndrome patients.

Spontaneous iliac vein rupture and thrombosis in patients with May-Thurner syndrome: A narrative review

Spontaneous iliac vein rupture (SIVR) is extremely rare and can lead to serious complications, including death. Etiologies include inflammatory processes and hormonal and mechanical triggers, with concomitant May-Thurner syndrome (MTS) being a rare cause. Management can be challenging due to the difficult balance between reducing thrombotic burden and life-threatening hemorrhage that can result from aggressive anticoagulation. Furthermore, surgical interventions are associated with high mortality, making conservative management more desirable. We report a case of SIVR with retroperitoneal hematoma and concurrent MTS that was successfully managed using conservative measures. We further provide a narrative review of the current literature addressing the diagnosis, management, and outcome of SIVR focusing on cases with concurrent MTS.

Clinical characteristics and treatment outcomes of 68 patients with spontaneous iliac vein rupture: A case report and systematic review

Objective

Spontaneous iliac vein rupture (SIVR) is a rare but life-threatening condition with limited understanding regarding its clinical presentation, pathogenesis, diagnosis, management, and risk factors for mortality. This study aims to address this gap by providing comprehensive insights into SIVR through personal case reports and a systematic review of previous cases.

Methods

We detail a case of right SIVR caused by inappropriate positioning of the stent in the inferior vena cava and systematically reviewed previous cases. Logistic regression analysis was used to identify risk factors for mortality.

Results

Our SIVR case was successfully managed with percutaneous mechanical thrombectomy and covered stent placement. In the systematic review, 68 patients were included in the analysis with an average age of 62.01 ± 13.25 years; 86.76% were female, 91.17% had left iliac vein rupture, 55.88% presented hemodynamic instability, 76.47% had lower abdomen or iliac fossa pain, 67.64% had deep venous thrombosis (DVT), and 32.35% had May‒Thurner syndrome (MTS). The mortality rates of conservative treatment and open surgery were 2.94% and 17.65%, respectively. All 12 patients receiving endovascular treatment survived. The factors associated with a worse outcome were younger age (52.86 ± 12.96 years, OR: 1.085, 95% CI: 1.002-1.174) and SIVR patients without DVT (OR:10.111, 95% CI: 1.637-62.443).

Conclusion

This first systematic review on SIVR shows that SIVR should be highly suspected in elderly females who develop lower extremity DVT and concurrent lower abdominal pain, particularly those with a retroperitoneal mass and unstable hemodynamics. Thrombosis secondary to MTS may be the main cause of SIVR. Angiography and endovascular therapy should be prioritized for DVT patients with unexplained retroperitoneal hematoma. This study classifies SIVR into two types: iliac vein rupture alone and iliac vein rupture with DVT. These findings provide critical insights for clinicians to accurately diagnose and manage SIVR, thereby improving patient outcomes.

Successful Management of Spontaneous Iliac Vein Rupture with Double Bare Stent Technique: A Case Report and Review of Literature

Spontaneous rupture of the iliac vein is a rare cause of retroperitoneal hematoma. A misdiagnosis may delay the treatment and consequently put the patient in a life-threatening emergency. We report the case of a 73-year-old woman who presented with hemorrhagic shock from bleeding caused by a large left retroperitoneal hematoma. She was successfully treated with an endovascular approach by using a double bare stent technique. An extensive review of the literature was conducted and a total 44 articles with 50 patients were identified. Among these patients, 88.2% were women, 94.1% presented with a left-sided rupture, and the mortality rate was 13.7%. Spontaneous iliac vein rupture was more likely to occur in the left side in female patients. Conservative treatment was an option in hemodynamically stable patients. Exploratory laparotomy and surgical iliac vein repair was necessitated in most patients. Endovascular treatment including placement of covered stent and coil embolization had been widely used to treat spontaneous vein rupture since 2003. Double bare stent technique was also an effective alternative if a suitable covered stent was unavailable.

