Huge Retroperitoneal Hematoma Research Articles

Huge Retroperitoneal and Pelvic Hematoma Following VBAC (TOLAC): A Case Report

Huge Retroperitoneal and Pelvic Hematoma Following VBAC (TOLAC): A Case Report

Embolization for massive bleeding due to spontaneous left external iliac vein rupture: report of a successful case

BackgroundSpontaneous rupture of the iliac vein has rarely been reported. Its associated hypovolemic shock-related symptoms and signs, including syncope and hypotension, have been observed in most of these cases. Successful transcatheter venous embolization for massive bleeding due to spontaneous rupture of the external iliac vein was herein reported.Case presentationAn 82-year-old female patient developed sudden left lower abdominal and back pain. Immediately, she lost consciousness and went into shock. CT images of her abdomen revealed a huge retroperitoneal hematoma, with leakage of contrast medium in the hematoma in the left flank. These findings suggested left external iliac vein rupture.Open surgery was considered; however, since the patient’s condition may have deteriorated further due to the time needed to prepare for surgery, including general anesthesia, transcatheter venous embolization of the left iliac vein was selected. A 5.2-Fr compliant balloon catheter (nominal diameter of 10 mm) was inflated at the distal site of the external iliac vein to reduce extravasation. N-butyl-2-cyanoacrylate (NBCA) was mixed with Lipiodol at a ratio of 1:2. The left Iliac vein was filled and completely embolized with the NBCA/Lipiodol mixture (total injected volume, 5 mL) using a 1.8-Fr microcatheter. After embolization, the patient quickly. An inferior vena cava filter was placed 1 day after embolization.ConclusionSpontaneous rupture of the iliac vein is a very rare and lethal condition. Transcatheter venous embolization may control potentially life-threatening bleeding. Rapid bleeding control in a critical condition is facilitated by this minimally invasive approach.

TCTAP C-177 Successful Balloon Displacement Technique to Retrieve Embedded Inferior Vena Cava Filter: Novel Strategy

### Patient Initials or Identifier Number AUTI ### Relevant Clinical History and Physical Exam 34-year obese female, history of cerebral venous sinus thrombosis (CVST) underwent hysterectomy for DUB. She developed fever and massive DVT after 5 days along with huge retroperitoneal hematoma from

Ligation of the Left Hepatic Duct and Proper Hepatic Artery Following a Traffic Accident Injury.

A 32-year-old man was admitted to our hospital due to a traffic accident. Intraoperative observations revealed hemoperitoneum, splenic transection, pancreatic tail contusion, comminuted injury in the porta hepatis, rupture in the left hepatic duct, an irregular crevasse in the ductus hepaticus communis, the caudate lobe was transversely broken on the left, and under the gap, there was a fracture in retrohepatic inferior vena cava with huge retroperitoneal hematoma. We carried out a ligation of the left hepatic duct and the proper hepatic artery. Postoperation, the man recovered smoothly. At 5years and 5months postoperation, MRI showed that the left liver had atrophied partly. So, we consider that the ligation of the left hepatic duct is a safe procedure for patients without cirrhosis under the conditions of ligation of the proper hepatic artery.

Two Different Coagulopathy Episodes in a Single Patient with Metastatic Prostate Cancer

We reported a case of two different episodes of critical coagulopathy in a single patient with metastatic prostate cancer (mPC). The patient initially visited the emergency room with a huge left retroperitoneal hematoma, high serum prostate-specific antigen level, and signs of acute disseminated intravenous coagulation (DIC) from mPC. With blood product replacement and anti-androgen therapy, the DIC-related symptoms and signs were relieved. During the follow-up, he was treated with docetaxel chemotherapy for hormone refractory PC. Four years later, he visited the emergency room again with relapsed coagulopathy and severe anemia that were not replaced with blood products. The laboratory findings were consistent with thrombotic thrombocytopenic purpura rather than DIC. A satisfactory recovery was achieved with a new cycle of docetaxel chemotherapy. Differentiation of the coagulopathies in PC is difficult; therefore, we describe the different features of two overlapping coagulopathies, which will be helpful in deciding on urgent treatment.

