Management of spontaneous and iatrogenic retroperitoneal haemorrhage: conservative management, endovascular intervention or open surgery?

Clinical Outcomes and Safety of Transcatheter Arterial Embolization in Patients with Traumatic or Spontaneous Psoas and Retroperitoneal Hemorrhage

Background: We aimed to assess the effectiveness and safety of transcatheter arterial embolization (TAE) in the management of spontaneous or traumatic psoas and/or retroperitoneal hemorrhage. Methods: This single-center retrospective study enrolled 36 patients who underwent TAE for the treatment of psoas and/or retroperitoneal hemorrhage between May 2016 and February 2024. Results: The patients' mean age was 61.3 years. The spontaneous group (SG, 47.1%) showed higher rates of anticoagulation therapy use compared with the trauma group (TG, 15.8%) (p = 0.042). The TG (94.7%) demonstrated higher survival rates compared with the SG (64.7%; p = 0.023). Clinical failure was significantly associated with the liver cirrhosis (p = 0.001), prothrombin time (p = 0.004), and international normalized ratio (p = 0.007) in SG and pRBC transfusion (p = 0.008) in TG. Liver cirrhosis (OR (95% CI): 55.055 (2.439-1242.650), p = 0.012) was the only identified independent risk factor for primary clinical failure in the multivariate logistic regression analysis. Conclusions: TAE was a safe and effective treatment for psoas and/or retroperitoneal hemorrhage, regardless of the cause of bleeding. However, liver cirrhosis or the need for massive transfusion due to hemorrhage increased the risk of clinical failure and mortality, necessitating aggressive monitoring and treatment.

Spontaneous retroperitoneal haemorrhage after pulmonary endarterectomy surgery

Spontaneous retroperitoneal hematoma (SRH) is a rare complication of anticoagulation therapy. Presentation may vary from limb paresis to hypovolemic shock due to blood loss. The optimal treatment is controversial. It can be managed conservatively or surgically. We report a case of a 73-year-old man presenting with progressively worsening abdominal pain and severe pain radiating to his left lower limb twenty-five days after his pulmonary endarterectomy (PEA) surgery. He was on anticoagulation per our institutional protocol for PEA patients. Investigations revealed a large, spontaneously occurring iliopsoas hematoma. Our patient was treated conservatively, and the SRH stabilised.

Ultrasonography of acute retroperitoneum

The retroperitoneum is an important space in the human body that is often implicated in a range Epub ahead of print of acute medical conditions, some of which can be life-threatening. Ultrasonography may serve as a pivotal first-line imaging technique when assessing patients with suspected retroperitoneal abnormalities. Effective ultrasonography of the retroperitoneum requires a comprehensive grasp of its anatomy, adjacent structures, and potential pathologies. Being well-acquainted with the imaging characteristics of acute conditions can meaningfully assist in an accurate diagnosis and guide subsequent management. This review article summarizes and illustrates the acute conditions involving the retroperitoneum through the lens of ultrasound imaging.

Transcatheter arterial embolization outperforms surgery in reducing blood transfusions for postpartum vulvovaginal hematoma

BACKGROUND

Postpartum vulvovaginal hematoma is a complication of vaginal delivery that may progress to life-threatening conditions. However, the management of hematomas, including conservative therapy, surgery, and arterial embolization, is yet to be standardized.

OBJECTIVE

This study aimed to: (1) evaluate hematoma features that can be treated conservatively, and (2) determine whether surgery or transcatheter arterial embolization is superior in reducing blood transfusion.

STUDY DESIGN

This cross-sectional study included postpartum women transferred to Tohoku University Hospital, Japan, between January 2016 and September 2023 for postpartum vulvovaginal hematomas. Notably, all patients except 1 underwent contrast-enhanced computed tomography. The patients were classified into the following groups: (1) the conservative group who received neither surgery nor transcatheter arterial embolization and (2) the therapeutic intervention group who received surgery or transcatheter arterial embolization. The primary analysis included all patients. Variables for the choice of therapeutic intervention, including the shock index, hemoglobin concentration at arrival, hematoma size, and presence of extravasation, were assessed using a modified Poisson regression model. The secondary analysis included patients who received therapeutic intervention (ie, surgery or transcatheter arterial embolization). Variables for estimating the total amount of blood transfusion, including shock index, hemoglobin concentration at arrival, hematoma size, type of intervention, and presence of extravasation, were analyzed using multiple linear regression.

RESULTS

Fifty-seven cases were included in this study. Patients underwent conservative treatment (n=19), surgery (n=11), or transcatheter arterial embolization (n=27). In primary analysis, only the presence of extravasation was significantly associated with the choice of therapeutic intervention (adjusted risk ratio [95% confidence interval], 5.30 [1.53-18.37]). In the secondary analysis, the choice of surgery as a therapeutic option (unstandardized coefficient [95% confidence interval], 4.64 [1.15-8.13]; reference: transcatheter arterial embolization), lower hemoglobin concentration at arrival (-2.84 [-4.71 to -0.97]; 1 g/dL increment), and larger hematoma size (3.38 [1.23-5.53]; 100 cm3 increments) were significantly associated with increased blood transfusion.

CONCLUSION

When a vulvovaginal hematoma does not exhibit extravasation, it can be treated conservatively regardless of size. When a therapeutic intervention is selected, transcatheter arterial embolization reduces the total amount of blood transfusion compared with surgery.

[Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review]

BACKGROUND

 Retroperitoneal and rectus sheath hemorrhage (RRSH) has been described as a potentially fatal condition with mortality rates of up to 30 % due to the risk of exsanguination in combination with often nonspecific clinical symptoms. Patients at risk are > 65 years of age as well as those receiving anticoagulation/antiplatelet medicine. Classifications based on etiology consist of trauma, surgery, and/or underlying vascular pathologies, though spontaneous occurrences without precipitating factors have been reported and are expected to increase with the high number of patients undergoing anticoagulant therapy.

METHOD

 Analysis, summary, and discussion of published review articles and expert recommendations.

RESULTS

 The most commonly described symptom during clinical examination is abdominal pain. However, depending on the volume loss, clinical symptoms may include signs of abdominal compartment and hemorrhagic shock. Computed tomography angiography (CTA) with high sensitivity and specificity for the presence of active bleeding plays an important role in the detection of RH and RSH. Therapy management is based on different pillars, which include surgical and interventional measures in addition to conservative measures (volume replacement, optimization of coagulation parameters). Due to its lower invasiveness with simultaneously high technical and clinical success rates, interventional therapy in particular has gained increasing importance.

CONCLUSION

 Diagnostic and therapeutic workup of the patients by an interdisciplinary team is essential for optimal patient care. In case of transcatheter arterial embolization, a standardized approach to the detection of bleeding sites within the vascular territory of the core hematoma appears to favorably influence success and patient outcome.

