Hemorrhage After Percutaneous Transluminal Angioplasty Localized in the Lateral Abdominal Wall: A Rare Location

VASCULAR DISEASE MANAGEMENT 2010;7(12):E240-E244

Abstract

Purpose. We sought to increase awareness of hemorrhage to the lateral abdominal wall after percutaneous transluminal angioplasty. We report on 3 female patients who presented with complaints of peripheral vascular occlusive disease. Duplex and magnetic resonance imaging showed stenosis or occlusion of an iliac or more distal artery. Via puncture of the femoral artery, the patients underwent percutaneous transluminal angioplasty of the stenotic portion of the vessel with simultaneous recanalization or a stent. After the procedure, all 3 patients suffered from bleeding which spread to the lateral abdominal wall. Surgical decompression and repair of the artery were necessary. Conclusion. Hemorrhage to the lateral abdominal wall is a rare anatomic location but can have fatal consequences if abdominal compartment syndrome develops. In our opinion, it is important to be vigilant about this life-threatening condition when hemorrhage occurs after percutaneous transluminal angioplasty.

Introduction

Peripheral vascular illness, according to the Fontaine classification with staging 2B, 3 and 4, is frequently treated by percutaneous transluminal angioplasty (PTA). In such a procedure, access is gained via the femoral artery. Over the past few decades the incidence of bleeding complications after PTA has decreased due to smaller catheter sizes.¹ In the literature, the incidence of local vascular complications that required surgical repair varies between 4% and 12%.^2–4 The rate of bleeding complications is often difficult to precisely analyze because of multiple factors. The significant hematomas occurring after catheterization, however, occur mostly as groin, thigh or retroperitoneal hematomas. We report 3 cases of a seldom observed anatomic location of this hemorrhage by puncture of the femoral artery — namely in the lateral abdominal wall.

Case Reports

Case 1

A 76-year-old female presented to the outpatient clinic with complaints of a constant burning sensation in her feet and mostly her toes. She suffered day and night from this sensation. In her previous medical history she was diagnosed with decompensatio cordis, paroxysmal atrial fibrillation, for which she was taking sintromitis; she also was found to have hypertension and hypercholesterolemia. At physical examination there was erythema of her 5 toes of the left foot. Furthermore, the skin was blistering. There were normal pulsations at the groin level on both sides, but further down all pulses were absent. One week later, she was admitted to the cardiology department because of a new episode of cardiac decompensation. During this admission we were asked to evaluate her feet and toes again. At this time, the distal ends of her toes of her left foot were blue. There was a symmetrical sensibility in comparison to her right foot and the muscle function was also normal. We performed an ankle/arm index, which scored 0.4 on the left side; the right side was normal. An additive duplex test showed an occlusion of her femoral artery over a length of 9 cm. We scheduled the patient for PTA and recanalization of the vessel lumen. The procedure was done with a 6 Fr catheter to enable the placement of a self-expandable stent. Because of urokinase treatment she was admitted to the intensive care unit (ICU) for observation. On the second day of urokinase treatment, the patient developed a small hematoma in her left groin. She had abdominal pain and was feeling nauseous. Her blood pressure dropped markedly and her Hb-level decreased to 4.4 mmol/L. On computed tomographic (CT) imaging a false aneurysm of the femoral artery was visible with spreading of the bleeding to the left abdominal wall. The patient was brought to the operating room where a large puncture hole was seen in the artery and was repaired by suture. The bleeding had spread upwards via Poupart’s ligament. This was explored via a small incision in the right lower abdomen. We removed 2 liters of blood from the flank. The patient stabilized and was transported back to the ICU. Postoperatively, the patient recovered without complications and was discharged home in a stable condition 8 days later.

Case 2

An 82-year-old female was diagnosed with peripheral arterial occlusive disease (PAOD), Rutherford category 4. On magnetic resonance imaging with contrast there were 2 stenoses: 1 localized at the left common iliac artery and 1 at the left popliteal artery. The patient underwent PTA with a 5 Fr catheter. In spite of a long period of manual pressure after the PTA, within 2 hours she developed a hematoma in her left groin. She was pale and perspiring. Her blood pressure dropped to 100/60 mmHg and her pulse rose above 100 beats per minute. The patient was brought to the operating room. We made a lengthwise incision over her groin continuing to her lower left abdomen through Poupart’s ligament. A very large hematoma was relieved from the flank. After manual pressure and evacuation of most of the blood, the puncture hole was identified and repaired. Case 3. An 80-year-old female who was in follow-up for PAOD complaints (category 3 Rutherford) and who had undergone PTA of the left external iliac artery in 2006, presented to the out-patient clinic with progression of pain in her right leg. A duplex test showed a 70–90% stenosis of the popliteal artery. Her ankle/arm index decreased from 0.7 to 0.3 when walking. She underwent PTA with a 5 Fr catheter. A couple of hours after the procedure a hematoma appeared in her right groin. Her blood pressure was stable and she had a steady pulse of approximately 65 beats per minute. On ultrasound examination it became clear that there had been bleeding from the external iliac artery. The patient was brought to the operation room where we explored the iliac artery. An incision was then made in the right groin continuing to the lower right abdomen. Here we evacuated a large hematoma from the flank. The bleeding was identified and repaired.

