2418 Abdominal Wall Hematoma Due to Dissection of the Deep Circumflex Iliac Artery: A Rare Complication of Ultrasound Guided Paracentesis

Abstract

INTRODUCTION: Aspiration of ascitic fluid via paracentesis is performed for both diagnostic and therapeutic purposes, using a landmark based approach (LBA) or the safer ultrasound guided method. Complication rate for paracentesis is less than 2% and LBA carries a nearly four-fold increase as opposed to the sonographic approach. Complications include bowel perforation, infection/peritonitis, and bleeding. It is well documented that hemorrhagic complications due to accidental transection of the inferior epigastric artery (IEA) or its branches can lead to abdominal wall hematomas, pseudoaneurysms and hemoperitoneum. We report a rare complicated case of accidental iatrogenic laceration of the deep circumflex iliac artery (DCIA) due to altered anatomy in a patient with ascites. CASE DESCRIPTION/METHODS: 50-year-old female with decompensated alcoholic liver cirrhosis, coagulopathy and thrombocytopenia (Child-Pugh class C and MELD 29) presented with abdominal distention due to worsening abdominal ascites. Vitals were normal. Physical exam demonstrated fluid shift and mental status was intact. Laboratory findings reported thrombocytopenia of 118 K/uL, INR of 1.8 and Albumin of 2.2 g/dL. Ultrasound revealed extensive abdomino-pelvic ascites with the largest pocket of 19 cm in diameter in the right lower quadrant. She underwent sonographic diagnostic paracentesis of the right lower quadrant with drainage of 60 cc of serous fluid. Spontaneous bacterial peritonitis was ruled out. The next day, she endorsed sharp pain near the incision site and her hemoglobin dropped by 2 units. Patient was hypotensive and underwent CT abdominal angiography. This revealed a large right anterior abdominal wall hematoma measuring 24 cm × 9 cm with active arterial extravasation from the ascending branch of the right DCIA. She underwent angiographic transcatheter coil embolization of the DCIA. She remained stable and a repeat CT angiogram demonstrated reduced size of the hematoma and was discharged. DISCUSSION: The literature reveals that distribution of the abdominal wall vasculature, primarily the IEA is often displaced laterally in patients with ascites. Our case proves that this holds true for the DCIA, the second branch of the external iliac artery that travels along the iliac crest. Future studies should focus on incidence of the aberrant anatomy of abdominal wall vasculature, which might help clarify if pre-procedure precautions like the color doppler mode could possibly reduce risk of all paracentesis related morbidity and mortality.