KEY POINTS

  · The clinical presentation of retroperitoneal and rectus sheath hematomas can be very heterogeneous and nonspecific. Quick diagnosis is essential due to the relatively high mortality rate (approx. 12-30 %).. · The main risk factors are age > 65 years and the intake of anticoagulants, the use of which has increased 2.5 times in the last 10 years. Coagulopathies, retroperitoneal masses, and hemodialysis are less common causes.. · Computed tomography angiography (CTA) has a high sensitivity and specificity for the presence of active bleeding and has replaced diagnostic subtraction angiography (DSA).. · Treatment should be performed in a multidisciplinary setting with the inclusion of internal medicine, radiology, and surgery. The main indications for embolization are the detection of active contrast extravasation on CTA and the presence of abdominal pain. In cases without active bleeding and with stable vital parameters, conservative treatment measures can be sufficient. Surgical treatment is often reserved for treatment-refractory bleeding with symptoms of abdominal compartment.. · A systematic standardized approach to the detection of bleeding on DSA seems to have advantages regarding technical and clinical success rates..

CITATION FORMAT

· Becker LS, Dewald CLA et al. Spontaneous retroperitoneal and rectus sheath hematomas and their interventional therapy: a review. Fortschr Röntgenstr 2024; 196: 163 - 175.

Peripartum Abdominal Compartment Syndrome Following Extracorporeal Hemodynamic Support

In massive pulmonary embolism (PE), anticoagulation and thrombolytics may increase the risk of retroperitoneal bleeding following vascular cannulation for extracorporeal hemodynamic support resulting in abdominal compartment syndrome (ACS). A 27-year-old women at 33 weeks of gestation presented with acute chest pain and shortness of breath. Massive PE was diagnosed. Intravenous unfractionated heparin was started together with catheter-directed tissue plasminogen activator (tPA) infusion and mechanical thrombectomy. During the procedure, cardiac arrest developed. Cardiopulmonary resuscitation, intravenous tPA, and urgent perimortem cesarean delivery were performed. After return of spontaneous circulation, profound right ventricular failure required venoarterial membrane oxygenation. Six hours afterward, ACS secondary to retroperitoneal bleeding developed, requiring surgical intervention. ACS may result from retroperitoneal bleeding following cannulation for extracorporeal hemodynamic support.

Chinese expert consensus on the construction of the fluoroless cardiac electrophysiology laboratory and related techniques

Transcatheter radiofrequency ablation has been widely introduced for the treatment of tachyarrhythmias. The demand for catheter ablation continues to grow rapidly as the level of recommendation for catheter ablation. Traditional catheter ablation is performed under the guidance of X-rays. X-rays can help display the heart contour and catheter position, but the radiobiological effects caused by ionizing radiation and the occupational injuries worn caused by medical staff wearing heavy protective equipment cannot be ignored. Three-dimensional mapping system and intracardiac echocardiography can provide detailed anatomical and electrical information during cardiac electrophysiological study and ablation procedure, and can also greatly reduce or avoid the use of X-rays. In recent years, fluoroless catheter ablation technique has been well demonstrated for most arrhythmic diseases. Several centers have reported performing procedures in a purposefully designed fluoroless electrophysiology catheterization laboratory (EP Lab) without fixed digital subtraction angiography equipment. In view of the lack of relevant standardized configurations and operating procedures, this expert task force has written this consensus statement in combination with relevant research and experience from China and abroad, with the aim of providing guidance for hospitals (institutions) and physicians intending to build a fluoroless cardiac EP Lab, implement relevant technologies, promote the standardized construction of the fluoroless cardiac EP Lab.

Massive Retroperitoneal Hematoma After Inguinal Hernia Repair Using Prolene® Hernia System: A Case Report

Retroperitoneal hematoma is a possibly fatal condition that is frequently observed as a complication of procedures such as femoral artery catheterizations. We currently present a case of massive retroperitoneal hematoma after inguinal hernioplasty using Prolene® Hernia System mesh in a warfarin-treated patient. Especially in the case of inguinal hernioplasty in a patient receiving warfarin therapy, surgeons must pay close attention to prevent hemorrhage from the preperitoneal space, or they may opt for a different technique, such as the Lichtenstein method or laparoscopic approach.

Iliopsoas Hematoma Progression to Abscess in the Setting of Diabetic Ketoacidosis

Iliopsoas hematomas (IPH) are defined as a spontaneous or traumatic retroperitoneal collection of blood involving the iliopsoas muscle. In some cases, intramuscular hematomas can progress to abscesses and put the patient at risk for further complications. Our objectives are: to describe the etiology of intramuscular hematoma and psoas abscess, to describe the clinical signs and treatment of intramuscular hematoma and psoas abscess, and to analyze the association between uncontrolled diabetes mellitus and psoas abscess progression, which we achieve through retrospective case analysis and associated literature review on symptom constellation. We present the case of a 40-year-old male patient with a history of diabetes mellitus and alcohol abuse who presented with three days of increasing back and left lower extremity pain, confusion, auditory hallucinations, and fever found to be in diabetic ketoacidosis. Six days prior, the patient presented to the Emergency Department (ED) after being struck by a motor vehicle while ambulating found to have bruising, weakness in his lower extremities, and an L2 vertebrae fracture found on CT. During the presentation, the patient was found to have decreased muscle strength, leukocytosis with elevated lactate, and CT findings suggestive of a left psoas abscess drained by interventional radiology. Vancomycin and Cefepime were used as an empiric antibiotic regimen. The culture of the wound was then found to grow Methicillin-susceptible Staphylococcus aureus (MSSA) bacteria and antibiotics were then adjusted to Vancomycin and Cefazolin. During the patient's hospital stay, he developed two more abscesses on his bilateral psoas muscles, which were promptly percutaneously drained by interventional radiology. This case describes an uncommon progression of an Iliopsoas hematoma to a psoas abscess, likely due to his immunocompromised status secondary to his uncontrolled diabetes mellitus. Uncontrolled diabetes mellitus has been shown in various studies to be an independent risk factor of intramuscular hematoma progress to psoas abscess. We suggest that patients displaying fever, chills, flank pain, limited hip movement, and indications of uncontrolled diabetes should be approached with a high degree of suspicion for a psoas abscess.

Severe major vessel injury during peadicle screw removal: a case report

Introduction

Pedicle screw fixation (PSF) has been the standard therapy for the treatment of various spinal diseases. Although complications are identified regularly, iatrogenic vascular injury is one of the rare but life-threatening complications. In this literature, we describe the first case of inferior vena cava (IVC) injury during pedicle screw removal.

Case description

A 31-year-old man was treated by percutaneous pedicle screw fixation for an L1 compression fracture. After a year, the fracture healed well and hardware removal surgery was performed. During the procedure, the hardware on the right was removed unremarkably except for the L2 pedicle screw which slipped into the retroperitoneum because of the improper technique. The CT angiogram revealed the screw had breached the anterior cortex of the L2 vertebral body and penetrated the IVC. After multidisciplinary cooperation, the defect of IVC was reconstructed and the L2 screw was removed from the posterior approach in the end.

Result

The patient recovered well and was discharged after 3 weeks without further events. The removal of the contralateral implants was unremarkable at 7 months postoperatively. At the 3-year follow-up, the patient returned to his normal daily activity without any complaints.