Discussion

Percutaneous transluminal angiography and angioplasty are nowadays performed with small-sized 5 or 6 Fr catheters. The use of these small catheters has proven to be safe and there is a good quality of contrast delivery to the blood vessel.⁵ Because of the smaller puncture hole, local vascular complications have decreased.¹ This includes bleeding complications from the puncture hole, which still is a concern for most doctors who perform PTA. The incidence of arterial injury requiring surgery has been reported to range from 0.35–5% in several large series.^3,6,7 Due to improved equipment, increased operator experience and the use of anticoagulants, this rate has rapidly improved and is now 8 Significant bleeding at the puncture site is a complication that requires immediate assessment and treatment. CT is the preferable imaging modality to detect the location and size of hematomas and can identify resultant significant bleeding requiring surgical intervention. There are several ways such bleeding spreads, the most common of which are groin and retroperitoneal bleeding.⁹ In our cases the bleeding spread to the abdominal wall. There are minimal reports in the literature of bleeding that spread to the abdominal wall following PTA. The present series of 3 patients in a 4-month timeframe with hemorrhage to the flank is quite remarkable. Taking into account our patients’ anatomy, the routes of the bleeding spread can be explained, and the location of hematomas was the result of spread along the fascial planes. The femoral sheath, containing the femoral artery, femoral vein and a few lymphatic vessels, is funnel-shaped with the tip directed inferiorly.¹⁰ If bleeding spreads to the abdominal wall, as in our cases, it is guided anteriorly by the wall of the sheath, which is formed by a continuation of the transversalis fascia and is therefore in direct communication with the anterior abdominal wall. An alternative route is along the epigastric vessel sheaths penetrating the transversalis fascia. In contrast to bleeding into the abdominal wall after PTA, there is another type of bleeding that can mimic similar symptoms, namely rectus sheath hematoma (RSH). RSH is an accumulation of blood in the sheath of the rectus abdominis secondary to rupture of an epigastric vessel or muscle tear.¹¹ RSH is usually located infra-umbilically and is often misdiagnosed as an acute abdomen, which may lead to unnecessary negative laparotomies and increased morbidity and mortality. RSH could, however, lead to the abdominal compartment syndrome and multiorgan dysfunction in cases of major bleeding.¹² Despite the fact that RSH has never been described after a PTA procedure, it could be considered in the differential diagnosis in post-PTA patients with acute abdominal pain. In the current era, the emphasis is increasingly shifting toward patient comfort and cost-effective treatment. As a result, various kinds of arterial puncture closure devices (APCDs) have been developed to avoid manual compression and shorten bed rest time. In our cases, however, no APCDs were used. The greatest benefit of APCD use is rapid achievement of hemostasis and early ambulation after PTA compared with manual compression.13 However, several studies have shown that APCDs are associated with an increased risk of vascular complications such as hematomas and pseudoaneurysms.^13,14 Thus, it is important to consider these results when performing a percutaneous vascular intervention with the use of an APCD. We feel that the advantages and disadvantages of APCDs for the cases described here are not of that great importance. The issue here was bleeding which spread to the abdominal wall. Such bleeding can be very difficult to detect, but is evident in surgery. As mentioned above, bleeding into the abdominal wall is rare. There are small visible clinical symptoms that indicate the spread of bleeding to the flank because the hematoma is not usually visible. In contrast to spreading to the groin or the retroperitoneal cavity, a life-threatening complication of a hematoma in the abdominal wall is abdominal compartment syndrome. Intra-abdominal pressure (IAP) is normally around 5 mmHg and increases when the volume of the abdominal contents or the surrounding spaces rises.¹⁵ When increased pressure (IAP > 20 mmHg) persists, this may result in abdominal compartment syndrome. This is a serious condition with severe organ dysfunction, which may cause sepsis and eventually lead to the death of the patient. Timely recognition and treatment of this syndrome is of the utmost importance. Therefore, surgical decompression of the hematoma of the abdominal wall is necessary to avoid the development of compartment syndrome and is the definitive treatment. Every year, an increasing number of people are diagnosed with PAOD, and because of the continued increase in life expectancy, the demand for PTA procedures will rise. Today, more and more hospitals are evaluating the possibilities of outpatient treatment. As a result, ambulation times are decreasing. As stated earlier, bleeding complications have already been reduced by smaller catheter sizes, but these complications are also dependent upon the compression time and duration of bed rest after the procedure. In our cases, we applied 15 minutes of manual compression before a compression bandage was placed. Then the patients were transported to the ward where they ambulated 6 hours after the procedure. In a randomized study by Thoré et al, it became clear that there was a significant difference in compression time in regard to immediate bleeding between the two groups they studied.¹⁶ The first group consisted of patients undergoing 5-minute compression and the second group consisted of patients undergoing 15-minute compression. Twelve patients (17%) from the first group and 3 (5%) from the second group had complications involving immediate bleeding (p 1 Baum and Gantt conducted a study of 205 patients where one group had 2-hour bed rest and the other had 4-hour bed rest. In the 2-hour group, 3 patients (3%) experienced re-bleeding and 2 patients (2%) formed a hematoma. In the 4-hour group, 2 patients (2%) had re-bleeding and 1 patient (1%) formed a hematoma. The authors state that on the basis of their results, 2-hour bed rest duration is safe in the majority of patients when a 5 or 6 Fr catheter is used.¹⁷ If we compare our own practice of 6-hour bed rest, we could reduce this time by at least 2 hours, increase patient comfort due to less time in bed and reduce hospital costs due to reduced length of stay for outpatient procedures.

Conclusion

In this era of constant striving by institutions to save time and money, we think it is important to stay alert to possible bleeding after PTA procedures. Despite the low incidence of bleeding, one should watch for hematomas, changed vital signs or pain, which can be symptoms that indicate a life-threatening condition such as hemorrhage with spreading to the abdominal wall or even to the retroperitoneal cavity.

Disclosure:The authors report no conflicts of interest regarding the content herein.

Manuscript submitted July 21, 2010, provisional acceptance given October 19, 2010, final version accepted November 3, 2010.

Address for correspondence: Roy J. Sauren, MD, Department of Surgery, Amphia Hospital, Molengracht 21, Breda, The Netherlands 4818 CK. E-mail: roysauren@hotmail.com

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