Treatment of Inferior Epigastric Pseudoaneurysm and Rectus Sheath Hematoma through Percutaneous Direct Sac Puncture and Embolization using N-Butyl Cyanoacrylate
In a recent case, a 72-year-old female with a complex medical history presented with abdominal pain and swelling. With a history of heart failure with preserved ejection fraction (HFpEF), atrial fibrillation on Eliquis, and an abdominal aortic aneurysm (AAA) status post endovascular aneurysm repair (EVAR), complicated by Type 2 endoleak, the patient's condition was a testament to the challenges that can arise in such cases.
Computed tomography angiography (CTA) of the abdomen and pelvis revealed a large left rectus sheath hematoma with a left inferior epigastric pseudoaneurysm, but no evidence of active extravasation. Rectus sheath hematomas, though rare, are often associated with abdominal wall trauma and anticoagulation, particularly in elderly patients.
The large left rectus sheath hematoma and left inferior epigastric pseudoaneurysm were visualized in Figs. 1 and 2. Vascular injury, especially involving the inferior epigastric artery, is more common below the arcuate line due to the absence of a posterior sheath. The case highlighted the use of N-butyl cyanoacrylate (NBCA) for direct sac puncture and embolization of the inferior epigastric pseudoaneurysm, providing an alternative to conventional thrombin injection or transcatheter arterial embolization (TAE).
Several studies have demonstrated the safety and efficacy of liquid embolic agents such as NBCA for RSH treatment. The IR procedure for embolization was depicted in Fig. 3. The advantages of using NBCA include rapid polymerization, mechanical vessel occlusion that does not depend on the patient's coagulation status, superior penetration into distal and collateral vessels, and the ability to be delivered through small catheters (e.g., 5Fr), facilitating minimally invasive procedures. These properties lead to efficient and controlled embolization with lower risk of recanalization and complications related to incomplete occlusion.
On presentation, the patient was hemodynamically stable with a hemoglobin level of 8.5, which downtrended to 6.3. The patient was consulted for interventional radiology (IR) for embolization. NBCA offers advantages including controlled penetration into both afferent and efferent feeders, reducing recanalization risk, and maintaining its effectiveness regardless of coagulopathic status.
Re-bleeding remains a problem with TAE due to retrograde flow from collaterals, vessel recanalization, and loss of tamponade effect. Transcatheter arterial embolization (TAE) is a well-documented method for RSH management, with microcoils and gelfoam being the most commonly used embolic agents. However, the use of NBCA provides a viable alternative, especially for superficial pseudoaneurysms with challenging vascular anatomy.
Additional vascular supply to the rectus sheath includes the superficial epigastric artery and rarely the deep circumflex iliac artery. The case underscores the importance of understanding the vascular anatomy in such complex cases to ensure effective treatment.
In summary, NBCA's rapid action, independence from coagulation, and deep vascular penetration make it especially advantageous for embolizing challenging bleeding sources like inferior epigastric pseudoaneurysms and rectus sheath hematomas. Further research and clinical trials are needed to fully understand the potential of NBCA in these types of cases.
[1] Reference omitted for brevity. [4] Reference omitted for brevity.
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