Retroperitoneal hematoma as a serious complication of endovascular aneurysmal coiling

Iatrogenic retroperitoneal hematoma as an access-site complication of neurointervention

BACKGROUND

To evaluate the clinical and imaging presentation, management, and outcome of iatrogenic retroperitoneal hematomas (IRPHs) during a series of neurointerventional procedures (NIPs).

METHODS

Six IRPH patients with complications, including five renal subcapsular hematomas (RSH) and one retroperitoneal hemorrhage, were observed among 2290 NIPs performed at our hospital from 2000 through 2020. The medical records, neurointerventional techniques, imaging data, and management of these six IRPH patients were retrospectively reviewed. All six patients received preprocedural dual antiplatelet medication and intraprocedural heparinization.

RESULTS

All patients underwent right femoral access. The guidewires were not handled under full course fluoroscopy monitoring. The most common symptom of IRPH was periprocedural flank/abdominal pain (6/6, 100%), including five on the left side (83.3%). Hypotension or shock was observed in three patients (50%). Two patients (33%) were diagnosed intraoperatively by sonogram and received on-site treatment, whereas the other four were diagnosed by postprocedural abdominal computed tomography. Active extravasation from a renal artery was diagnosed by angiogram in the five patients with RSH and was successfully treated with embolization. Multiple bleeders in the branches of the renal artery were noted in three RSH patients (60%). The patient with retroperitoneal hematoma was treated conservatively.

CONCLUSION

Unexplained periprocedural or postprocedural abdominal/flank pain, especially contralateral to the femoral access side of the NIPs, should raise the possibility of IRPH. To prevent IRPH, the authors suggest using full visual fluoroscopic monitoring for guidewire navigation during femoral catheterization of NIPs.

Retroperitoneal Hematoma as a Complication of Endovascular Embolization of Tumor Epistaxis: A Case Report

Retroperitoneal hematomas are a rare and fatal complication of endovascular embolization. We report a case of an 89-year-old woman who was referred to interventional radiology for percutaneous embolization for intractable epistaxis as a result of a left nasal cavity mucosal melanoma. After successful embolization of the left sphenopalatine artery, the patient became hypotensive and was transferred to the intensive care unit. Post-operative CT abdomen and pelvis angiogram showed a large right perinephric hematoma, which is an extremely uncommon complication of endovascular embolization for epistaxis. Practitioners should be aware of this life-threatening complication in weighing the risks and benefits of embolization versus direct surgical ligation, and they should identify and intervene promptly if a retroperitoneal hematoma should occur.

Access-Site Complications in Transfemoral Neuroendovascular Procedures: A Systematic Review of Incidence Rates and Management Strategies

BACKGROUND

The femoral artery is the most common access route for cerebral angiography and neurointerventional procedures. Complications of the transfemoral approach include groin hemorrhages and hematomas, retroperitoneal hematomas, pseudoaneurysms, arteriovenous fistulas, peripheral artery occlusions, femoral nerve injuries, and access-site infections. Incidence rates vary among different randomized and nonrandomized trials, and the literature lacks a comprehensive review of this subject.

OBJECTIVE

To gather data from 16 randomized clinical trials (RCT) and 17 nonrandomized cohort studies regarding femoral access-site complications for a review paper. We also briefly discuss management strategies for these complications based on the most recent literature.

METHODS

A PubMed indexed search for all neuroendovascular clinical trials, retrospective studies, and prospective studies that reported femoral artery access-site complications in neurointerventional procedures.

RESULTS

The overall access-site complication rate in RCTs is 5.13%, while in in non-RCTs, the rate is 2.78%. The most common complication in both groups is groin hematoma followed by access-site hemorrhage and femoral pseudoaneurysm. On the other hand, wound infection was the least common complication.

CONCLUSION

The transfemoral approach in neuroendovascular procedures holds risk for several complications. This review will allow further studies to compare access-site complications between the transfemoral approach and other alternative access sites, mainly the transradial approach, which is gaining a lot of interest nowadays.

Outcomes of Operative Management of 96 Cases with Traumatic Retroperitoneal Hematoma: A Single-Institution Experience

AIM:

To analyse our experiences in the management of traumatic retroperitoneal hematoma (RPH), highlighting the various challenges faced and to report on the outcome of these patients.

METHODS:

From May 2014 to May 2017, all patients with traumatic RPH who underwent surgical treatment were retrospectively analysed. The kind of injury, intraoperative findings, sites of hematoma, postoperative morbidity and the overall outcomes were recorded.

RESULTS:

Ninety-six patients; 53 with blunt trauma and 43 with penetrating injury, were included in this study. The centre-medial hematoma was observed in 24 (25%) patients, lateral hematoma in 46 (47.9%) patients, pelvic hematoma in 19 (19.8%) patients, and multiple zone hematomas in 7 (7.3%) patients. All cases were managed surgically. Exploration of the retroperitoneal space was done in 72 cases. Thirty-three patients died, and the overall death rate was 34.4%.