Spontaneous Iliac Vein Ruptures: A Systematic Review

INTRODUCTION

Spontaneous iliac vein rupture is a rare, but frequently lethal condition. It is important to timely recognize its clinical features and immediately start adequate treatment. We aimed to increase awareness to clinical features, specific diagnostics, and treatment strategies of spontaneous iliac vein rupture by evaluating the current literature.

METHODS

A systematic search was conducted in EMBASE, Ovid MEDLINE, Cochrane, Web of Science, and Google Scholar from inception until January 23, 2023, without any restrictions. Two reviewers independently screened for eligibility and selected studies describing a spontaneous iliac vein rupture. Patient characteristics, clinical features, diagnostics, treatment strategies, and survival outcomes were collected from included studies.

RESULTS

We included 76 cases (64 studies) from the literature, mostly presenting with left-sided spontaneous iliac vein rupture (96.1%). Patients were predominantly female (84.2%), had a mean age of 61 years, and frequently presented with a concomitant deep vein thrombosis (DVT) (84.2%). After various follow-up times, 77.6% of the patients survived, either after conservative, endovascular, or open treatment. Endovenous or hybrid procedures were frequently performed if the diagnose was made before treatment, and almost all survived. Open treatment was common if the venous rupture was missed, for some cases leading to death.

CONCLUSION

Spontaneous iliac vein rupture is rare and easily missed. The diagnose should at least be considered for middle-aged and elderly females presenting with hemorrhagic shock and concomitant left-sided DVT. There are various treatment strategies for spontaneous iliac vein rupture. An early diagnose brings options for endovenous treatment, which seems to have good survival outcomes based on previously described cases.

Mysterious Pelvic Hematoma in a Patient Who Speaks a Rare Ethiopian Dialect: A Case Report

INTRODUCTION

In reporting this case of a patient with spontaneous iliac vein rupture, we highlight the importance of maintaining a high clinical suspicion of this vascular emergency in the at-risk patient.

CASE REPORT

A 50-year-old female with an uncommon language barrier presented with left lower abdominal pain after falling. Initial imaging showed pelvic hematoma of unclear etiology. Repeat computed tomography showed expanding hematoma, and after hemodynamic decompensation, exploratory laparotomy revealed a ruptured iliac vein.

CONCLUSION

Although rare, spontaneous iliac vein rupture has a high mortality rate, even when identified early. This case serves as a reminder to consider this potentially fatal diagnosis in the at-risk group and highlights the need to remain vigilant in patients who present with unexplained shock. Additionally, this case is a reminder of our duty to provide emergency care that transcends language barriers.

Lethal hemorrhage from iliac vein rupture complicating inferior vena cava thrombosis demonstrated by post-mortem CT angiography

Spontaneous iliac vein rupture is a rare cause of retroperitoneal hemorrhage that may present to the forensic pathologist. It has been reported in association with venous thrombosis, anatomical variants such as May-Thurner syndrome, and as a complication of a long-term indwelling IVC filter. It has a female predominance and most often occurs due to rupture of the left iliac vein. This is the first report of the use of post-mortem computed tomography (PMCT) and post-mortem computed tomography angiography (PMCTA) as an adjunct to a conventional autopsy to diagnose rupture of the left iliac vein causing retroperitoneal hemorrhage arising as a complication of an inferior vena cava (IVC) thrombus. We discuss the use of PMCTA as a useful tool in the diagnosis of vascular injury and how it can be used to assist the forensic pathologist. The use of PMCT with PMCTA is an invaluable adjunct to conventional autopsy to diagnose the site of vascular rupture.

