Active Arterial Extravasation Research Articles

Computed tomographic features of suspected arterial pseudoaneurysm in the head and neck of four dogs.

Computed tomography is a valuable diagnostic technique in the clinical work-up of dogs with oropharyngeal trauma and bleeding. Traumatic extravasation can manifest as a pseudoaneurysm. A pseudoaneurysm is an extraluminal accumulation of blood that is contained by the adventitia layer or neighboring tissues. The purpose of this retrospective, multicenter, observational case series study was to describe the CT features in dogs with presumed oropharyngeal arterial pseudoaneurysm and its potential association with trauma. Imaging archives were searched for canine patients with head and neck CT studies showing visible extravasation of contrast-enhanced blood contained by soft tissue structures. Medical records of these patients were reviewed for oropharyngeal bleeding or trauma and reported. Four dogs met the inclusion criteria. CT findings included a well-defined, confined area of vascular contrast enhancement adjacent to the common carotid artery or its branches. The mean contrast enhancement in the corresponding artery and pseudoaneurysm lesion was similar, suggesting that these lesions represent active arterial extravasation. Four-dimensional CT was performed in one case and demonstrated contrast medium leaking from an artery and being contained by adjacent soft tissue structures. All dogs had a history and imaging findings consistent with oropharyngeal bleeding and trauma. Arterial pseudoaneurysm should be considered as a differential diagnosis in dogs with oral trauma and CT features of a well-defined, periarterial, strongly contrast-enhancing lesion.

Prediction of gastrointestinal active arterial extravasation on computed tomographic angiography using multivariate clinical modeling

To evaluate the ability of logistic regression and machine learning methods to predict active arterial extravasation on computed tomographic angiography (CTA) in patients with acute gastrointestinal hemorrhage using clinical variables obtained prior to image acquisition. CT angiograms performed for the indication of gastrointestinal bleeding at a single institution were labeled retrospectively for the presence of arterial extravasation. Positive and negative cases were matched for age, gender, time period, and site using Propensity Score Matching. Clinical variables were collected including recent history of gastrointestinal bleeding, comorbidities, laboratory values, and vitals. Data were partitioned into training and testing datasets based on the hospital site. Logistic regression, XGBoost, Random Forest, and Support Vector Machine classifiers were trained and five-fold internal cross-validation was performed. The models were validated and evaluated with the area under the receiver operating characteristic curve. Two-hundred and thirty-one CTA studies with arterial gastrointestinal extravasation were 1:1 matched with 231 negative studies (N=462). After data preprocessing, 389 patients and 36 features were included in model development and analysis. Two hundred and fifty-five patients (65.6%) were selected for the training dataset. Validation was performed on the remaining 134 patients (34.4%); the area under the receiver operating characteristic curve for the logistic regression, XGBoost, Random Forest, and Support Vector Machine classifiers was 0.82, 0.68, 0.54, and 0.78, respectively. Logistic regression and machine learning models can accurately predict presence of active arterial extravasation on CTA in patients with acute gastrointestinal bleeding using clinical variables.

A Comparison of Histotripsy and Percutaneous Cryoablation in a Chronic Healthy Swine Kidney Model

PurposeTo compare the safety and efficacy of histotripsy with cryoablation in a chronic human-scale normal porcine kidney model. Materials and MethodsEighteen female domestic swine were divided evenly into histotripsy and cryoablation treatment arms. A planned 2–3 cm diameter treatment was performed under ultrasound (histotripsy) or ultrasound and computed tomography (CT) guidance (cryoablation). Contrast-enhanced CT and serum blood analysis were performed immediately postprocedure and on day 7, with either immediate killing (n = 3) or continued survival to day 30 (n = 6), at which time contrast-enhanced CT, serum blood analysis, and necropsy were performed. Animal welfare, treatment zone appearance, procedure-related adverse events, and histopathology of the treatment zones and surrounding tissues were assessed. ResultsHistotripsy treatment zones (mean ±standard deviation diameters, 2.7 ± 0.12 × 2.4 ± 0.19 × 2.4 ± 0.26 cm; volume, 8.3 ± 1.9 cm3) were larger than cryoablation zones (mean diameters, 2.2 ± 0.19 × 1.9 ± 0.13 × 1.7 ± 0.19 cm; volume, 3.9 ± 0.8 cm3; P < .001). At 30 days, histotripsy and cryoablation treatment zone volumes decreased by 96% and 83% on CT, respectively (P < .001). Perirenal hematomas were present after 8 of 9 (89%) cryoablation (mean volume, 22.2 cm3) and 1 of 9 (11%, P < .001) histotripsy (volume, 0.4 cm3) procedures, with active arterial extravasation in 4 of 9 (44%) cryoablation and no histotripsy animals (P = .206). All 9 histotripsy animals and 5 of 9 (56%) cryoablation animals had collecting system debris (P = .042). Changes in serum creatinine were similar between the groups (P = .321). ConclusionsOther than a higher rate of bleeding after cryoablation, the safety and early efficacy of histotripsy and cryoablation were comparable for creating treatment zones in a chronic normal porcine kidney model.