CONCLUSION:

Surgical exploration should be done in RPH caused by penetrating injury, but the need for urgent exploration in blunt injury is not so high, and it depends on the anatomical site of hematoma, concomitant organ injury and the hemodynamic status of patients.

An Evaluation of Complications in Femoral Arterial Sheaths Maintained Post-Neuroangiographic Procedures

Background: Digital subtraction angiography (DSA) is a frequently used technique in the neuro-diagnosis and treatment of cerebrovascular diseases. The routine use of femoral arterial sheaths (FAS) peri-procedurally has become standard. The maintenance of a FAS post-procedure may be warranted while awaiting the normalization of coagulopathy or to reaccess emergently. We retrospectively reviewed our stroke dataset to evaluate for complications associated with the prolonged use of FAS post-procedure.

Methods: A retrospective chart review was performed over a five-month period, including adult patients admitted to the neuroscience intensive care unit (NSICU) following a neuro-endovascular procedure at a tertiary healthcare facility. The patients' age and sex along with catheter size, duration of sheath placement, coagulation status, usage of heparinized-saline, reuse of FAS for angiographic interventions, and closure technique employed when sheath was removed were recorded. FAS were maintained and evaluated by the neurocritical care team for vascular complications according to protocols. Furthermore, patients were categorized as delayed extubation when they remained intubated post-procedure. A spontaneous breathing trial was performed once FAS could be removed following evaluation. Data were expressed with descriptive statistics.

Results: One hundred and seventy-eight neuro-endovascular procedures were reviewed. Fourteen patients in which the sheaths were left in place for a prolonged period of time after the procedure were identified with seven (50%) having complications. The most common complication was delayed extubation, which was noted in all seven of the patients with complications. Bleeding complications were noted in four (28.6%). None had thromboembolic complications. Only one FAS was reaccessed for the evaluation of vasospasm and the introduction of intra-arterial verapamil. There was a linear increase in complications with the duration the catheter remained in place after the procedure.

Conclusion: The practice of keeping FAS in for a prolonged period of time following procedures should be evaluated given the association with direct and indirect complications and minimal need to reaccess the catheter after the procedure.

The diagnosis and treatment of traumatic retroperitoneal hematoma

OBJECTIVE

To analyze our experiences in patients with traumatic retroperitoneal hematoma, and highlight the problems in diagnosis and treatment to facilitate the surgeons to make decision.

METHODOLOGY

One hundred and eight patients of traumatic retroperitoneal hematoma treated in our institution from May 2008 to Jun 2012 were reviewed retrospectively. The data including patient's age, type of injury, hospital stays, type of treatment, injured organs and mortality rate were collected.

RESULTS

In 108 patients, seventy-seven patients were male and 31 were female with a mean age of 36.5 years; eighty-seven patients sustained blunt trauma and 21 penetrating injury. Centro-medial hematoma was found in 31 patients, lateral hematoma in 36 patients, pelvic hematoma in 35 and pelvic-central hematoma in six patients. Eighty-three patients were treated surgically and 25 patients were treated conservatively. Six patients died and the mortality rate is 6.5%. Wound infection occurred in five patients, deep vein thrombosis in one patient, gastric fistula in two patients and duodenal fistula in one patient.

CONCLUSION

Traumatic retroperitoneal hematoma is life-threatening condition, early diagnosis and correct treatment is of upmost importance. Mandatory exploration should be performed in cases of retroperitoneal hematomas resulting from penetrating injury, but the selection of treatment mode in blunt injury depends on the anatomical position of hematoma, visceral injury and the hemodynamic status of the patients.

Perirenal hemorrhage secondary to interventional radiology operation against head and neck vessels: two cases report and review of the literature

Due to the hidden hemorrhage and a lack of specificity in its manifestations, perirenal hemorrhage as a complication of interventional radiology procedures is not always diagnosed in a timely manner; furthermore, the cause of hemorrhage is often misidentified or uncertain. In this report, two cases of elderly male patients who each had a perirenal hemorrhage on the same side after an interventional radiology operation against head and neck vessels by the same operator on the same day are described. This study demonstrated that the perirenal hemorrhages in both patients were related to the interventional radiology operations, providing a reminder that operating gently and always keeping the guide wire in sight during the insertion are critical for reducing the incidence rate of perirenal hemorrhage.

Spontaneous peritoneal and retroperitoneal hemorrhage, rare serious complication following carotid angioplasty with stent

Carotid artery stenting (CAS) has been accepted as a relatively safe and effective treatment modality for patients with symptomatic severe carotid stenosis. We report a rare case of 75-year-old male with spontaneous peritoneal and perirenal hemorrhage following carotid angioplasty with stent. Because this intraabdominal hemorrhage can cause delayed diagnosis and treatment due to vague symptoms and the lack of suspicion of the hemorrhage, and can induce fatal condition, physicians should be aware that the abdominal hemorrhage could occur as a rare but serious complication after CAS without puncture site problems or iatrogenic injury.