Unusual cause of retroperitoneal hemorrhage: Acute deep vein thrombosis

Retroperitoneal hemorrhage is rarely associated with acute deep vein thrombosis (DVT). We present a case of retroperitoneal hemorrhage due to disruption of the external iliac vein associated with acute DVT, which was carefully treated with an anticoagulant. A 78-year-old woman complained of acute abdominal pain. Contrast-enhanced computed tomography (CT) showed left retroperitoneal hematoma and venous thrombosis from just above the bifurcation of the inferior vena cava to the left femoral vein. She was admitted for conservative treatment without an anticoagulant. The next day, she developed pulmonary embolism (PE), but administration of an anticoagulant was not started because of the possibility of rebleeding. Forty-four hours after the onset of PE, unfractionated heparin was administrated intravenously. After initiation of anticoagulation, retroperitoneal hemorrhage did not expand and PE did not get worse. Follow-up contrast-enhanced CT suggested May-Thurner syndrome (MTS). She was uneventfully discharged home on the 35th day with oral warfarin. Retroperitoneal hemorrhage is rarely caused by acute DVT in the case of potential causes such as MTS. In such cases, the timing of initiation of anticoagulation is difficult considering the possibility of rebleeding from retroperitoneal hemorrhage. We should start anticoagulation based on both the state of hemostatic and preventive procedures for PE.

Learning objective

Retroperitoneal hemorrhage is rarely caused by acute deep vein thrombosis because of the iliac vein rupture. The subsequent occurrence of pulmonary embolism (PE) makes it more complicated and critical because treatment strategies for these two conditions are the opposite: hemostasis versus anticoagulation. The initiation of administration of an anticoagulant should be determined based on status of patients, the procedures of hemostasis, and prevention of PE.

Spontaneous Left External Iliac Vein Rupture

Spontaneous rupture of the Iliac Vein is very rare in practice. In over 90% of cases, the venous lesion is located on the left side. The exact etiology of this condition is unknown. Spontaneous injury of the iliac vein is thought to be favored by intense exercise, constipation, cough, labor, May-Thurner syndrome or pre-existing inflammatory changes in the venous wall are also implicated. We present the case of an 83-year-old woman who is brought to the Emergency Department for abdominal pain located in the left flank and in the left iliac fossa, which appeared after a medium physical exertion. After an emergency contrast-enhanced abdominal CT scan, the diagnosis of spontaneous rupture of the left external iliac vein is established. Surgery is performed with extreme urgency by retroperitoneal approach and due to the very precarious condition of the patient, venous ligation is done, wishing to perform a Palma-Dale venous bypass at a later time. Although a rare cause of spontaneous retroperitoneal hematoma, a non-traumatic rupture of the common or external iliac vein should be considered in patients in shock with massive retroperitoneal bleeding, accompanied by a high mortality rate.

Spontaneous iliac vein rupture showed by femoral contrast bolus: A case report

Introduction: Spontaneous iliac vein rupture (SIVR) is an uncommon disease with less than sixty cases reported before. This disease often requires surgical intervention. SIVR has never been imaged in the literature. This report shows how to image this diagnosis. Case report: A 71-year-old female was diagnosed with SIVR with the use of CT venography. Endovascular repair with 2 endografts and a sinus XL stent was performed. Postoperatively, the patient developed abdominal compartment syndrome and a large part of the intestines had to be removed because of ischemia. Discussion: This is the first report that shows SIVR before and after endovascular treatment with the use of CT venography by injecting a contrast bolus in the femoral vein. This information is of high interest for a broad range of clinicians to show or exclude a venous abdominal bleeding in an early stage.

Spontaneous iliac vein rupture: An uncommon, but frequently lethal, event

Spontaneous rupture of the iliac veins is a distinctly uncommon problem often misdiagnosed as an arterial rupture because of significant retroperitoneal bleeding. It often occurs with acute left-sided deep vein thrombosis and physical activities that exacerbate acute venous hypertension. A significant number of these patients will have anatomy associated with May-Thurner syndrome. Delayed imaging on computed tomography scanning might suggest a venous etiology for a retroperitoneal hematoma rather than arterial bleeding. We found 53 previously reported cases of iliac vein rupture Our report details two additional cases and the treatment options and outcomes.