The Case Files

A patient presented after a cardiac cath with a football-sized mass in her groinFigure 1.: Axial CT angiography demonstrating right anterior thigh hematoma measuring 11.9 cm by 15.4 cm by 21 cm with active arterial extravasation (arrow).FigureFigureFigureA 56-year-old woman presented with shortness of breath and a cough she had had for a month. She also had associated orthopnea, paroxysmal nocturnal dyspnea, and dyspnea on exertion. A workup revealed an NSTEMI and new systolic heart failure, dilated cardiomyopathy (estimated ejection fraction 18%), and a sizable left ventricular apical thrombus on echocardiogram. Cardiac catheterization was performed and complicated by stable focal dissection of the right femoral artery and external iliac artery. She was discharged home on warfarin and enoxaparin for the LV thrombus. The patient returned to the ED one week later with symptoms of right groin pain and generalized lethargy, and she was in hypovolemic shock and had a massive right groin mass. Bedside ultrasound of the mass revealed a large hyperechoic fluid collection prompting resuscitation with two units of packed red blood cells to treat suspected hemorrhagic shock. She was also started on norepinephrine infusion for blood pressure and MAP support. Anticoagulation reversal was administered with 10 mg of vitamin K and one unit of FFP. CT angiography of the mass was obtained (Figures 1 and 2), and the patient was immediately taken to the OR for right femoral groin exploration for suspected right femoral artery injury with active arterial extravasation.Figure 2.: Coronal CT angiography demonstrating right anterior thigh hematoma with active arterial extravasation (arrow).Massive Hematoma The patient was diagnosed with post-catheterization femoral artery dissection with massive hematoma and active hemorrhage. She presented with hypotension, progressing to hypovolemic shock requiring aggressive fluid resuscitation, blood transfusion, vasopressors, and anticoagulation reversal. CT angiography showed a mixed density hematoma measuring 11.9 cm by 15.4 cm by 21 cm, and a small central focus of contrast blush. The patient was taken to the OR, where the surgeon found a hematoma the size of a football, which is roughly 17 cm in diameter and roughly 28 cm long. The hematoma was evacuated, and the femoral artery and external iliac arteries were repaired. Hematomas are the most common complication after cardiac catheterization. One review found that the incidence of femoral hematomas was 2.8 percent while active femoral and retroperitoneal bleeds were even lower at 0.6 percent and 0.3 percent, respectively. Dissection of the femoral or iliac arteries is also extremely rare, with an incidence of 0.46 percent. (Glob J Health Sci. 2012;4[1]:65; https://bit.ly/42TUAv5.) A large multicenter cohort study investigating vascular complications following endovascular cardiac procedures found that the incidence of major vascular complications was only 1.6 percent, defined as major hematoma (>10 cm), unstable bleeding, retroperitoneal hematoma, pseudoaneurysm, and arteriovenous fistula within a 48-hour periprocedural window. (Rev Lat Am Enfermagem. 2018;26:e3060; https://bit.ly/3lXFhRx.) The study also found that most vascular complications took place within six hours of surgery, making this patient's prolonged presentation even more unexpected. Most hematomas are self-limited, but larger ones with bleeding can cause hemodynamic instability. This patient was on anticoagulation for an LV thrombus, which likely complicated the bleeding. This case highlighted the importance of physician awareness of an emergent, rare presentation of a common hospital procedure—the cardiac cath. Clinical suspicion, especially in the periprocedural setting, rapid identification of the bleeding source, and immediate imaging make the diagnosis. Patients who continue to deteriorate despite resuscitative efforts require operative management. (StatPearls. Jan. 16, 2023; http://bit.ly/3nnkmaL.) Share this article on Twitter and Facebook. Access the links in EMN by reading this on our website: www.EM-News.com. Comments? Write to us at [email protected].