Conclusion

Although pedicle screw removal is a rather simple procedure, severe complications may have occurred from this procedure. Surgeons should keep vigilant to avoid the complication noted in this case.

Preventing thrombotic events in a case of postpartum ovarian artery aneurysm rupture: clinical challenges and management approaches

Ovarian artery aneurysm is a rare asymptomatic condition usually diagnosed when it ruptures. It causes massive bleeding, often in the peripartum period of multiparous women, who are already at an increased risk for thromboembolic events. Balancing the bleeding risk against the thrombotic complications remains unexplored in such cases. A 35-year-old woman presented with hemorrhagic shock 3 days after delivering her seventh healthy child. During the emergent exploratory laparotomy, she responded well to the blood transfusion; the stable retroperitoneal hematoma indicated no need to explore it. A subsequent episode of hemodynamic instability necessitated another laparotomy, during which the hematoma was evacuated and both ovarian arteries were ligated. Shortly thereafter, the patient suffered a pulmonary embolism (PE). In multiparous patients presenting with peripartum retroperitoneal hematoma and hemorrhagic shock, exploring the hematoma and ligating the ovarian and uterine arteries may reduce the risk of PE or the need for reoperation.

Intraarterial embolizations in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH): a three-center experience

PURPOSE

To retrospectively evaluate the technical and clinical success of interventional treatments employed in three University medical centers and to develop work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH).

MATERIALS AND METHODS

Retrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018 to 12/2022, amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed.

RESULTS

Pre-interventional contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. The majority of patients underwent embolization with either n-butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21), or a combination of embolic agents (n=23). While the technical success rate was documented at 97.8%, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25 to 86% between the centers, each following different diagnostic algorithms.

CONCLUSION

Embolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. To maximize clinical success and survival rates, we propose a standardized approach to angiography as well as a low threshold for re-angiography.

Retroperitoneal and abdominal bleeding in anticoagulated COVID-19 hospitalized patients: Case series and brief literature review

BACKGROUND

Hospitalized and severely ill coronavirus disease 2019 (COVID-19) patients necessitate prophylactic or therapeutic anticoagulation to minimize the risk of thrombosis at different sites. Life-threatening bleeding complications include spontaneous iliopsoas hematoma, peritoneal bleeding, and extra-abdominal manifestations such as intracranial hemorrhage.

CASE SUMMARY

Bleeding in the abdominal wall results in less severe complications than seen with iliopsoas hematoma or peritoneal bleeding. In our case series of 9 patients, we present retroperitoneal and abdominal bleeding complications following anticoagulation in hospitalized COVID-19 patients with severe acute respiratory syndrome coronavirus 2 pneumonia. Contrast-enhanced computed tomography (CE-CT) is the best imaging modality for assessing hematoma secondary to anticoagulation and determines the therapeutic approach, whether interventional, surgical, or conservative management.

CONCLUSION

We present the role of CE-CT for rapid and precise localization of the bleeding site and prognostic counseling. Finally, we provide a brief review of the literature.

Spontaneous retroperitoneal hematoma: a case report

BACKGROUND

Spontaneous retroperitoneal hematoma is defined as bleeding in the retroperitoneal space without any triggers such as trauma, invasive procedures, and abdominal aortic aneurysm.

CASE PRESENTATION

A 48-year-old Japanese man who experienced sudden abdominal pain, severe hypotension, and decreased hemoglobin was diagnosed with spontaneous retroperitoneal hematoma. Contrast-enhanced computed tomography revealed massive left retroperitoneal hematoma; however, neither extravasation nor causative aneurysm was noted. Through conservative management with close monitoring, he was treated and discharged on the tenth hospital day without any morbidity.

CONCLUSIONS

Spontaneous retroperitoneal hematoma treatment comprises conservative management, transcatheter arterial embolization, and surgical intervention. The mortality rate of spontaneous retroperitoneal hematoma is so high that the optimal treatment timing needs to be carefully judged on the basis of detailed evaluation, and management algorithm with clear criteria.

A fatal retroperitoneal bleeding from iliolumbar artery following open reduction and internal fixation of an unstable pelvic ring injury: A case report

RATIONALE

Retroperitoneal bleedings are the result of injury to parenchymal tissue or vascular structures within retroperitoneal cavity. This may arise spontaneously, as a result of trauma or iatrogenically. Patients usually do not manifest clinically apparent signs and symptoms until a substantial amount of blood loss has occurred. Therefore, it is associated with high morbidity and mortality. Herein we present and discuss a case of fatal iatrogenic retroperitoneal bleeding following open reduction and internal fixation of an unstable pelvic ring injury.

PATIENT CONCERNS

A 66-year-old female patient presented to the Level I regional trauma center with severe pelvic pain after a pedestrian collision by a car.

DIAGNOSES

In initial radiography and computed tomography, she was diagnosed with unstable pelvic ring injury.

INTERVENTIONS

Definitive surgery for open reduction and internal fixation through the anterior approach to the sacroiliac joint and anterior intrapelvic approach was performed on the 8th day after the injury.

OUTCOMES

Patient died 3 days after the surgery due to a massive retroperitoneal bleeding from iliolumbar artery.

LESSONS

Insidious retroperitoneal bleeding from the small vessel may lead to fatal massive retroperitoneal hematoma. Therefore, active retroperitoneal bleeding should be suspected in cases of unexplained unstable hemodynamic status following orthopedic pelvic and acetabular surgery.

An alarm device for mechanical compression device displacement at femoral artery puncture sites

OBJECTIVE

To develop an alarm device for the mechanical compression device displacement (MCD), and further evaluate its effectiveness in clinical use.

MATERIAL AND METHODS

The alarm device is mainly composed of buzzer, indicator light, magnetic sheet. This is a prospective randomized and controlled study. Four hundred patients who met the inclusion/exclusion criteria were included and randomly assigned to two groups (MCD group vs alarm + MCD group). The primary outcome measures were the sensitivity and specificity of the alarm device to detect MCD displacement, time to hemostasis (TTH), time to ambulation (TTA), time to hospital discharge (TTHD), hospital costs (HC), complication rates, and patient satisfaction.

RESULTS

The sensitivity and specificity of the alarm device in detecting MCD displacement were 94.44% and 88.46%, respectively. The study group achieved shorter TTH (p = .034), shorter TTA (p = .021), lower complication rates (p = .025), and better patients' satisfaction (p < .001) compared to the control group. However, no significant difference was observed in TTHD (p = .361) and HC (p = .583).

CONCLUSION

The alarm device is highly sensitive in detecting MCD displacement, while achieving better clinical outcomes compared with artificial monitoring.

Injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lower intercostal arterial bleeding at a level-1 trauma centre: A 10-year retrospective review

OBJECTIVE

Haemorrhagic shock is a life-threatening complication of trauma, but remains a preventable cause of death. Early recognition of retroperitoneal haemorrhage (RPH) is crucial in preventing deleterious outcomes including mortality. Injury to the 9-11th intercostal arteries (i.e. arteries of the lower thoracic region) are complicit in RPH. However, the associated injuries, implications and management of such bleeds remain poorly characterised.