Spontaneous retroperitoneal haemorrhage secondary to anticoagulation polypharmacy

Retroperitoneal haemorrhage (RH) is not uncommon in patients with provoking events like trauma. However, spontaneous RH (SRH) is a rare and life-threatening complication described as the development of bleeding into the retroperitoneal cavity, appearing spontaneously and without a preceding history of trauma or other predisposing illness. We are reporting a case of an elderly patient with recurrent deep vein thrombosis who had developed SRH secondary to concurrent use of multiple anticoagulation agents, resulting from poor healthcare follow-up and lack of sufficient medication reconciliation. This article highlights the significance of recognising risk factors for SRH, as well as management strategies through literature review.

Successful staged management of a spontaneous iliac vein rupture associated with May-Thurner syndrome: a case report

BACKGROUND

Spontaneous iliac vein ruptures have only been reported in approximately 50 cases. An accurate preoperative diagnosis is difficult even with contrast-enhanced computed tomography (CT), and the operative mortality and morbidity rates are quite high. The cause of spontaneous iliac vein ruptures and their optimal diagnosis and management remain unclear.

CASE SUMMARY

A 69-year-old woman without a history of prior trauma presented with low back pain, left lower limb swelling, and hypovolaemic shock. An initial contrast-enhanced CT revealed a large retroperitoneal haematoma without arterial extravasation. Her blood pressure dropped again under a noradrenaline administration. A second venous phase contrast-enhanced CT revealed venous extravasation in the external iliac vein with a suspected compression of the common iliac vein (May-Thurner syndrome) and deep vein thrombosis (DVT). Her haemodynamics were stabilized whilst a laparotomy was arranged. An inferior vena cava (IVC) filter was placed due to concerns about rebleeding with initiating anticoagulation therapy. Given the failed conservative management, elective endovascular treatment (EVT) was performed including percutaneous Fogarty venous thrombectomy and placement of self-expanding and covered stents. After the intervention, the lower limb swelling significantly improved under oral anticoagulation therapy, and the IVC filter was retrieved. At the 3-month follow-up, the lower limb swelling completely disappeared, and the contrast-enhanced CT demonstrated the complete disappearance of the retroperitoneal haematoma and DVT.

DISCUSSION

This case provided not only the potential value of the venous phase contrast-enhanced CT in diagnosing a spontaneous iliac vein rupture but also the potential benefit of conservative management followed by elective EVT.

Embolization for massive bleeding due to spontaneous left external iliac vein rupture: report of a successful case

BACKGROUND

Spontaneous rupture of the iliac vein has rarely been reported. Its associated hypovolemic shock-related symptoms and signs, including syncope and hypotension, have been observed in most of these cases. Successful transcatheter venous embolization for massive bleeding due to spontaneous rupture of the external iliac vein was herein reported.

CASE PRESENTATION

An 82-year-old female patient developed sudden left lower abdominal and back pain. Immediately, she lost consciousness and went into shock. CT images of her abdomen revealed a huge retroperitoneal hematoma, with leakage of contrast medium in the hematoma in the left flank. These findings suggested left external iliac vein rupture. Open surgery was considered; however, since the patient's condition may have deteriorated further due to the time needed to prepare for surgery, including general anesthesia, transcatheter venous embolization of the left iliac vein was selected. A 5.2-Fr compliant balloon catheter (nominal diameter of 10 mm) was inflated at the distal site of the external iliac vein to reduce extravasation. N-butyl-2-cyanoacrylate (NBCA) was mixed with Lipiodol at a ratio of 1:2. The left Iliac vein was filled and completely embolized with the NBCA/Lipiodol mixture (total injected volume, 5 mL) using a 1.8-Fr microcatheter. After embolization, the patient quickly. An inferior vena cava filter was placed 1 day after embolization.

CONCLUSION

Spontaneous rupture of the iliac vein is a very rare and lethal condition. Transcatheter venous embolization may control potentially life-threatening bleeding. Rapid bleeding control in a critical condition is facilitated by this minimally invasive approach.