Abstract 13444: Acute Anemia With Mechanical Circulatory Support; Unmasking the Culprit

Introduction: Mechanical circulatory support (MCS) is known to potentiate hemolytic anemia. Nevertheless, patients are also at an increased risk of spontaneous bleeding due to anticoagulation or post-procedural complication. We present two cases of acute anemia due to spontaneous retroperitoneal bleeding following insertion of the Impella assist device. Case Presentation: Two male patients aged 65 and 74 presented with cardiogenic shock secondary to ischemic cardiomyopathy with a low ejection fraction of 10% and 15%). Both patients initially had an intra-aortic balloon pump (IABP) inserted. Because of progressively deteriorating hemodynamics, IABP was switched to the Impella 5.5 device through the axillary artery. Following insertion of the Impella, they developed anemia requiring multiple blood transfusions. Despite repositioning of Impella, hemoglobin continued to drop prompting further workup. CT abdomen/pelvis revealed left retroperitoneal hematoma. CT angiogram showed active bleeding from the left L3 lumbar artery in one patient and multiple foci of active arterial extravasation in the other patient. Coil embolization was performed, achieving hemostasis and stabilization of hemoglobin levels in both patients. Discussion: Hemolytic anemia associated with the use of the Impella that improves with repositioning or device removal is well known and documented. However, patients with MCS are also at increased risk of spontaneous bleeding due to procedural injury and the use of anticoagulation. We report 2 cases with retroperitoneal bleeding from the lumbar artery diagnosed a few days after the placement of Impella. The occurrence of retroperitoneal hemorrhage was possibly spontaneous due to anticoagulation along with Impella-induced hemolysis resulting in acute anemia. Neither patient had any vascular access through the left groin making post-procedural complications less likely. The concealed nature and non-specific symptoms of retroperitoneal bleed can lead to a delay in diagnosis. Early identification and control of bleeding can prevent fatal outcomes. Conclusion: Our cases highlight the importance of clinicians having a broad differential and low threshold to investigate other causes of anemia in patients with MCS.

S1889 A Case of Ruptured Gastroduodenal Artery Pseudoaneurysms in a Patient With Chronic Pancreatitis