METHODS

We performed a retrospective review of the medical records of patients diagnosed with RPH who presented to our level-1 trauma centre (2009-2019). We described the associated injuries, management and outcomes relating to RPH of the lower thoracic region (the 9-11th intercostal arteries) from this cohort to identify potential predictors and evaluate the impact of early identification and management of non-cavitary bleeds.

RESULTS

Haemorrhage of the lower intercostal arteries (LIA) into the retroperitoneal space is associated with an increased number of posterior lower rib fractures and pneumothorax/haemothorax. A higher proportion of patients in the LIA group required massive transfusion, angioembolisation or surgical ligation when compared to other causes of RPH.

CONCLUSION

The present study highlights the importance of injury patterns, particularly posterior lower rib fractures, as predictors for early recognition and management of RPH in the prevention of deleterious patient outcomes. RPH secondary to bleeding of the LIA may require early and aggressive management of haemorrhage through massive transfusion, and angioembolisation or surgical ligation when compared to RPH because of other causes.

Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation

PURPOSE

To assess the efficacy of conservative management and embolisation in patients with spontaneous retroperitoneal haemorrhage.

METHODS

Single-centre retrospective case-control study of patients with spontaneous retroperitoneal haemorrhage treated conservatively or with embolisation. Patients aged ≥ 18 years were identified from CT imaging reports stating a diagnosis of retroperitoneal haemorrhage or similar and images reviewed for confirmation. Exclusion criteria included recent trauma, surgery, retroperitoneal vascular line insertion, or other non-spontaneous aetiology. Datapoints analysed included treatment approach (conservative or embolisation), technical success, clinical success, and mortality outcome.

RESULTS

A total of 54 patients met inclusion criteria, who were predominantly anticoagulated (74%), male (72%), older adults (mean age 69 years), with active haemorrhage on CT (52%). Overall mortality was 15%. Clinical success was more likely with conservative management (36/38) than embolisation (9/16; p < 0.01), and all-cause (1/38 vs 7/16; p < 0.01) and uncontrolled primary bleeding (1/38 vs 5/16; p < 0.01) mortality were higher with embolisation. However, embolised patients more commonly had active bleeding on CT (15/38 vs 13/16; p < 0.01), shock (5/38 vs 6/16; p < 0.04), and higher blood transfusion volumes (mean 2.2 vs 5.9 units; p < 0.01). After one-to-one propensity score matching, differences in clinical success (p = 0.04) and all-cause mortality (p = 0.01) remained; however, difference in uncontrolled primary bleeding mortality did not (p = 0.07).

CONCLUSION

Conservative management of SRH is likely to be effective in most patients, even in those who are anticoagulated and haemodynamically unstable, with variable success seen after embolisation in a more unstable patient group, supporting the notion that resuscitation and optimisation of coagulation are the most vital components of treatment.

The injury patterns, management and outcomes of retroperitoneal haemorrhage caused by lumbar arterial bleeding at a Level-1 Trauma Centre: A 10-year retrospective review

PURPOSE

Haemorrhagic shock remains a leading preventable cause of death amongst trauma patients. Failure to identify retroperitoneal haemorrhage (RPH) can lead to irreversible haemorrhagic shock. The arteries of the middle retroperitoneal region (i.e., the 1st to 4th lumbar arteries) are complicit in haemorrhage into the retroperitoneal space. However, predictive injury patterns and subsequent management implications of haemorrhage secondary to bleeding of these arteries is lacking.

MATERIALS AND METHODS

We performed a retrospective cohort study of patients diagnosed with retroperitoneal haemorrhage who presented to our Level-1 Trauma Centre (2009-2019). We described the associated injuries, management and outcomes relating to haemorrhage of lumbar arteries (L1-4) from this cohort to assess risk and management priorities in non-cavitary haemorrhage compared to RPH due to other causes.

RESULTS

Haemorrhage of the lumbar arteries (LA) is associated with a higher proportion of lumbar transverse process (TP) fractures. Bleeding from branches of these vessels is associated with lower systolic blood pressure, increased incidence of massive transfusion, higher shock index, and a higher Injury Severity Score (ISS). A higher proportion of patients in the LA group underwent angioembolisation when compared to other causes of RPH.

CONCLUSION

This study highlights the injury patterns, particularly TP fractures, in the prediction, early detection and management of haemorrhage from the lumbar arteries (L1-4). Compared to other causes of RPH, bleeding of the LA responds to early, aggressive haemorrhage control through angioembolisation. These injuries are likely best treated in Level-1 or Level-2 trauma facilities that are equipped with angioembolisation facilities or hybrid theatres to facilitate early identification and management of thoracolumbar bleeds.

Retroperitoneal hematoma in patients with COVID-19 infection during anticoagulant therapy: A case series and literature review

Due to the hypercoagulable status of patients with severe COVID-19 infection, anticoagulants are often used to prevent thrombosis. However, these agents may cause bleeding events such as retroperitoneal hematoma (RPH). We report here on six patients with COVID-19 who developed RPH during treatment. Early evidence of bleeding led to confirmatory diagnosis with imaging. Four patients recovered with supportive treatment (IV fluids and blood transfusions) and two patients recovered by angioembolization. RPH should be considered in COVID patients on anticoagulants as soon as haemoglobin or blood pressure falls. Further studies are required to provide guidance and recommendations on use of anticoagulants in critically ill patients with COVID-19.

Left testicular venous infarction secondary to large spontaneous retroperitoneal haematoma compressing left testicular vein: a case report

A man in his early 50s presented with a spontaneous large left-sided retroperitoneal haematoma (RPH), on a background of therapeutic anticoagulation with warfarin for homozygous factor V Leiden. His international normalised ratio was found to be supra-therapeutic at 9.0 on presentation. He was treated non-operatively with prompt reversal of the coagulopathy and close monitoring. On day 4 of the admission, the patient reported scrotal pain and swelling. An urgent scrotal ultrasound revealed infarction of the left testis and the patient was taken to an emergency scrotal exploration. Intraoperatively, the left testis was found to be no longer viable with the left spermatic vein and venules completely thrombosed with extensive clots, while the left testicular artery remained intact. Consequently, a left orchidectomy was performed. Therapeutic anticoagulation was recommenced on day 3 postoperatively. It is thought that the large RPH caused extrinsic compression of the left testicular vein, in addition to the patient's pre-existing factor V Leiden, which resulted in thrombosis of the blood vessel.

Spontaneous bilateral subdural hematoma in a patient with a prosthetic valve and association with plasmodium vivax malaria: A rare case report

Introduction and importance

Bilateral subdural hematoma (SDH) is a very rare condition which can occur without any apparent etiology. It's characterized by a lower frequency of focal neurological impairments, which could delay the diagnosis and postpone treatment. The reported incidence of an acute spontaneous subdural hematoma (SSH) varies between 2% and 6.7% of all acute SDH. SDH following Plasmodium vivax (P. vivax) infection are uncommon to our knowledge, only two cases of SDH linked with P. vivax infection have been documented in the literature.