Endovascular Repair of Spontaneous Iliac Vein Rupture

Spontaneous iliac vein rupture is a relatively rare but fatal disease. Herein, 2 cases are reported. The two middle-aged and elderly females complaining of abdominal pain were admitted without any history of trauma. The computed tomography image both showed one huge hematoma in the lower abdominal cavity and the left external iliac venous thrombus. Venogram showed ruptures of the left external iliac vein and stenosis of the left common iliac vein after percutaneous mechanical thrombectomy. Stent grafts were implanted by endovascular technique. Favorable outcomes were achieved in both cases.

A Case of May-Thurner Syndrome

May-Thurner syndrome, which is also known as iliac vein compression syndrome, is caused when an anatomical variant of the left common iliac vein with a lateral or anterior spur is compressed by the right iliac artery, resulting in thrombosis of the vein. It can present as left deep vein thrombosis which can lead to pulmonary embolism or chronic changes of venous insufficiency in the left lower limb. We report a 27-year-old female with pain abdomen, who was diagnosed to have May-Thurner syndrome.

Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas

BACKGROUND

Retroperitoneal and rectus sheath hematomas can occur spontaneously. There is a lack of research about the disease progression, optimal treatment strategies and the need for surgical intervention. Our study investigated their outcomes and management.

STUDY DESIGN

Adult patients admitted during a one-year period with non-traumatic retroperitoneal or rectus sheath hematomas were retrospectively identified. Biographical, hospital-course, and outcome data were extracted.

RESULTS

99 patients were included; median age was 73-years (IQR 61-80). 88 patients were on an anticoagulant or antiplatelet agent. Warfarin and intravenous heparin being the most commonly utilized agents (42% and 36.4%, respectively). All 99 patients were diagnosed by CT scan. 79 patients received some sort of blood product (79.8% PRBC, 43.4% FFP, 17% platelets), and 26 patients were in hemorrhagic shock. 17 patients underwent angiography and/or angioembolization. Neither anticoagulation in general nor any specific agent was associated with the need for blood product transfusion or angiography. 13 patients died but none were attributable to the hematoma.

CONCLUSION

Both hematomas are usually self-limiting and rarely require surgical intervention. A subset may require angioembolization.

Acute bilateral pulmonary embolism in a 21-year-old: is May-Thurner syndrome in our differential?

May-Thurner syndrome (MTS) is a clinical condition where the left common iliac vein gets compressed by the overlying right common iliac artery anterior to the fifth lumbar vertebra and the sacral promontory. It results in vessel wall injury and predisposition to thrombosis. We present a case of a 21-year-old African-American man with no significant past medical history who came to the emergency department with left lower limb swelling associated with shortness of breath, and was eventually diagnosed to have extensive left lower extremity deep vein thrombosis (DVT) along with acute bilateral extensive pulmonary embolism (PE) as a consequence to MTS. MTS should be considered in the differential when young patients present with unprovoked or recurrent left-sided DVT. Diagnosis of this anatomical variant is critical as it may need long-term anticoagulation and consideration of pharmaco-mechanical intervention such as mechanical thrombectomy and venoplasty with or without stenting.

Spontaneous Iliac Vein Rupture Due to May-Thurner Syndrome and Its Staged Management

We present a case of a 58-year-old otherwise healthy women who presented with left lower extremity deep venous thrombosis and was found to have pulmonary embolism along with a ruptured left internal iliac vein. Our patient was hemodynamically stable upon presentation; therefore, a staged approach was undertaken. Initially, an inferior vena cava filter was placed and the patient was slowly advanced to therapeutic anticoagulation and subsequently discharged. She then returned 2 weeks after discharge for venogram, mechanical thrombectomy, and stenting. At 1-year follow-up in clinic, she was found to have patent stents and resolution of symptoms.

A Novel Use of Aortic Stent Graft Components in Massive Venous Retroperitoneal Hematoma

Venous retroperitoneal hematoma (VRH) can present as a sudden-onset life-threatening condition. Unlike arterial hematoma, VRH is difficult to treat because of anatomic and structural considerations. Moreover, because VRH is rare and iatrogenic, there are no commercially available devices to treat this problem. We present a novel use of aortic stent graft components to treat a large, life-threatening VRH.