Introduction: Pancreatic pseudoaneurysm is a rare vascular complication of pancreatitis, with an estimated prevalence of 10%. Pseudoaneurysm can result from trauma, inflammation, infection, and iatrogenic causes. Due to its weak structural support, the risk of rupture is higher for pseudoaneurysm than that of a true aneurysm of similar size. Pancreatic pseudoaneurysms can lead to life-threatening complications such as rupture and bleeding, with increased morbidity and mortality up to 90% in untreated patients and 12.5% despite treatment. Due to its high mortality rate with rupture, pseudoaneurysms should be treated immediately once it is identified, regardless of their size or whether it is symptomatic or not Case Description/Methods: We present a case of a 68-year-old male patient with a past medical history significant for chronic pancreatitis who presented with altered mental status and hypovolemic shock secondary to unexplained gastrointestinal and retroperitoneal hemorrhage (Table). Computed tomography (CT) Angiography was done which showed an enlarging retroperitoneal and right-sided intraperitoneal hematoma with suspicion for active arterial extravasation or punctate pseudoaneurysms in the pancreatic head (Figure). Celiac angiogram was done under fluoroscopic guidance, which showed gastroduodenal and superior pancreaticoduodenal artery pseudoaneurysms. He underwent successful endovascular coil embolization of the gastroduodenal artery. Post procedure he was monitored in intensive care unit. His clinical condition continued to improve and was discharged to a skilled nursing facility in stable condition. Discussion: Physicians should be aware of pancreatic pseudoaneurysms as rare vascular complication associated with chronic pancreatitis that may lead to fatal gastrointestinal or retroperitoneal bleeding with a high mortality rate. Our case highlights the importance of early diagnosis and prompt treatment in these patients.Figure 1.: A: CT abdomen and pelvis without intravenous contrast showing peripancreatic inflammation surrounding the pancreatic body and head along with retroperitoneal bleed (red arrow). Pancreatic calcifications present (yellow arrow) signifying radiologic evidence of chronic pancreatitis B: CT Angiography showing retroperitoneal and right-sided intraperitoneal hematoma with active arterial extravasation or punctate pseudoaneurysms in the pancreatic head. Table 1. - Laboratory Investigation Investigation Day 1 of Hospitalization Day 5 At Time of Discharge Reference Range White Blood Cell count 24.3 14.3 k/uL 7 k/uL 4.8-10.8 k/uL Red Blood Cell Count 4.77 2.69 MIL/uL 3.19 MIL/uL 4.50-5.90 MIL/uL Hemoglobin 15.8 8.5 mg/dl 10.2 mg/dl 12.0-16.0 g/dL Hematocrit 47.6 25.7 % 30.5% 42-51 % Platelet count 171 155 k/uL 215 k/uL 150-400 k/uL Sodium, Serum 132 139 mEq/L 140 mEq/L 135-145 mEq/L Potassium, Serum 3.0 3.2 mEq/L 3.9 mEq/L 3.5-5.0 mEq/L Blood Urea Nitrogen, Serum 41 17 mg/ml 10 mg/ml 8-26 mg/dL Creatinine, Serum 1.2 0.5 mg/dl 0.6 mg/dl 0.5-1.5 mg/dL Bilirubin, Serum total 0.5 0.7 mg/dl 0.3 mg/dl 0.2-1.1 mg/dL Serum Direct Bilirubin 0.3 0.3 mg/dl < 0.2 mg/dl 0.0-0.3 mg/dL Alkaline Phosphatase 51 48 units/L 73 units/L 56-155 unit/L Aspartate Transaminase 125 21 units/L 18 units/L 9-48 unit/L Alanine Aminotransferase 81 30 units /L 12 units /L 5-40 unit/L Lactic acid Level 8.2 0.8 mmoles/L 1.1 mmoles/L 0.5-1.6 mmoles/L Prothrombin Time 15.2 13.9 sec 10.5 sec 9.9-13.3 seconds International Normalized Ratio 1.31 1.20 0.92 0.85-1.14 Serum Calcium 6.6mg/dl 7.6 mg/dl 9.2 3 mg/dl 8.5-10.5 mg/dl Serum Lipase 24 U/L < =61U/L Serum Triglyceride 163mg/gl 55-150 mg/dl Serum Ethanol < 10 < = 10mg/dl Urine Toxicology Cocaine and methadone Negative

S2632 Challenge a Diverticular Bleeding

Introduction: Colonic diverticular bleeding is the most common cause of acute LGI bleeding. Colonoscopy is recommended as the initial diagnostic modality. Although, the detection rate of the bleeding is variable as it is a challenging diagnosis Case Description/Methods: A 67 yo Man with a history of hypertension and diabetes mellitus, on baby aspirin presented to our emergency department with 4 episodes of painless hematochezia of 1day duration. The patient was initially stable but blood pressure dropped to 74/52 mmHg with continuous bleeding. Initial hemoglobin 12.5 g/dL dropped to 7.9 g/dL. A computed tomography (CT) scan showed intraluminal active arterial extravasation in the proximal transverse colon with scattered colonic diverticula. After IV resuscitation and blood transfusions, a selective and subselective angiography of the celiac axis and the superior mesenteric artery showed no evidence of active hemorrhage. Subsequent colonoscopy using a CF-HQ190L with an attached cap was performed, after oral preparation with 4 L of polyethylene glycol 3350. Multiple diverticula with medium openings were seen in the whole colon. Diverticula were washed and examined very carefully. One diverticulum in the transverse colon was noted with a visible clot. The base of the diverticulum was injected with epinephrine 1/10000 which inverted the diverticulum and exposed the culprit vessel. 3 endoclips were applied with successful hemostasis. The patient was followed and showed no recurrent hemorrhage. A repeat non-contrast CT showed the clips at the site of previous active extravasation (Figure 1). Discussion: Colonic diverticular bleeding accounts for 20.8 to 41.6% of LGI bleeding. After resuscitation, colonoscopy is recommended as an initial diagnostic modality. Although the detection rate of the bleeding varies from 6% to 42%. Detecting stigmata of recent bleeding is challenging, but improved if performing the colonoscopy urgently, within 24 h, with oral lavage solutions, by expert endoscopists who have performed >1,000 colonoscopies, and with the use of disposable distal attachments and water-jet systems. Having CT angio ahead of time is beneficial as it guides us anatomically. Therapeutic endoscopic options include clipping, epinephrine injection, band ligation or conservative management. Injecting the diverticulum with saline with or without epinephrine will invert the diverticulum and expose the inside including a clot or visible vessel and make hemostasis easier. This represents a new technique in diverticular bleeding control.Figure 1.: Diverticular bleeding control.