Retroperitoneal hematoma after use of oral anticoagulants in the postoperative period complicated by atrial fibrillation - A case report

One of the elements of therapeutic conduct aimed at avoiding the most severe cardiovascular events such as: heart attack or brain ischemic stroke is the treatment against thrombosis with the use of low molecular weight heparin, anticoagulants and anti - platelet drugs. This therapy is related with bleeding complications, occurring 2 -20% of the patients during treatment with anticoagulants. The aim of this study is to analyze the complications of anticoagulation with oral anticoagulants and low molecular weight heparin in the treatment of cardiac event in the early postoperative period after total hip replacement In 5 day after right THA an event of atrial fibrillation (AF) occurred in 69 year old patient. According to cardiologist recommendation oral anticoagulant was administered to accompany previously used low molecular heparin on the 14th day after surgery. At the moment when the therapeutic dose was achieved the patient presented severe pain which was localized in a right inguinal region and also in a surgically treated hip. The next day it was observed further increase in pain intensity as a right - sided femoral neuralgia accompanied by neurological deficits such as: progressive disorder of sensation on the front surface of the right thigh, weakness right knee reflex muscle, weakness in the active hip flexion and knee extension. In CT and ultrasonography examination the huge retroperitoneal hematoma in a right lumbar-illiac muscle was imaged. Severe hip pain after total hip replacement with progressive symptoms of peripheral nerve lesion obligated to do additional examination in the field of diagnostic imaging of the abdomen and requires a multidisciplinary evaluation. Taking into consideration indications and contraindications and an extensive clinical and laboratory monitoring are crucial conditions to prevent bleeding during anticoagulant therapy.

Rupture of a giant abdominal aortic aneurysm

We admitted a 76-year old male person with a ruptured abdominal aortic aneurysm. He was immediately brought to the emergency room (ER). The blood pressure was 80/40 mmHg, HTC less than 0.17. We decided to perform an emergent CT angiography wich verified referral diagnosis. The ruptured AAA was 12 cm in diameter. An emergent life saving operation had to be done so the patient was brought to the operation theatre (OT). The approach to the abdomen was a classic median laparotomy. After we had opened the abdomen, we found a huge retroperitoneal haematoma that pushed beside the intra-abdominal organs rising almost to the edge of the rectal fascia. The blood pressure suddenly dropped down to 45/25 mm Hg for the next several minutes. A continuous infusion of norepinephrine was administered (60 mcg/min) and we also administered several doses of pure adrenalin (3 mg) and pure norepinephrine (1 mg). We pulled out the intestines from the abdominal cavity and clamped the aorta just under the renal arteries. The blood pressure immediately rose to 80 mm Hg. Both common iliac arteries were clamped, too. During the surgery the patient was anuric. Autologous blood transfusion helped by cell saver was administered and additionally he got several doses of blood, blood derivates (fresh frozen plasma, cryoprecipitate, platelets) and other intravenous solutions at the amount of approximately eight litres. We replaced the ruptured AAA using 20 mm PTFE vascular graft. After surgery the patient was transferred to the intensive care unit (ICU) where the blood pressure rose and diuresis was established. First postoperative day the patient was woken up without neurological deficits. Second postoperative day the patient was able to expel the stool and he was transferred to the department of cardiovascular surgery. Tenth day after surgery he was discharged home. Six weeks after surgery we performed a control CT angiography that showed normal founding on the abdominal iliac and leg vessels.