Case presentation

We describe a case of a 31-year-old male with a history of mitral mechanical valve replacement on anti-coagulant presented with spontaneous bilateral subdural hematoma in the presence of malaria. The patient had a limited vague symptom, which delayed a prompt diagnosis of his disease.

Clinical discussion

Spontaneous subdural hematoma has only a few documented cases. Hypertension, infections, vascular malformations, ruptured aneurysms, thrombocytopenia caused by hematological and oncological illnesses, acquired or inherited types of coagulopathies, and drug abuse are all risk factors. Also, SDH has been documented in the literature as a consequence of Plasmodium infection. In addition to that this patient was on anti-epileptic medicines which might potentiate vitamin K antagonists. Numerous factors were thought to have contributed to this significant bleeding.

Conclusion

Patients on anticoagulants who exhibit nebulous symptoms, including a mild headache, should be subjected to a thorough history and examination. And any factor delaying an accurate diagnosis should be eliminated. This will complement the patient's plan and management.

•

Patients taking anticoagulants who experience a slight headache should be considered a risk symptom in endemic areas where malaria is frequent.

•

In anticoagulation patients, malaria can be aggravating factor for high bleeding, in Such patients should be subjected to a complete history and examination.

•

Any misinterpreting factors impacting medication pharmacodynamics and pharmacokinetics should be investigated for patients taking anticoagulants. This will be a role in the patient's approach and will pave the way for the other management strategy.

Successful Closure of External Iliac Artery Perforation with Super-selective Transcatheter Coil Embolization

We present two cases of external iliac artery perforation occurring after endovascular interventions successfully treated with direct closure using super-selective transcatheter coil embolization. Two patients, one 78-year-old man and one 78-year-old woman, underwent cardiac catheterization via the right femoral approach for coronary artery disease and atrial fibrillation. Following the procedures, both patients suffered severe acute hypotension, and contrast-enhanced computed tomography revealed a massive retroperitoneal hematoma due to perforation of the right external iliac artery. We attempted direct perforation site closure with super-selective transcatheter embolization using microcoils and achieved complete hemostasis in both cases. Our technique could be an alternative treatment option for external iliac artery perforations associated with the endovascular intervention.

Spontaneous retroperitoneal hematoma induced by vitamin K antagonist therapy: A case report

Vitamin K antagonists (VKA) are recommended in patients with mechanical heart valves. Major bleeding events remain the most life-threatening complication of this therapy and sometimes it can occur in unusual anatomic areas. Spontaneous retroperitoneal hematoma is one of the rare complications of anticoagulation therapy, which needs to be recognized early and managed promptly. Here, we report a case of a 40-year-old woman with mechanical heart valve treated with acenocoumarol, who was admitted to the emergency department with abdominal pain and whose investigations came back in favor of a massive retroperitoneal hematoma. The patient was successfully treated through conservative management resulting in a good outcome. Clinicians should be careful when prescribing VKA and should always think of retroperitoneal bleeding in the event of abdominal pain or a sudden decrease in the hemoglobin levels of anticoagulated patients.

Intraperitoneal Hematoma After Femoral Catheterization: A Case Report and Literature Review

Central venous catheters (CVCs) are often crucial in managing severely ill patients, especially those in the intensive care unit. It is estimated that over 5 million CVCs are inserted per year in the United States. The internal jugular, subclavian, or femoral veins are the most used access sites. The catheter is advanced until its tip lies within the proximal third of the superior vena cava, the right atrium, or the inferior vena cava. Unfortunately, the use of CVCs is not without its drawbacks, and multiple immediate and delayed complications have been described. Herein, we report a case of a 70-year-old female with a past medical history significant for chronic obstructive pulmonary disease, coronavirus disease 2019, pneumonia, type 2 diabetes mellitus, and hypertension, who presented to the emergency department from a skilled nursing facility with a two-day history of dyspnea. She was later diagnosed with an intraperitoneal hematoma, an uncommon complication caused by a CVC placement.

Spontaneous Retroperitoneal Hematoma Treated with Percutaneous Transarterial Embolization in COVID-19 Era: Diagnostic Findings and Procedural Outcome

(1) Background: Spontaneous retroperitoneal hematomas are a relatively common occurrence in hospitalized patients with COVID-19 related pneumonia, and endovascular treatment of trans-arterial embolization (TAE) may be a life-saving procedure after failure of medical and supportive therapy. The aim of our study was to evaluate spontaneous retroperitoneal hematomas in the COVID-19 era, focusing on their imaging features at CTA and DSA and on the safety, as well as technical and clinical success, of TAE, comparing patients affected by COVID-19 and non-COVID-19 patients. (2) Materials and Methods: We retrospectively enrolled 24 patients with spontaneous retroperitoneal hematoma who underwent TAE; of these, 10 were hospitalized for COVID-19-related pneumonia, while the other 14 were without COVID-19 infection. We evaluated the demographic data, hemoglobin values before and after the procedure, preprocedural aPTT, preprocedural INR, diagnostic and interventional imaging findings, procedural outcome (technical success) and survival periprocedural (clinical success), and major and minor complications. (3) Results: The mean age of the study population was 72.7 ± 11.2 years. CTA revealed signs of active bleeding in 20 patients (83%). DSA showed signs of active bleeding in 20 patients (83%). In four patients (17%), blind embolization was performed. The overall technical success rate was 100%. Clinical success was achieved in 17 patients (71%), while seven patients (29%) rebled within 96 h, and all of them were retreated. No major periprocedural complication was reported. The comparison between the two groups did not show statistically significant differences for gender, mean age, mean pre- and postprocedural hemoglobin, aPTT and INR, mean hematoma volume (cm3), or mean delay between CT and DSA. Active bleeding at CTA was detected in 90% of COVID-19 patients and 79% of non-COVID-19 patients (p = 0.61). At DSA, active bleeding was assessed in eight out of 10 (80%) patients in the COVID-19 group and 12 out of 14 (86%) patients in the non-COVID-19 group (p = 1). Technical success was obtained in 100% of patients in both groups. Clinical success rates were 70% for COVID-19 group and 71% for the non-COVID-19 group. We found no statistical significance between the clinical success rates of retroperitoneal spontaneous hematoma embolization in patients with or without SARS-CoV-2 infection. (4) Conclusions: We suggest that, similar to what has been reported in other studies in non-COVID-19 patients, TAE should be considered an important safe, effective, and potentially life-saving option for the management and the treatment of patients affected by COVID-19 who present with spontaneous retroperitoneal hematoma and who could not benefit from conservative treatment.

Spontaneous Iliopsoas Muscle Hemorrhage-Predictors of Associated Mortality

RATIONALE AND OBJECTIVES

Spontaneous iliopsoas muscle hemorrhage (SIPH) is a rare clinical condition associated with high mortality. In this work we aimed to retrospectively investigate the predictors of mortality in a single-institution cohort of consecutive SIPH patients.