S1718 Delayed Gastrointestinal Hemorrhage From Visceral Artery Pseudoaneurysm in Necrotizing Pancreatitis After LAMS Removal

Introduction: Delayed bleeding from visceral artery pseudoaneurysm (PA) formation is an uncommon complication of lumen-apposing metal stent (LAMS) placement. Risk factors for gastrointestinal bleeding (GIB) in patients with LAMS remain largely undefined. We report a case of delayed GIB due to rupture of a splenic artery PA 16 months after LAMS removal. Case Description/Methods: A 34-year-old female with a history of severe necrotizing pancreatitis presented to our hospital with massive hematemesis. 23 months prior to presentation, she underwent uncomplicated placement of a 15x10 mm LAMS and 2 7 Fr x 4 cm double pigtail plastic stents for drainage of walled-off pancreatic necrosis. She was briefly lost to follow-up and returned for LAMS removal 5 months later. Contrast was injected into the residual cyst cavity and contrast filling was noted of what appeared to be a splenic vessel without active bleeding (Figure A). CT angiogram showed no PA but proximity of the splenic hilar vasculature to the LAMS (Figure B). The LAMS was successfully removed 2 months later without complication. On presentation, she was tachycardic but normotensive. Laboratory studies were notable for hemoglobin 8.8 g/dL (baseline 14 g/dL). Upper endoscopy showed brisk bleeding in the proximal gastric body near the area of prior LAMS. Her bleeding was refractory to endoscopic hemostatic maneuvers, and she underwent emergent mesenteric angiography. Angiography revealed active arterial extravasation arising from the inferior segmental branch of the splenic artery ( Figure C) which was successfully embolized with no further bleeding. Discussion: Visceral artery PA development after LAMS placement is thought to occur due to friction of the inner flange against regional vasculature surrounding the necrotic cavity as it collapses. Close anatomical proximity of LAMS to regional vasculature increases the risk of PA development. In our case, the LAMS was placed near the rich vascular supply of the splenic hilum. Most reported bleeding events related to LAMS have occurred within 8 weeks of placement. Our case is notable for the prolonged delay between LAMS removal and bleeding presentation. Adherent scar tissue between the gastric wall and vasculature could potentially cause delayed PA development after LAMS removal. This case reinforces that high clinical suspicion for PA bleeding is necessary for patients who have previously undergone distant LAMS removal who present with massive GIB.Figure 1.: (A) Fluoroscopic image of contrast injection into residual cyst cavity demonstrating opacification of likely splenic vasculature; (B) Coronal images demonstrating the proximity of the LAMS to the vasculature of the splenic hilum (yellow arrow); (C) Super-selective angiography demonstrating active extravasation into the lateral aspect of the stomach from a pseudoaneurysm (White arrow) involving an inferior segmental branch of the splenic artery.

Abstract No. 536 Dual energy iodine overlay images reduce time to interpret active arterial extravasation, particularly for less experienced readers

Active arterial extravasation in the trauma patient requires timely detection. The purpose of this study was to evaluate the utility of using iodine overlay (IO) reconstructions from dual-energy computed tomography (DECT) as compared with conventional CT images in diagnosing active arterial extravasation amongst radiologists at different levels of training. We hypothesized that the use of DECT would be particularly useful for more inexperienced radiologists.

Point-of-care Ultrasound for the Evaluation of Acute Arterial Pathology in the Emergency Department: A Case Series.

