Spontaneous Epigastric Arterial Bleeding Associated with Abciximab: Successful Percutaneous Treatment with Coil Gel-Foam Emboliz

The use of glycoprotein IIb/ IIIa antagonists in the cardiac catheterization laboratory has continued to increase. These agents, however, have been associated with an increase in both minor and major bleeding complications.1,2 Such complications include bleeding from access sites as well as from the gastrointestinal tract.1,2 Although infrequent, intracerebral bleeding is a well-recognized catastrophic complication.1,2 We describe a case of spontaneous hemorrhage from a branch of the right inferior epigastric artery, unrelated to the access site. This complication occurred in association with the administration of abciximab. Prompt identification of this unusual complication resulted in successful bleeding control using coil and gel-foam embolization. Case Report. A 60-year-old female with a history of hypertension, hyperlipidemia and diabetes mellitus presented with unstable angina. Coronary angiography demonstrated an ulcerated culprit lesion in the left circumflex artery for which an intervention was planned. Anticoagulation in the catheterization laboratory was achieved using unfractionated heparin at a dose of 70 mg/kg targeted to maintain an activated clotting time of 250 seconds. Peri-procedure abciximab was administered utilizing the standard bolus and infusion regimen (0.25 mg/kg bolus followed by 0.125 µg/kg/minute infusion). Uncomplicated percutaneous transluminal angioplasty and stent deployment were performed in the left circumflex artery with excellent angiographic results. The right femoral arterial sheath was sewn in place following stent deployment. Approximately 1 hour after the procedure, the patient complained of abdominal pain. On physical examination, she was found to be hypotensive with a systolic blood pressure of 88 mmHg and pulse rate of 122 bpm. The patient was found to have a tender abdominal mass measuring 15 cm x 15 cm, suggestive of a rectus sheath hematoma. No bleeding was noted around the femoral arterial access site. Prompt fluid resuscitation was instituted and the abciximab infusion was discontinued. Computed tomography of the abdomen demonstrated large amounts of blood in the pelvis bilaterally and in the retroperitoneal space. A smaller hematoma was also identified within the rectus sheath. The patient’s hematocrit dropped from 36% to 14% at 3 hours post-procedure, and she was transfused with packed red cells, platelets and fresh frozen plasma. Emergent angiography revealed the bleeding site to be a branch of the right inferior epigastric artery deep in the pelvis and remote from the sheath site (Figure 1). A 0.014´´ guidewire was placed through a transport catheter utilizing a retrograde approach from the left femoral artery. Three coils were then deployed in the bleeding branch and gel-foam was deployed proximal to the coils. Successful gel-foam embolization was confirmed by the absence of contrast extravasation into the pelvis on repeat angiography (Figure 2). Due to a large volume of residual blood in the abdomen and pelvis, the patient subsequently underwent surgery. Three liters of blood were evacuated from the abdominal cavity. The patient’s post-operative recovery was unremarkable and she was discharged 4 days later. Discussion. Abciximab, a potent inhibitor of the platelet glycoprotein IIb/IIIa receptor, reduces thrombotic complications and is of added benefit in patients undergoing percutaneous coronary intervention.1,3–5 It is, however, recognized that the widespread use of abciximab has resulted in significant bleeding complications.1,2 These hemorrhagic events include but are not limited to bleeding from puncture sites, intracranial hematoma, gastrointestinal bleeding and alveolar hemorrhage.1,2 Our purpose is to draw attention to yet another potentially catastrophic adverse side effect of abciximab infusion. It is difficult to speculate as to the etiology of the rupture; however, it is possible that the presence of a heightened sympathetic state may have led to arterial disruption in this already diseased arterial bed. To our knowledge, spontaneous rupture of an inferior epigastric artery during abciximab therapy has not been previously reported. In addition, coil and gel-foam treatment of this artery in such a setting has not been described. As with the other described complications, due diligence is required so that spontaneous arterial bleeding can be identified and swift intervention be undertaken. Acknowledgment. We would like to thank Aubrey Palestrant, MD, for his expertise with the gel foam embolization.

1. The EPIC Investigators. Use of a monoclonal antibody directed against the platelet glycoprotein IIb/IIIa receptor in high-risk coronary angioplasty. N Engl J Med 1994;330:956–961. 2. Hemorrhagic and vascular complications after percutaneous coronary intervention with adjunctive abciximab. Mayo Clin Proc 2001;76:890–896. 3. The CAPTURE Investigators. Randomized placebo-controlled trial of abciximab before and during coronary intervention in refractory unstable angina: The CAPTURE Study. Lancet 1997;349:1429–1435. 4. The EPILOG Investigators. Platelet glycoprotein IIb/IIIa receptor blockade and low-dose heparin during percutaneous coronary revascularization. N Engl J Med 1997;336:1689–1696. 5. The EPISTENT Investigators. Randomized placebo-controlled and balloon-angioplasty-controlled trial to assess safety of coronary stenting with use of platelet glycoprotein IIb/IIIa blockade. Lancet 1998;352:87–92.