MATERIALS AND METHODS

Consecutive patients (n = 61, 30 men, 76 years [range 51-93]) with computed tomography (CT) confirmed diagnosis of SIPH were retrospectively included between January 2010 and April 2020. CT studies were assessed for signs of active bleeding, extramuscular retroperitoneal hematoma, visible sedimentation, and hematoma volume. Medication history, laboratory parameters, comorbidities, and disease management were also recorded. All parameters were subsequently examined with regard to their impact on outcome and survival. Univariate and multivariate Cox regressions were performed to identify variables associated with time to death.

RESULTS

The overall mortality was 22.9%. A total of 77% of patients received anticoagulant therapy prior to the onset of SIPH. Active bleeding in contrast enhanced CT (CECT) was the only independent variable associated with shorter survival (p = 0.01, hazard ratio 7.05 [1.45-34.20]). Hematoma volume or extramuscular retroperitoneal hematoma had no significant influence on short-term mortality.

CONCLUSION

Only active bleeding but not hematoma volume or extra-muscular bleeding is an independent risk factor for short-term mortality in patients with SIPH.

A case report of idiopathic spontaneous peritoneal and retroperitoneal hematoma of a pregnant woman

Context

Peritoneal and retroperitoneal hematoma are usually secondary to trauma, an obstetrical pathology, an aneurysmal pathology or a tumorous pathology. A spontaneous idiopathic form remains rare, especially when it occurs to a pregnant woman, which makes the clinical and etiological diagnosis difficult, as well as the therapeutic management both the mother and the fetus.

Case report

We report the case of a spontaneous idiopathic hemoperitoneum and hemoretroperitoneum of a 26-year-old woman, pregnant (30th week of amenorrhea), presenting a hemodynamic instability and a clinical acute surgical abdomen. No secondary cause was identified during exploratory laparotomy, neither through imaging. The therapeutic management relied on hemodynamic stabilization after exploratory laparotomy.

Conclusion

Idiopathic spontaneous peritoneal and retroperitoneal hematoma -in the presence of several differential diagnoses-remain an extremely rare entity to evoke in front of an acute surgical abdomen in a pregnant woman.

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Idiopathic spontaneous hemoperitoneum and hemoretroperitoneum is a rare condition, with only few cases reported in literature.

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The occurrence of an idiopathic spontaneous hemoperitoneum and hemoretroperitoneum in pregnant women is a serious condition engaging both the patient's and the fetus's prognosis.

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Management consist of a thorough investigation in search of an etiological process before retaining the diagnosis, as well as a hemostatic procedure.

[Hypotension after catheter ablation]

A 80-year-old female patient with symptomatic atrial tachycardia develops cold sweat and hypotension in the recovery room after pulmonary vein isolation. The procedure included an anterior line and an endo- and epicardial mitral isthmus line. Echocardiography excluded a hemodynamically relevant pericardial effusion. The patient's symptoms deteriorated over time. A rare cause was found.

Psoas Major and Iliopsoas Hematomas without Anticoagulant Therapy as a Complication of Carbon Monoxide Poisoning: A Case Report

BACKGROUND Carbon monoxide poisoning is a common reason for Emergency Department admissions worldwide. The symptoms of carbon monoxide poisoning vary from headache and dizziness to severe neuropsychological and cardiac impairment. However, psoas major and iliopsoas hematomas are a rare complication of carbon monoxide poisoning. CASE REPORT A 46-year-old man with carbon monoxide poisoning, after he had been exposed to burning coal without proper ventilation, presented with right low back pain on day 7 after onset. After 2 days, ecchymosis of the right flank occurred, and his hemoglobin concentration gradually decreased. Psoas major and iliopsoas hematomas were shown on computed tomography (CT). The hematomas were successfully treated with transfusions and physical therapy. Owing to the absence of skeletal muscle compartment syndrome, surgical decompression was unnecessary. The patient did not receive anticoagulant therapy during his hospitalization. CONCLUSIONS The direct toxicity of carbon monoxide on the muscles and body weight-induced muscle compression caused skeletal muscle ischemia and necrosis in our patient. The risk of rhabdomyolysis and coagulation abnormality was elevated. Finally, intramuscular hemorrhages occurred in our patient. When a patient has back pain and decreased hemoglobin levels, clinicians should consider the possibility of psoas major and iliopsoas hematomas, and the administration of anticoagulation should be used with caution after admission.

Spontaneous retroperitoneal hematoma: a rare bleeding occurrence in COVID-19

Emerging evidence suggest that COVID-19 is associated with hypercoagulability, predisposing patients to increase risk of thromboembolism. Anticoagulation is not without its risks of bleeding and decision to initiate anticoagulation should be carefully considered with close monitoring. Spontaneous retroperitoneal hematoma is a rare complication, and there are only a few documented reports implicating anticoagulant or antiplatelet agents as a potential cause. We report a 57-year-old gentleman with COVID-19 pneumonia who developed hypotension on Day 10 of illness while on prophylactic anticoagulation. Computed tomography scan of abdomen revealed a large right retroperitoneal and psoas muscle hematoma and he underwent surgical exploration to evacuate the hematoma. His condition improved and was discharged well. Although prophylactic anticoagulation may reduce thrombotic complications in severely ill COVID-19 patients, a high index of suspicion for rare bleeding complications should be maintained if patients become hemodynamically unstable. Early diagnosis and appropriate intervention may improve outcome and prevent mortality.

Management of Spontaneous Bleeding in COVID-19 Inpatients: Is Embolization Always Needed?

BACKGROUND

critically ill patients with SARS-CoV-2 infection present a hypercoagulable condition. Anticoagulant therapy is currently recommended to reduce thrombotic risk, leading to potentially severe complications like spontaneous bleeding (SB). Percutaneous transcatheter arterial embolization (PTAE) can be life-saving in critical patients, in addition to medical therapy. We report a major COVID-19 Italian Research Hospital experience during the pandemic, with particular focus on indications and technique of embolization.

METHODS

We retrospectively included all subjects with SB and with a microbiologically confirmed SARS-CoV-2 infection, over one year of pandemic, selecting two different groups: (a) patients treated with PTAE and medical therapy; (b) patients treated only with medical therapy. Computed tomography (CT) scan findings, clinical conditions, and biological findings were collected.

RESULTS

21/1075 patients presented soft tissue SB with an incidence of 1.95%. 10/21 patients were treated with PTAE and medical therapy with a 30-days survival of 70%. Arterial blush, contrast late enhancement, and dimensions at CT scan were found discriminating for the embolization (p < 0.05).

CONCLUSIONS

PTAE is an important tool in severely ill, bleeding COVID-19 patients. The decision for PTAE of COVID-19 patients must be carefully weighted with particular attention paid to the clinical and biological condition, hematoma location and volume.

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.

The way to a man's heart is through his stomach: a case of myocardial infarction mimic and pseudo-tamponade in a polytrauma patient

Background

There exists a therapeutic conflict between haemorrhage control and prevention of thromboembolic events following polytrauma and complications are not uncommon. Such opposing therapies can result in unexpected pathophysiology and there is a real risk of misdiagnosis resulting in harm. This case presents a previously unreported complication of prevention and management of thromboembolism- STEMI (ST elevation myocardial infarction) and tamponade mimic secondary to retroperitoneal haematoma.