IntroductionThe use of point-of care ultrasound (POCUS) in the evaluation of vascular emergencies including abdominal aortic aneurysm and deep vein thrombosis is well established. However, no current guidelines exist to outline the use of POCUS in the management of acute peripheral arterial pathology.Case SeriesHere, we present a case series that illustrates the utility of POCUS in the assessment of both traumatic and nontraumatic peripheral arterial disease. Direct visualization of the vasculature via B-mode, color Doppler, and pulsed-wave Doppler assisted in the diagnosis of the following: 1) an acute, post-catheterization thrombus of the proximal radial artery; 2) a complete, traumatic radial artery transection; 3) a forearm hematoma with active arterial extravasation; 4) a traumatic arteriovenous fistula; 5) an acute thrombosis of an artery bypass graft; and 6) an infected pseudoaneurysm.ConclusionThe incorporation of POCUS into patient care allowed for rapid identification of significant peripheral arterial pathology and led to changes in clinical management, expedited patient care, and circumvented potentially harmful complications.

Gallbladder perforation and massive intraperitoneal bleeding secondary to haemorrhagic cholecystitis

A 76-year-old man on apixaban presented with abdominal pain, vomiting, and signs of haemorrhagic shock. Imaging showed large volume haemoperitoneum with active arterial extravasation in the gallbladder fossa. The patient proceeded to emergency laparotomy, where haemorrhage was thought to arise from within a perforated gallbladder. Cholecystectomy was performed and haemostasis was achieved. Histology showed features of subacute on chronic cholecystitis, with some sections suggestive of an underlying arteritis. Haemorrhagic cholecystitis is rare, and gallbladder perforation with massive intraperitoneal haemorrhage is rarer still. This article presents a case report and literature review of this entity.

P.224 A Case Report of Spinal Screws Penetrating the Pulmonary Artery

Background: Spinal instrumentation is commonly utilized to mechanically stabilize the spine in trauma, oncology and degenerative disease. Although several complications have been reported, this is the first case of screw penetration of the pulmonary artery. Methods: We present a case of a 74-year old gentleman who suffered from a thoracic spine chordoma. He underwent a T8 resection with T8-T12 instrumented fusion with subsequent radiation. Recurrence of his disease led to resection of his 3rd and 4th ribs and repeat radiation. He presented 6 years later with 2 episodes of massive hemoptysis. Review of the literature was conducted to search for similar complications. Results: A Chest Computed Tomography scan demonstrated the presence of a pedicle screw tip in the right pulmonary artery. Angiogram revealed no evidence of active arterial extravasation. In the operating room, the patient had a right lower lobectomy, with segmental pulmonary artery sacrifice, as well as replacement of the spinal fixation hardware. Literature review revealed multiple aortic injuries following spinal instrumentation. However, this was the first case of pulmonary artery erosion. Conclusions: Spinal instrumentation has been associated with screw migration and penetration of nearby tissues and vessels. A high incidence of suspicion is required when patients present with delayed and unusual complications.

Clinical and laboratory parameters in blunt pelvic trauma not associated with subsequent positive conventional angiography in patients with positive CTA.

This study evaluates clinical and laboratory parameters, as well as extravasation and hematoma size on CTA as potential predictors of conventional angiogram (CA) results. This is a retrospective study of 380 adult patients presenting with pelvic trauma over a 9-year period. Of these patients, 91 were found to have active arterial extravasation on initial CTA. Statistical analysis between the two groups +CA versus -CA was performed to determine whether clinical and laboratory parameters, as well as extravasation size and hematoma size could predict CA results. There were no significant differences in all clinical and laboratory data, including hemodynamic instability (defined as systolic blood pressure < 90 mmHg) on presentation (22.2% vs. 21.4%), except for Glasgow Coma Scale (p = 0.015) when comparing the two groups. Extravasation size and hematoma size as continuous or categorical variables were not predictive of subsequent positive CA. Secondary analysis demonstrated no association between select parameters (i.e., hematocrit, systolic blood pressure, and lactate) and subsequent positive CA while controlling for extravasation size or hematoma size. Clinical and laboratory parameters in blunt pelvic trauma with arterial hemorrhage were not significantly associated with subsequent conventional angiography results, once accounting for degree of hemorrhage. The area of the foci of active extravasation and hematoma size in the axial plane were not significantly associated with the need for embolization. We conclude from these findings that catheter angiography should be considered in patients with blunt pelvic trauma found to have active arterial extravasation, regardless of size of bleed or the patient's clinical or laboratory values.

