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Lukies M, Gipson J, Tan SY, Clements W. Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation. Cardiovasc Intervent Radiol 2023; 46:488-495. [PMID: 36720738 PMCID: PMC9888734 DOI: 10.1007/s00270-023-03359-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 01/03/2023] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Matthew Lukies
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ,Department of Diagnostic and Interventional Imaging, KK Women’s and Children’s Hospital, Singapore, Singapore
| | - Jacob Gipson
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Sia Yang Tan
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, 55 Commercial Road, Melbourne, VIC 3004 Australia ,Department of Surgery, Monash University, Melbourne, VIC Australia ,National Trauma Research Institute, Melbourne, VIC Australia
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Schlegel RN, Fitzgerald M, O'Reilly G, Clements W, Goh GS, Groombridge C, Johnny C, Noonan M, Ban J, Mathew J. 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. Injury 2023; 54:145-149. [PMID: 35948513 DOI: 10.1016/j.injury.2022.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 07/13/2022] [Accepted: 07/26/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- R N Schlegel
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia.
| | - M Fitzgerald
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia
| | - G O'Reilly
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - W Clements
- National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - G S Goh
- National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Department of Radiology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Surgery, Monash University Central Clinical School, Australia
| | - C Groombridge
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - C Johnny
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - M Noonan
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
| | - J Ban
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - J Mathew
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia; National Trauma Research Institute (NTRI), Melbourne, VIC, Australia; Emergency and Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
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Lu XC, Pei JG, Xie GH, Li YY, Han HM. Median arcuate ligament syndrome with retroperitoneal haemorrhage: A case report. World J Clin Cases 2022; 10:7509-7516. [PMID: 36158028 PMCID: PMC9353894 DOI: 10.12998/wjcc.v10.i21.7509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/27/2022] [Accepted: 06/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Median arcuate ligament syndrome (MALS) is relatively rare and is due to extraluminal compression of the coeliac artery by the median arcuate ligament of the diaphragm. Here, we report a case of MALS found in a patient with abdominal pain and retroperitoneal haemorrhage for education and dissemination.
CASE SUMMARY This article describes a 46-year-old female patient who was admitted to our hospital with abdominal pain as her chief complaint. She had experienced no obvious symptoms but had retroperitoneal bleeding during the course of the disease. Contrast-enhanced computed tomography (CT) and noninvasive CT angiography (CTA) led to an initial misdiagnosis of pancreaticoduodenal artery aneurysm (PDAA) causing retroperitoneal hemorrhage. After intraoperative exploration and detailed analysis of enhanced CT and CTA images, a final diagnosis of MALS was made. The cause of the haemorrhage was bleeding from a branch of the gastroduodenal artery, not rupture of a PDAA. The prognosis of MALS combined with PDAA treated by laparoscopy and interventional therapy is still acceptable. The patient was temporarily treated by gastroduodenal suture haemostasis and was referred for further treatment.
CONCLUSION MALS is very rare and usually has postprandial abdominal pain, upper abdominal murmur, and weight loss. It is diagnosed by imaging or due to complications. When a patient has abdominal bleeding or PDAA, we should consider whether the patient has celiac trunk stenosis (MALS or other etiology). When abdominal bleeding is combined with an aneurysm, we generally think of aneurysm rupture and hemorrhage first, but it may also be collateral artery rupture and hemorrhage.
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Affiliation(s)
- Xiao-Chen Lu
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Jian-Guo Pei
- Department of Imaging, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Guang-Hua Xie
- Department of Hepatobiliary Surgery, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Yong-Yu Li
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
| | - Hong-Mei Han
- Department of Gastroenterology, Affiliated Hospital of Yanbian University, Yanji 133000, Jilin Province, China
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Ricci G, Riu P, Attinà GM, Trombetta S, Ialongo P, Di Cosimo C, Mancuso R, Marini P. Endovascular treatment of ruptured pancreaticoduodenal artery aneurysm: The importance of collateral vessels. A case report. Int J Surg Case Rep 2017; 41:205-208. [PMID: 29096344 PMCID: PMC5686227 DOI: 10.1016/j.ijscr.2017.10.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Revised: 10/18/2017] [Accepted: 10/22/2017] [Indexed: 11/26/2022] Open
Abstract
Ruptured pancreaticoduodenal artery aneursym is a very rare but potentially catastrophic occurence in an emergency department and its treatment is challenging. Very few cases of emergency endovascular treatment of ruptured visceral aneursyms are reported in the literature. This case report has the intention to elucidate in pancreaticodudoenal artery aneursym the importance of collateral vessels that could feed the aneurysm sac even after embolization of the inflow and outflow of the aneurysm.
Introduction True pancreaticoduodenal artery aneurysm occurrence is infrequent, but it is a fatal disease and accounts for accounts for <2% of all visceral aneurysms. Presentation of case A 62-year-old man with a two-day history of epigastric pain was admitted at emergency department. CT showed a retroperitoneal haematoma due to a 1.5 cm posterior inferior PDA ruptured aneurysm. Angiography had been conducted immediately: both inflow and outflow of the aneurysm were embolized. Another CT scan had been conducted, which revealed residual flow inside the aneurysm sac fed by small collateral vessels. Sub-selective catheterization was repeated and definitive haemostasis was obtained by embolizing the collateral vessels. Postoperative course was uneventful. CT scan follow-up at 36 months showed no abnormalities. Discussion The incidence rate of pancreaticoduodenal artery aneurysm rupture has been estimated to be less than or equal to 65%. In the case of rupture the treatment is challenging and mortality had been reported up to 50%. Endovascular treatment showed superior results as compared to surgical treatment of aneurysms, especially in emergency settings. Conclusion The authors elucidate the importance of occlusion of inflow and outflow of the aneurysm in conjunction with the occlusion of collateral vessels to avert reperfusion of the sac. Simultaneous handling of celiac axis stenosis is still prone to controversy: no relapse of aneurysm have been reported in patients with celiac axis stenosis at long-term follow-up, simultaneous treatment should be reserved when angiography is alarming for likely hepatic or duodenal ischemia.
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Affiliation(s)
- Gabriele Ricci
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Pascale Riu
- Division of Interventional Radiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Grazia Maria Attinà
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Silvia Trombetta
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pasquale Ialongo
- Division of Radiology 2, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Carla Di Cosimo
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Rosaria Mancuso
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
| | - Pierluigi Marini
- Division of General and Emergency Surgery, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense 87, 00152 Rome, Italy
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