Case presentation

We present a 50-year-old male polytrauma patient who following treatment for presumed pulmonary embolus demonstrated classical clinical findings of myocardial infarction and pericardial tamponade secondary to a retroperitoneal haematoma. This is an event not previously reported in the literature. The risk of adverse outcome by management along the standard lines of STEMI (ST elevation myocardial infarction) was averted through awareness for alternative aetiology via a multi-team approach which resulted in percutaneous drainage of the haematoma and complete resolution of symptoms.

Conclusions

This manuscript highlights the therapeutic conflict between haemorrhage control and prevention of thromboembolic events in critically injured, the importance of high index of suspicion in this patient cohort and the benefits of multidisciplinary decision making in the complex patient through a not previously published pathophysiologic phenomenon.

Imaging spectrum of abdominal manifestations of COVID-19

Coronavirus disease 2019 (COVID-19) has posed a serious threat to global public health with its rapid spread, high fatality, and severe burden on health care providers all over the world. Although COVID-19 has been established as a respiratory tract infection, it can manifest with gastrointestinal symptoms as a consequence of direct infection by the virus or due to inflammation-mediated cytotoxicity. It has been observed that COVID-19 patients presenting with gastrointestinal symptoms tend to progress to a severe form of disease with increased morbidity and mortality, thus indicating the need for timely management. COVID-19 manifests with a wide spectrum of radiologic findings on gastrointestinal tract imaging, encompassing bowel abnormalities, hepato-biliary and pancreatic involvement, vascular occlusion, and solid organ infarction. Early recognition of these imaging features can facilitate timely treatment of COVID-19 associated gastrointestinal tract complications and may prompt the diagnosis of COVID-19 in patients with atypical disease manifestations. The aim of this article is to provide an overview of the various gastrointestinal imaging manifestations that can be encountered in patients with COVID-19, with an emphasis on early diagnosis of the disease as well as treatment related complications.

A spontaneous retroperitoneal haemorrhage resulting in abdominal compartment syndrome requiring laparotomy: A case report and proposed management algorithm

Introduction and importance

Spontaneous Retroperitoneal Haemorrhage (SRH) is a rare condition, which in its extreme state can result in Abdominal Compartment Syndrome (ACS). The aim of this case report is to provide an overview of the diagnosis and management of SRH and to present an algorithm to inform and guide clinical decision-making in the context of ACS.

Case presentation

A 74-year-old woman with multiple risk factors for SRH developed a tense abdomen in ICU post-cardiac graft study. Radiological imaging confirmed multiple bleeding points to the contralateral side of the graft access site. She underwent endovascular treatment for her condition, however, developed ACS necessitating surgical evacuation of the haematoma.

Clinical discussion

SRH is a rare condition that may be difficult to diagnose on physical exam. Medical, endovascular and surgical approaches are recognised treatments. ACS is an extreme variant of SRH and although endovascular management can specifically address the acute bleed, surgical evacuation of the haematoma is the only treatment that can effectively reduce abdominal compartment pressures.

Conclusion

SRH can cause abdominal compartment syndrome with subsequent multiorgan failure. Ultimately, as outlined in this case, surgical evacuation of the haematoma was the only treatment able to reduce abdominal compartment pressures.

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Retroperitoneal haemorrhage can cause ACS and multiorgan failure.

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Medical, endovascular and surgical approaches are recognised treatments.

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Endovascular management should be considered in patients with ongoing bleeding.

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Endovascular approaches may cease bleeding but not alleviate any mass effects.

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Surgical management is indicated if conservative or endovascular measures fail.

Large retroperitoneal hematoma following vaginal delivery: a case report

Background

Retroperitoneal hematoma after vaginal delivery is rare but can lead to maternal morbidity and mortality. Diagnosis of this condition is challenging due to its complexity and its nonspecific signs and symptoms. To date, studies and case reports regarding retroperitoneal hematoma are few, particularly in low-income countries where risk factors for this condition may be more prevalent and the prognosis poorer.

Case presentation

We report the case of a 37-year-old multiparous african (Congolese) woman who presented to the emergency department of a large referral hospital in Bukavu, Democratic Republic of the Congo (DRC), 2 weeks after a spontaneous nontraumatic vaginal delivery. She had abdominal pain that began immediately after delivery and progressed throughout the postpartum period. The patient had anemia, hypotension, tachycardia, and a left costo-lumbar arch distorting the body shape on a soft and depressed abdomen. She had visited a private clinic on days 3 and 7 postpartum; however, signs and symptoms of retroperitoneal hematoma went unrecognized. Using abdominal ultrasound, we diagnosed an extensive hematoma in the retroperitoneal space from the left iliac fossa to the left flank. Laparotomy was performed to evacuate the hematoma, and the patient recovered.

Conclusion

Retroperitoneal hematoma following a nontraumatic vaginal delivery is an unusual situation in general obstetrical practice. The knowledge of this potentially life-threatening condition in resource-limited settings enables effective diagnosis and management by ultrasound and laparotomy.

Spontaneous retroperitoneal haemorrhage post-coronary angioplasty: a case report

Background

Spontaneous retroperitoneal haemorrhage (SRH) is a rare cause of retroperitoneal haemorrhage in patients who are on anticoagulants or antiplatelet agents or both.

Case summary

We report here a rare and catastrophic complication of use of anticoagulants and antiplatelet drugs in a case undergoing coronary angioplasty. The patient had multiple coronary risk factors and developed acute myocardial infarction with pulmonary oedema and hypotension during hospitalization for treatment of lower respiratory tract infection and diabetic ketoacidosis. He underwent successful angioplasty of the culprit vessel but later developed hypotension attributable to retroperitoneal haemorrhage. No bleeding site was identified despite extensive evaluation of the aorta and iliac vessels.

Discussion

A diagnosis of SRH is considered when a patient on anticoagulants or antiplatelet drugs develops retroperitoneal haemorrhage without any specific identifiable site of bleeding in the retroperitoneum. Diffuse vasculopathy and atherosclerosis or vasculitis of the small vessels in the retroperitoneum may result in rupture of the most friable vessels and result in bleeding. Intense cough, forceful vomiting or sneezing may also be responsible for traumatizing the vessels and resulting in bleeding. Most cases recover with conservative management but some may benefit from interventional occlusion of the leak or surgical decompression in cases of abdominal compartment syndrome.

Wunderlich Syndrome: Wonder What It Is

Wunderlich syndrome (WS) refers to spontaneous renal or perinephric hemorrhage occurring in the absence of known trauma. WS is much less common than hemorrhage occurring after iatrogenic or traumatic conditions. Lenk's triad of acute onset flank pain, flank mass, and hypovolemic shock is a classic presentation of WS but seen in less than a quarter of patients. The majority of patients present only with isolated flank pain and often imaged with an unenhanced CT in the emergency department. The underlying etiology is varied with most cases attributed to neoplasms, vascular disease, cystic renal disease and anticoagulation induced; the etiology is often occult on the initial exam and further evaluation is necessary. Urologists are familiar with this unique entity but radiologists, who are more likely to be the first to diagnose WS, may not be familiar with the imaging work up and management options. In the last decade or so, there has been a conspicuous shift in the approach to WS and thus it will be worthwhile to revisit WS in detail. In our review, we will review the multimodality imaging approach to WS, describe optimal follow up and elaborate on management.