Between a Lift and a Hard Place

Between a Lift and a Hard Place

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

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.

04:21 PM Abstract No. 247 Factors that may affect extravasation seen on institutional trauma CT evaluation of patients with traumatic injuries

To determine if systolic blood pressure and hemoglobin concentration impact detection of acute traumatic hemorrhage/extravasation on our institutional trauma computed tomography (tCT) protocol. A retrospective chart review of patients who underwent selective angiography after tCT (late arterial/early portal venous phase) and demonstrated traumatic injury between June 2015 and July 2018 was performed. A positive tCT was defined as extravasation noted in association with traumatic injury. Corresponding angiograms were considered positive if extravasation was noted on arteriograms. Demographic data, type injury, coexisting traumatic injuries, hemodynamic parameters, relevant lab values (i.e hemoglobin (Hgb) concentration, platelets, INR), time of tCT, time of angiography and post-angiography outcomes were recorded. A Wilcoxon-Mann Whitney analysis was performed to compare groups. 118 patients received a tCT for evaluation after presenting with trauma. Of these, 101 patients (70 males (69%) and 31 females (31%), (mean age 44 ± 22 yrs)) had systolic blood pressures documented at the time of the tCt, and 109 patients (81 males (74%) and 28 females (27%), (mean age 44 ± 21 yrs)) had hemoglobin levels documented at the time of the tCt. The cohort was divided into 2 groups depending on findings on tCT: Group A demonstrated active arterial extravasation on tCT and Group B did not. The average systolic blood pressure for Group A (122.16 ± 26.86 mm Hg; n=67) was greater than Group B (110.0 ± 31.6 mm Hg; n = 34), and this difference was statistically significant (p < 0.05). The average hemoglobin level for Group A (12.8 ± 2.0 mg/dl; n=71) was greater than Group B (11.7 ± 2.0 mg/dl; n = 38), and this difference was also statistically significant (p < 0.01). Systolic blood pressure and hemoglobin levels may impact active extravasation seen on late arterial/early portal venous phase CT imaging in patients presenting for evaluation of trauma. Resuscitation prior to imaging may result in improved sensitivity of the examination.

Active Reperfusion Hemorrhage during Thrombectomy: Angiographic Findings and Real-Time Correlation with the CT “Spot Sign”

Introduction: Symptomatic intracranial hemorrhage represents one of the most feared complications of endovascular reperfusion. We aim to describe a series of patients that experienced immediate reperfusion injury with active intraprocedural extravasation within the territory of the deep penetrating arteries and provide real-time correlation with CT “spot sign.” Methods: This was a retrospective analysis of patients that suffered reperfusion injury with active arterial extravasation during endovascular stroke treatment in two tertiary care centers. Results: Five patients were identified. Median age was 63 (58–71) years, 66% were male. Median NIHSS was 13.5 (9.5–23.0), platelet level 212,000 (142,000–235,000), baseline systolic blood pressure 152 (133–201) mm Hg, and non-contrast CT ASPECTS 7.0 (6.5–9.0). Two patients were taking aspirin and one had received intravenous thrombolysis. There were three middle cerebral artery M1, one internal carotid artery terminus, and one vertebrobasilar junction occlusion. Three patients had anterior circulation tandem occlusions. Stroke etiology was extracranial atherosclerosis (n = 2), intracranial atherosclerosis (n = 2), and cervical dissection (n = 1). The median time from onset to puncture was 5.5 (3.9–8.6) h. Intravenous heparin was administered in all patients (median dose of 4,750 [3,250–6,000] units) and intravenous abciximab in four. All tandem cases had the cervical lesion addressed first. Four lenticulostriates and one paramedian pontine artery were involved. Intraprocedural flat-panel CT was performed in four (80%) cases and provided real-time correlation between the active contrast extravasation and the “spot sign.” The bailout included use of protamine, blood pressure control, and balloon guide catheter or intracranial compliant balloon inflation plus coiling of targeted vessel. All patients had angiographic cessation of bleeding at the end of the procedure with parenchymal hemorrhage type 1 in one case and type 2 in four. Three patients had modified Rankin score of 4 and two were dead at 90 days. Conclusions: Active reperfusion hemorrhage involving perforator arteries was observed to correlate with the CT “spot sign” and to be associated with poor outcomes.