Nightmare of Lumbar Diskectomy

Case report. To present a rare case of a patient who during posterior lumbar spinal decompression and diskectomy underwent a laceration of the aorta. The patient survived with prompt treatment. Intraoperative injuries of the prevertebral and pelvic vessels are infrequent but serious complications of posterior lumbar disc surgery. Injury may cause laceration of the vessel with acute life-threatening retroperitoneal hemorrhage, which is usually massive. The aortic bifurcation is closely approximated to the anterior surface of the L4-L5 disc. A 70-year-old gentleman with prolapsed intervertebral disc between fourth and fifth lumbar vertebrae and left-sided radiculopathy of L5 root was operated with L4-L5 laminectomy and L4-L5 diskectomy. During diskectomy, it was noticed by the surgeon that there was one episode of giving way of the pituitary rongeur anteriorly. However, no major bleeding was encountered from the disc space immediately after the event; vital signs were stable hemodynamically and we completed the diskectomy. Five minutes later, we noted the dural sac to have a collapsing pulsation. Prevertebral vessel injury was suspected. Patient became pulseless. We turned the patient supine for cardiopulmonary resuscitation without extubation. Vascular surgeons proceeded with laparotomy. Huge retroperitoneal hematoma and a 1.5 × 1.5 cm laceration at the bifurcation of aorta were noted anterior to the L4-L5 intervertebral disc. The vascular surgeon repaired the aorta by primary repair. The patient was extubated on day 5 and was allowed to ambulate. He was discharged subsequently with a normal neurological and vascular examination. No pseudoaneurysm or arteriovenous fistula formation was detected on magnetic resonance imaging and magnetic resonance angiography at 2 years follow-up. Iatrogenic vascular injury during posterior lumbar disc surgery, although rare, should be suspected if signs of circulatory instability or abnormal pulsation of the dural sac are noted, especially if any lapse in the ordinary technique has been observed. In preoperative imaging, note the position of the aorta and prevertebral veins and the depth and integrity of the anterior wall of the disc.

Abdominal Compartment Syndrome Due to Spontaneous Retroperitoneal Hemorrhage in a Patient Undergoing Anticoagulation

Spontaneous retroperitoneal hemorrhage is one of the most serious and often lethal complications of anticoagulation therapy. The clinical symptoms vary from femoral neuropathy to abdominal compartment syndrome or fatal hypovolemic shock. Of these symptoms, abdominal compartment syndrome is the most serious of all, because it leads to anuria, worsening of renal failure, a decrease in cardiac output, respiratory failure, and intestinal ischemia. We report a case of a spontaneous retroperitoneal hemorrhage in a 48-year-old female who had been receiving warfarin and aspirin for her artificial aortic valve. She presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate. Computed tomography demonstrated a huge retroperitoneal hematoma and active bleeding from the right internal iliac artery. After achieving successful bleeding control with transcatheter arterial embolization, surgical decompression of the hematoma was performed for management of the femoral neuropathy and the abdominal compartment syndrome. She recovered without any complications. We suggest that initial hemostasis by transcatheter arterial embolization followed by surgical decompression of hematoma is a safe, effective treatment method for a spontaneous retroperitoneal hemorrhage complicated with intractable pain, femoral neuropathy, or abdominal compartment syndrome.

Spontaneous rupture of the left common iliac vein associated with May–Thurner syndrome: successful management with surgery and placement of an endovascular stent

We report a case of spontaneous rupture of the left common iliac vein diagnosed pre-operatively with CT and successfully treated with surgery and placement of a stent. A 60-year-old woman was referred to our emergency room because of a sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal haematoma and extrinsic compression of the left common iliac vein with acute thrombosis of deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After thrombectomy with use of a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under the C-arm fluroscopic guidance. Follow-up CT 10 days and 8 months after initial examination demonstrated a venous stent with preserved luminal patency and striking resolution of deep vein thrombosis of the left lower extremity.

Blunt traumatic abdominal aortic rupture: CT imaging

Blunt abdominal aortic trauma is a rare but potentially lethal event. It is commonly associated with high-speed motor vehicle accidents. Intimal flap, thrombosis, and pseudoaneurysm of the abdominal aorta are the more common findings. We present a case of blunt abdominal aortic trauma in which CT disclosed free aortic rupture with intraabdominal bleeding and a huge retroperitoneal hematoma, an extremely rare finding among patients reaching the hospital alive, due to its high and immediate mortality rate.

Spontaneous Rupture of the Left Common Iliac Vein: Management with Surgical Repair and Endovascular Stent

We report here on a case of spontaneous rupture of the left common iliac vein that was diagnosed preoperatively with computed tomography (CT), and the patient was successfully treated with surgery and stent placement. A 60-year-old woman was referred to our emergency room because of sudden left lower abdominal pain and swelling of the left lower extremity. CT revealed a huge retroperitoneal hematoma and extrinsic compression of the left common iliac vein with acute thrombosis of the deep veins of the left lower extremity. Venous patch angioplasty was performed at the site of spontaneous rupture. After performing thrombectomy with using a Forgaty catheter, a stent was placed at the occluded segment of the left common iliac vein under C-arm fluoroscopic guidance. The follow-up CT scans taken at 10 days and 8 months after the initial examination demonstrated a venous stent with preserved luminal patency and the striking resolution of the deep vein thrombosis of the left lower extremity.