Early periaortic hematoma development after EVAR in the presence of severely calcified and modestly conical-shaped aortic neck: A potential trigger for sudden aneurysm progression toward rupture

OBJECTIVE

The aim of this report is to present a singular case of early post-endovascular aneurysm repair abdominal aortic aneurysm rupture and discuss the possible etiopathogenic mechanism promoting the sudden aneurysm progression toward rupture.Methods/Results: An 84-year-old man was submitted to endovascular aneurysm repair via second-generation endograft (Cordis-Incraft Stent-graft) during which, the left occluded common iliac artery was recanalized via balloon-expandable covered-stent-graft (Atrium-Advanta-V12). The aneurysm presented a severely calcified and modestly conical-shaped aortic-neck. The post-operative course was complicated by a broncho pneumonic infiltrate and a CT scan performed two weeks postoperatively accidentally revealed a relatively small hematoma surrounding the aortic wall. No active bleeding, endoleak, or aneurysm increase in diameter was documented. Nevertheless, the patient remained closely monitored. Three days later, he suffered from abdominal aortic aneurysm rupture. A CT scan revealed an arterial wall tear at the neck level. Intra-operatively the reanalyzed common iliac artery was intact and a good endograft-sealing was confirmed. Following this event, small lumbar arteries suture saccotomy was performed. The patient eventually died of multiorgan failure one month later.

CONCLUSIONS

The apparently "self-limiting" post-endovascular aneurysm repair CT-scan finding of periaortic hematoma may have represented a potential trigger for abdominal aortic aneurysm rupture. The possibility of developing undetected aortic lesions during endovascular aneurysm repair, specifically in the presence of potentially "at risk" anatomical conditions, should always be considered.

Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma

AIM

To evaluate the technical and clinical success of embolisation in patients with life-threatening spontaneous retroperitoneal haematoma (SRH) and to assess predictors of clinical outcome.

MATERIALS AND METHODS

Thirty patients (mean age: 71.9±9.8 years) with SRH underwent digital subtraction angiography (DSA). All patients received anticoagulant or antiplatelet medication or a combination of both at the time the SRH occurred.

RESULTS

Pre-interventional computed tomography angiography (CTA) revealed active retroperitoneal bleeding in 28 of 30 (93.3%) patients. DSA identified active haemorrhage in 22 of 30 patients (73.3%). Twenty-nine of 30 (96.7%) patients underwent embolisation. n-Butyl-2-cyanoacrylate (NBCA) was used in 15 patients (51.7%), coils were used in 10 patients (34.5%), and both embolic agents were used in four patients (13.8%). The technical success rate was 100%. Pre-interventional haemoglobin levels increased significantly after embolotherapy from 70.9±16.1 g/l to 87±11.3 g/l (p<0.001), whereas partial thromboplastin time decreased from 58±38 to 30±9 seconds (p<0.001) after embolotherapy. The need for transfusion of concentrated red cells decreased from 3±2.2 to 1±1.1 units (p<0.001) after the intervention. Clinical success was achieved in 19 of 29 (65.5%) patients. No major procedure-related complications occurred. Seven patients (24.1%) died within 30 days after the procedure.

CONCLUSION

Embolotherapy in patients with life-threatening SRH leads to a high technical success rate and is a safe therapeutic option. The clinical success rate was acceptable and influenced by pre-interventional coagulation status and by the amount of transfused concentrated red cells.

A case of iliopsoas hematoma as a complication of tetanus in a patient who did not receive anticoagulant therapy

Background

The specific clinical feature of tetanus is whole body muscle spasms. These spasms are intensely painful and sometime lead to some injuries. Vertebral fractures have been reported as a common complication of tetanus, however iliopsoas hematoma is a rare complication. We describe a case of iliopsoas hematoma in a tetanus patient who had not been treated with any anticoagulant or antiplatelet agents.

Case presentation

A 72-year-old female patient was transferred to our hospital 7 days after the onset of tetanus. An iliopsoas hematoma was identified in her right iliopsoas muscle on computed tomography. There was no extravasation; thus, the hematoma improved with conservative therapy. There were no episodes that suggested a bleeding tendency, or no factors associated with hemorrhagic conditions.

Conclusion

This is the first report of iliopsoas hematoma as a complication in a tetanus patient who did not received anticoagulation therapy. The possibility of IPH as a complication of tetanus should be considered before and during the administration of anticoagulation therapy.

Endovascular management of an unsual case of spontaneous Retroperitoneal Haemorrhage due to Fibromuscular Dysplasia

Background

Fibromuscular dysplasia (FMD) is an uncommon vascular disease that results in stenosis, dissection or aneurysmal degeneration. However, it can sometimes manifest atypically, as we show in this case.

Case presentation

A 24-year old patient with no relevant medical history with severe left hypochondrium pain. The physical examination showed blood pressure levels of 160/90 mmHg. An abdominopelvic CT evidenced left retroperitoneal haematoma associated with active bleeding and left renal artery stenosis. Given these findings, it was decided to perform an endovascular treatment. Significant stenosis was seen during the arteriography in both renal arteries, suggesting fibromuscular dysplasia and development of a collateral neovascular network responsible for the retroperitoneal haematoma. It was embolised in association with angioplasty of the left renal artery. The patient had a favourable outcome; however, high blood pressure levels persisted. A new bilateral renal angioplasty was performed, which returned blood pressure values to normal. The patient was discharged without needing antihypertensives.

Conclusions

FMD is a rare disease that can show multiple clinical presentations and need individualized treatment options. Endovascular techniques are in the first therapeutic line regarding fibromuscular dysplasia.

Percutaneous Intervention of Iatrogenic Iliac Artery Vascular Complication

The mortality of patients from a retroperitoneal hematoma remains high if treatment is delayed or inappropriate. Percutaneous endovascular repair of iatrogenic vascular complications is quickly becoming the treatment of choice. Here, we report a case of a 76-year-old female with a non-ST-elevation myocardial infarction, whose cardiac catheterization revealed a 70% distal left main coronary artery (LMCA) stenosis. She underwent successful rotational atherectomy and deployment of drug-eluting stents of the distal LMCA. Following percutaneous coronary intervention, she suffered acute profound hypotension and was found to have a retroperitoneal hematoma. Given the high cardiac risk for vascular surgery due to recent intervention and overall comorbidities, she was immediately taken to the cardiac catheterization laboratory and had a diagnostic angiogram, which revealed a right external iliac artery perforation that was treated with a covered stent. She tolerated the procedure well. This case highlights the importance of early diagnosis of retroperitoneal bleed, the prompt decision to take the patient to the cardiac catheterization laboratory, and potential use of intravascular interventions to ensure a successful outcome.