[Wünderlich syndrome due to a ruptured iliac vein secondary to deep venous thrombosis]

Wünderlich syndrome, or spontaneous retroperitoneal hematoma, secondary to spontaneous rupture of the iliac vein is a rare clinical entity and a medical emergency. Often the aetiology is difficult to identify and different hypotheses have been proposed, such as the presence of hormonal, inflammatory and/or mechanical factors. It may be important to assess the presence of a factor that triggered the deep vein thrombosis and secondary rupture of the iliac vein and retroperitoneal hematoma. We present a case where venous thrombosis could have caused rupture of the iliac vein and we discuss the entity in light of the current literature.

Endovascular management of a case of spontaneous retroperitoneal haematoma complicated with deep vein thrombosis and pulmonary embolism

Spontaneous retroperitoneal haematoma (SRH) can be a life-threatening emergency presenting with hypovolaemic shock. SRH has been rarely reported with May-Thurner syndrome (MTS) where it occurs due to rupture of the iliac vein or venous collaterals. We report a case of MTS that presented with deep venous thrombosis of the left lower limb complicated by bilateral pulmonary embolism (PE) and a large pelvic haematoma. The simultaneous occurrence of a large pelvic haematoma and PE offered a therapeutic challenge. Successful endovascular management of the case is discussed in this report.

Endovascular Stent Can Be the Treatment of Choice for Spontaneous Iliac Vein Rupture: A Case Report

INTRODUCTION

Spontaneous iliac vein rupture is a rare but lethal disease. Most patients suffer from shock status in the emergency department. Until now, open laparotomy combined with primary suture is the most common treatment of iliac vein rupture. However, there is high mortality and morbidity in the patients who underwent open laparotomy.

CASE PRESENTATION

A 71-year-old woman denied trauma history and sustained hypovolemic shock. The abdominal computed tomography showed one huge retroperitoneal hematoma. The emergency angiography revealed one obvious rupture point on the left external iliac vein. We repaired the lesion with endovascular stent and open laparotomy for abdominal decompression. The patient progressed well and was discharged.

CONCLUSION

Endovascular repair is an effective and safe treatment. Compared with open laparotomy and primary suture, stent leads to fewer complications and a lower mortality rate.

Biventricular ICD Placement Percutaneously Via the Iliac Vein: Case Reports and a Review

Cardiac resynchronization therapy (CRT) has been demonstrated to improve symptoms of heart failure. As a result, it has become the standard of care in selected patients, and is commonly completed with three leads placed via an upper-extremity vein. However, in rare situations, such as in the case of superior vena cava occlusion, venous access is not possible via the upper extremity. It is in such instances that alternative means must be sought. Here, two patients who received a CRT defibrillator via an iliac vein approach with a mid-abdominal generator are introduced, and a review of the techniques used is presented. Technical aspects to this approach are discussed, including iliac venous access, defibrillation electrode positioning, coronary sinus access, and lead tunneling to an abdominal generator for patient comfort. This approach should be considered when vascular access is compromised, at least until combined leadless CRT pacing and subcutaneous implantable cardioverter-defibrillator devices become available and feasible for use.

[Clinical spectrum of patients with spontaneous retroperitoneal hematomas]

INTRODUCTION AND OBJECTIVE

Spontaneous retroperitoneal hematoma (SRH) is a potentially fatal clinical entity requiring immediate recognition and intervention.

MATERIAL AND METHODS

The clinical records of 18-year-old and older patients admitted to the University Hospital Marqués de Valdecilla from 2003 to 2013 were reviewed. "Spontaneous" was defined as unrelated to trauma, invasive procedures or bleeding due to aortic aneurysm rupture.