Fatal retroperitoneal haemorrhage associated with enoxaparin and impaired renal function

Fig. 1. CT scan showing a huge retroperitoneal haematoma. Two different densities are visible inside the haematoma, possibly reflecting different bleeding times. A 66-year-old woman with previous renal transplantation—baseline creatinine of 1.6 mg/dl—was admitted to the hospital with the diagnosis of unstable angina and treated with enoxaparin (1 mg/kg/12 h, subcutaneously). On the 12th day of admission, the patient developed diffuse abdominal tenderness and hypotension. Hemoglobin suddenly decreased 4 g/dl compared to baseline levels. Abdominal/pelvic CT revealed a right retroperitoneal haematoma measuring 14 14 2 cm (Fig. 1). The patient was transferred to the intensive care unit, but her medical status continued to deteriorate. She became anuric, requiring highdose dopamine as well as intravenous fluids and blood products to maintain her blood pressure. Finally, she developed a refractory hypovolemic shock causing her death. Enoxaparin has been shown to be superior to unfractionated heparin (UFH) in the management of patients with an acute coronary syndrome [1,2]. However, no prospective data are available about its safety and efficacy in patients who are obese and patients with severe renal impairment (creatinine level>2 mg/dl or creatinine clearance 30 ml/min if an adjusted enoxaparin dose was used.

Celiac artery stenting: a new strategy for patients with pancreaticoduodenal artery aneurysm associated with stenosis of the celiac artery.

We report a new strategy--celiac artery stenting--to relieve stenosis of the celiac arterial root. This was performed in two patients with pancreaticoduodenal artery (PDA) aneurysm associated with a stenotic celiac arterial root. The first patient was a 66-year-old man complaining of abrupt onset of upper abdominal pain. Abdominal computed tomography revealed a huge retroperitoneal hematoma behind the duodenum, and superior mesenteric artery (SMA) angiography demonstrated an aneurysm arising from inferior pancreaticoduodenal artery and celiac arteriography showed a stenotic celiac arterial root. Transcatheter embolization of the aneurysm was tried, but failed. Because of his unstable hemodynamics, emergent laparotomy with resection of the aneurysm was performed. Fourteen days after the operation, percutaneous transluminal angioplasty with celiac arterial stenting was done. The patient was discharged 2 days later, and has had no further bleeding episode for 3 years. The second patient was a 46-year-old woman, who also complained of acute upper abdominal pain. Abdominal computed tomography disclosed a huge retroperitoneal hematoma, and selective SMA angiography demonstrated an aneurysm arising from the inferior pancreaticoduodenal artery, and celiac arteriography showed a stenotic celiac arterial root. Because angiography showed no active bleeding from the aneurysm, percutaneous transluminal angioplastic stenting of the stenotic celiac artery was performed. She was discharged 5 days later and has had no further bleeding episode for 2 years. Celiac arterial stenting, as shown in our two patients, could be easily and safely employed in patients with PDA aneurysm associated with a stenotic celiac arterial root to release the stenosis of the celiac arterial root and to prevent further possible bleeding.

DUODENAL OBSTRUCTION BY RETROPERITONEAL HEMATOMA INDUCED BY SEVERE BLUNT RENAL TRAUMA

Blunt trauma is the most common cause of renal injury. Of renal injuries 85% are classified as minor, corresponding to grades I to II on the organ injury scale, and are treated conservatively.1 Major renal injuries (grades III to V) represent the remaining 15% of cases and management remains controversial.1, 2 Perirenal and/or retroperitoneal hemorrhage is a common complication of renal trauma. Significant hypovolemia, abdominal tenderness, adynamic ileus, tender palpable mass and bluish discoloration of the flank are signs of retroperitoneal hemorrhage. In our patient major right renal injury resulting in a huge retroperitoneal hematoma was treated conservatively. However, obstruction of the second portion of the duodenum by the retroperitoneal hematoma developed 16 days after trauma. To our knowledge obstruction of the duodenum induced by severe retroperitoneal hematoma has not been reported in patients with major renal trauma, al-