Life-Threatening Retropharyngeal Hemorrhage Secondary to Rupture of the Inferior Thyroid Artery.

Inferior thyroid artery (ITA) rupture is rare and may progress to life-threatening conditions. We present a patient who visited the emergency department after an episode of syncope and dizziness in which he had a mechanical fall that resulted in abrasions and a hematoma to his left forehead. The patient presented with dysphagia and anterior neck swelling that progressed rapidly into airway compromise requiring endotracheal intubation. Emergent computed tomography revealed a large retropharyngeal hematoma, with active arterial extravasation that was thought to be arising from the thyrocervical trunk on the left. The hematoma measured approximately 6.7 cm transversely and 3.2 cm anteroposteriorly and extended from the level of the lower nasopharynx, down the neck into the retropharyngeal and danger space and into the mediastinum posterior to the esophagus, overall approximately 25 cm. The larynx was deviated anteriorly and there was esophageal compression. An emergent arteriogram and catheterization confirmed bleeding from branches of the ITA, and successful embolization was performed. It is important to recognize the ITA rupture as a potential etiology of an acute airway compromise. In emergent situations, while securing an airway is a priority, rapidly initiating diagnostic testing to confirm the diagnosis and arranging for arterial embolization can be life-saving.

Penetrating Wounds to the Torso: Evaluation with Triple-Contrast Multidetector CT

Penetrating injuries account for a large percentage of visits to emergency departments and trauma centers worldwide. Emergency laparotomy is the accepted standard of care in patients with a penetrating torso injury who are not hemodynamically stable and have a clinical indication for exploratory laparotomy, such as evisceration or gastrointestinal bleeding. Continuous advances in technology have made computed tomography (CT) an indispensable tool in the evaluation of many patients who are hemodynamically stable, have no clinical indication for exploratory laparotomy, and are candidates for conservative treatment. Multidetector CT may depict the trajectory of a penetrating injury and help determine what type of intervention is necessary on the basis of findings such as active arterial extravasation and major vascular, hollow viscus, or diaphragmatic injuries. Because multidetector CT plays an increasing role in the evaluation of patients with penetrating wounds to the torso, the radiologists who interpret these studies should be familiar with the CT findings that mandate intervention.

Blunt Trauma: Feasibility and Clinical Utility of Pelvic CT Angiography Performed with 64–Detector Row CT

To retrospectively evaluate the integration of pelvic computed tomographic (CT) angiography into the thoracoabdominal CT examination of blunt trauma by using 64-detector row CT to differentiate active arterial from active venous hemorrhage. This study was institutional review board approved and HIPAA compliant; the requirement for informed patient consent was waived. Fifty-three patients (30 male, 23 female; mean age, 42 years) with multiple blunt trauma underwent pelvic CT angiography with 64-detector row CT at admission. Arterial phase and portal venous phase pelvic CT angiograms were evaluated for evidence of vascular injury. In patients with active extravasation, the size of the hemorrhaging area was measured on arterial, portal venous, and delayed phase images. The Fisher exact test was used to correlate presence of vascular injury with subsequent clinical management. The Wilcoxon rank sum test was used to test the association between size of active hemorrhage during the vascular enhancement phases and subsequent clinical outcome. Finally, the Fisher exact test was used to correlate presence of vascular injury with severity of osseous injury. At pelvic CT angiography, 21 of the 53 patients had evidence of vascular injury: 10 isolated active arterial extravasations, three isolated arterial occlusions, three cases of both arterial extravasation and occlusion, two cases of arterial and venous extravasations, and three isolated venous extravasations. Eleven of the 21 patients also underwent conventional angiography, with subsequent embolization performed in seven of these 11 patients. The remaining 10 patients were successfully treated conservatively. When the foci of active arterial extravasation were compared on arterial, portal venous, and delayed phase images, the mean areas of hemorrhage across all three phases were larger in patients who required conventional angiography than in those successfully treated with conservative management. With use of 64-detector row scanning, pelvic CT angiography was successfully integrated into the authors' CT protocols and enabled differentiation between active arterial and active venous hemorrhage, which may influence clinical management.