RESULTS

Thirty-four patients with SRH (44% were on anticoagulant drugs). One-third of cases had chronic renal insufficiency. Abdominal pain was the most common symptom both in anticoagulated and non-anticoagulated patients (80% in anticoagulated and 89% in non-anticoagulated patients). About one half of the patients developed shock. A CT scan was the most commonly performed diagnostic test, followed by abdominal ultrasound. Most cases were managed conservatively (80%). More than half of the patients (66%) restarted anticoagulation therapy after the acute event with a mean delay of 19 days (range 2-90 days). None of them suffered a new bleeding episode.

CONCLUSION

Restarting the anticoagulation treatment after hematoma resolution seems to be a safe practice. There is an increasing frequency of SRH in non-anticoagulated patients.

Successful treatment of a spontaneous rupture of the left external iliac vein in a man

Spontaneous rupture of the external iliac vein associated with a May–Thurner syndrome is infrequent, particularly in men. We report a case of previously healthy 73-year-old man with a left iliac vein thrombosis, who presented a large lower left abdominal hematoma of sudden-unset. Emergent laparotomy revealed a 3-cm longitudinal tear in the left external iliac vein, which was repaired primarily. Patient's recovery was uneventful. Possible etiological factors have been identified as venous hypertension due to iliac vein thrombosis associated with Cockett syndrome, as well as inflammatory venous wall. Some other estrogenic factors could explain female preponderance of the event.

May-Thurner syndrome: a not so uncommon cause of a common condition

May-Thurner syndrome is a rarely diagnosed condition in which patients develop iliofemoral deep venous thrombosis (DVT) due to an anatomical variant in which the right common iliac artery overlies and compresses the left common iliac vein against the lumbar spine. This variant has been shown to be present in over 20% of the population; however, it is rarely considered in the differential diagnosis of DVT, particularly in patients with other risk factors. Systemic anticoagulation alone is insufficient treatment, and a more aggressive approach is necessary to prevent recurrent DVT. Herein, we present a patient with multiple risk factors for DVT. With a comprehensive diagnostic approach, she was found to have May-Thurner syndrome. Local infusion of thrombolytics as well as mechanical thrombectomy failed to resolve the thrombus. Subsequently the patient underwent successful stent placement in the area that was compressed followed by 6 months of chronic anticoagulation with warfarin. There has been no recurrence of DVT in the ensuing 18 months.

Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome

BACKGROUND

Spontaneous retroperitoneal hematoma (SRH) can be fatal, requiring immediate recognition and intervention. Current literature is limited, providing little direction in patient care.

OBJECTIVE

To describe clinical characteristics of patients with SRH during an 8-year period.

METHODS

Observational cohort study of all consecutive patients 18 years and older with SRH from January 2000 to December 2007. SRH was defined as unrelated to invasive procedures, surgery, trauma, or abdominal aortic aneurysm.

RESULTS

Of 346 patients screened, 89 were eligible. Median age was 72 years; 56.2% were male. Overall, 66.3% were anticoagulated: 41.6% on warfarin, 30.3% heparin, and 11.2% low-molecular-weight heparin; 30.3% were on antiplatelet therapy; 16.5% were taking both anticoagulant and antiplatelet medications; 15.3% were taking neither. Primary presentation to the Emergency Department was seen in 36%; 64% developed SRH during inpatient anticoagulation therapy. The most common symptom was pain: abdominal (67.5%), leg (23.8%), hip (22.5%), and back (21.3%); 10.1% were misdiagnosed upon their initial encounter. Computed tomography (CT) was performed in 98.8%, ultrasound in 22.1%, and magnetic resonance imaging in 3.5%. Of all subjects, 40.4% were managed in an intensive care unit; 24.7% underwent interventional radiology (IR) procedures and 6.7% surgical evacuation; 75.3% received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months.

CONCLUSIONS

SRH is uncommon but potentially lethal, with a non-specific presentation that can lead to misdiagnosis. One-third of the cohort was not taking anticoagulants. CT was effective at identification. Most patients received aggressive management with transfusion or IR procedures.