Massive retroperitoneal hemorrhage associated with femoral vein cannulation

The right external iliac artery was inadvertently punctured during attempted right femoral vein catheterization. Severe hypotension developed several minutes after the arterial puncture. Concurrently, a large right lower abdominal quadrant swelling (≈5 cm in diameter) became apparent. Laparoscopic observation of the retroperitoneal region immediately revealed massive retroperitoneal hemorrhage. Abdominal computerized tomographic scan indicated development of a huge (≈10 cm in the maximum diameter) retroperitoneal hematoma along the right psoas muscle from the level of the right external iliac vessels up to the level of the upper pole of the right kidney. Consideration of the anatomy of the “right” femoral and retroperitoneal vessels ( ie, mediolateral relationship between the vein and artery) led us to conclude that the site for insertion of the needle was too proximal and the angle for advancement of the needle too low in our patient, allowing the needle to reach and injure the “incompressible” external iliac artery, thereby causing massive retroperitoneal hemorrhage. Although femoral vein catheterization has generally been considered a relatively safe method of intravenous access, a life-threatening serious complication can occur with the inappropriate technique used in our case.

RETROPERITONEAL HEMATOMA DUE TO RUPTURE OF A PSEUDOANEURYSM CAUSED BY ACUPUNCTURE THERAPY

Acupuncture, an ancient technique using needle insertion at specific points on the body for a specific therapeutic effect, has now become a major alternative treatment. Approrrimately 1 million patients visited an acupuncture professional in the United States in 1994.' However, several complications have been reported, including spinal cord injury, needle migration in the medulla oblongata, fatal cardiac tamponade, pneumothorax, spinal epidural hematoma and subcutaneous pseudoaneurysm.'Z3 To our knowledge we report the first case of retroperitoneal hematoma caused by acupuncture therapy. CASE REPORT A 72-year-old Japanese woman with essential hypertension underwent acupuncture therapy performed by a physician for relief of persistent lumbago. Several needles were inserted into the right loin region, followed by electroacupuncture stimulation. Four hours later the patient visited another hospital complaining of nausea and right flank pain. Abdominal computerized tomography (CT) demonstrated a large retroperitoneal mass around the right kidney (fig. 1, A). The patient was referred to our hospital due to hypotension with tachycardia. Selective right renal arteriography revealed 3 sections of pseudoaneurysm with rupture, presumably caused by acupuncture therapy (fig. 2). Subsequent selective arterial embolization by metallic coil resulted in good function of the affected kidney (fig. 1, B). DISCUSSION Various complications due to acupuncture therapy have been reported, including spinal cord injury (acute transverse myelopathy), perineal nerve palsy, embedded type needle migration in the medulla oblongata, fatal cardiac tamponade, pneumothorax, spinal epidural hematoma and pseudaneury~m.~,~ A huge retroperitoneal hematoma requiring a subsequent hemostatic procedure is a rare and serious complication of acupuncture therapy. The diagnosis is easy to establish in cases of embedded needle, since the needle may be identified on radiography. However, a detailed patient

Idiopathic Rupture of the Iliac Vein

<i>To the Editor</i>.—It was with great interest that we noted the report "Idiopathic Rupture of the Iliac Vein," by Brown et al (<i>Arch Surg</i>112:95, 1977). In September of 1976, we encountered a strikingly similar case. A 70-year-old woman was admitted to the Toronto Western Hospital with an eight-hour history of severe low back pain of sudden onset. Initial examination revealed a systolic blood pressure of 40 mm Hg and a mass in her abdomen. A tentative diagnosis of a leaking abdominal aortic aneurysm was made and she was taken to surgery. The findings at laparotomy included a huge retroperitoneal hematoma originating from a 3-cm tear in the left common iliac vein. Despite extensive search, no other source for the bleeding was found and no other pathology was demonstrated. The tear was repaired and the procedure was terminated. The patient's postoperative course was marked by a left iliofemoral venous