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Retroperitoneal hematoma as a complication of coronary angiography and stenting

      To the Editor:—Retroperitoneal hematomas (RPH) are usually the result of trauma of the retroperitoneal organs such as the pancreas, duodenum, and kidneys. In elderly people and those with long-standing hypertension and atherosclerotic disease, they could also be a sign of a leaking abdominal aortic aneurysm (AAA).
      • Johnson G.A
      Aortic dissection and aneurysms.
      Although most cases are associated with trauma or leakage of an AAA, they could also be caused by vascular procedures such as percutaneous transluminal coronary angioplasty (PTCA), cardiac catheterization, peripheral angioplasty, valvuloplasty, and peripheral arterial access catheterization.
      • Johnson G.A
      Aortic dissection and aneurysms.
      These hematomas are often difficult to diagnose and could masquerade as other retroperitoneal and intestinal pathology. The diagnosis is thus a challenge. We report a case of RPH in a middle-aged man, suffered after cardiac catheterization, to discuss possible misdiagnoses and to review this uncommon entity.
      A 43 year-old man presented to the ED with vomiting for 8 hours. He awoke 9 hours prior with sudden onset of left groin/testicular pain. He took a standard over-the-counter dose of ibuprofen, which brought about minor relief. One hour after, the patient had several episodes of vomiting and was unable to tolerate anything by mouth. He denied any chest pain or shortness of breath, hematemesis, diarrhea, melena, or bright red blood per rectum. All other review of systems was negative. His medical history was significant for coronary artery disease, stent placement 7 years previously, and two coronary angiograms with stent placement 1 week ago. His regular medications were metoprolol, clopidrogel, atorvastatin, lisinopril, and aspirin. He had no known drug allergies and denied alcohol, tobacco, or illicit drug use.
      On physical examination, the patient was pale, diaphoretic, and writhing in pain. Vital signs were all normal. The physical examination was normal except for the abdominal examination. On abdominal examination, the patient was mildly tender to palpation, without rebound or guarding, in the hypogastric area. It was noted that the patient was also tender in the left inguinal canal but no hernias were appreciated and the genitourinary examination was normal. Rectal examination was positive for occult blood.
      A complete blood count, chemistry panel, including liver enzymes, and urinalysis were performed. All results were normal. Electrocardiogram, chest x-ray, and abdominal series were all normal.
      The patient was thought to have a hernia and a surgical consult was obtained. No hernia was present at the time, but the thinking was that the patient could have had a hernia on presentation, which led to the nausea and vomiting but had subsequently reduced by itself. A computed tomography (CT) abdomen/pelvis scan was obtained to evaluate for possible bowel obstruction, hernia (inguinal or obturator), abscess, or fluid collection.
      The CT abdomen/pelvis scan demonstrated a RPH and the patient was admitted to the Medicine service (FIGURE 1, FIGURE 2). A unilateral lower extremity arterial duplex was performed to rule out pseudoaneurysm. No evidence of a pseudoaneurysm was found and the patient’s hemoglobin/hematocrit remained stable. The patient was discharged home without complication on hospital day 3.
      Figure thumbnail GR1
      FIGURE 1Computed tomography scan showing a fluid collection abutting the left psoas muscle.
      Figure thumbnail GR2
      FIGURE 2Computed tomography scan demonstrating the retroperitoneal hematoma tracking inferiorly into the pelvis.
      Cardiac catheterization has an incidence of major vascular complications between 0.3% and 6%.
      • Ricci M.A
      • Trevisani G.T
      • Pilcher D.B
      Vascular complications of cardiac catheterization.
      ,
      • Sreeram S
      • Lumsden A.B
      • Miller J.S
      • et al.
      Retroperitoneal hematoma following femoral arterial catheterization a serious and often fatal complication.
      Hematoma is the most frequent complication (0.9–1.27%), with the incidence of retroperitoneal hematoma resulting from cardiac catheterization reported to be approximately 0.12%.
      • Ricci M.A
      • Trevisani G.T
      • Pilcher D.B
      Vascular complications of cardiac catheterization.
      ,
      • Sreeram S
      • Lumsden A.B
      • Miller J.S
      • et al.
      Retroperitoneal hematoma following femoral arterial catheterization a serious and often fatal complication.
      ,
      • Johnson L.W
      • Esente P
      • Giambartolomei A
      • et al.
      Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques.
      Four distinct types of postcatheterization hematomas are mentioned in the literature: retroperitoneal hematoma, intraperitoneal hematoma, groin and thigh hematoma, and abdominal wall hematoma. Other vascular complications include retroperitoneal bleeding, false aneurysms, arterial occlusion, arterial dissection, arterial laceration, arteriovenous fistula, infection, and cholesterol em-boli.
      • Johnson L.W
      • Esente P
      • Giambartolomei A
      • et al.
      Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques.
      ,
      • Kent K.C
      • Moscucci M
      • Mansour K.A
      • et al.
      Retroperitoneal hematoma after cardiac catheterization prevalence, risk factors, and optimal management.
      ,
      • Franco C.D
      • Goldsmith J
      • Veith F.J
      • et al.
      Management of arterial injuries produced by percutaneous femoral procedures.
      There are several risk factors for the development of a postcatheterization hematoma. These include advanced patient age (greater than 60), female sex, hypertension, low platelet count, large-bore catheters, operator inexperience, poor groin compression after catheter removal, high puncture site, abnormal vessel or graft, clinical evidence of peripheral vascular disease, and anticoagulant—thrombolytic therapy.
      • Ricci M.A
      • Trevisani G.T
      • Pilcher D.B
      Vascular complications of cardiac catheterization.
      ,
      • Johnson L.W
      • Esente P
      • Giambartolomei A
      • et al.
      Peripheral vascular complications of coronary angioplasty by the femoral and brachial techniques.
      ,
      • Trerotola S.O
      • Kuhlman J.E
      • Fishman E.K
      Bleeding complications of femoral catheterization CT evaluation.
      The likelihood of a vascular injury is higher after coronary angioplasty or stent placement than after angiography alone.
      • Ricci M.A
      • Trevisani G.T
      • Pilcher D.B
      Vascular complications of cardiac catheterization.
      ,
      • Kent K.C
      • Moscucci M
      • Mansour K.A
      • et al.
      Retroperitoneal hematoma after cardiac catheterization prevalence, risk factors, and optimal management.
      The diagnosis is elusive and could mimic other diseases. Spontaneous RPHs usually do not present with a Cullen’s sign or Grey-Turner’s sign. Retroperitoneal blood could also dissect into the perineum or groin and cause scrotal hematomas, inguinal masses, or scrotal/inguinal pain, as observed in this case.
      • Johnson G.A
      Aortic dissection and aneurysms.
      It has also been reported that retroperitoneal blood could irritate the psoas muscle and produce an iliopsoas sign such as is occasionally seen in appendicitis. Neurologic signs could be present as a result of compression of the femoral, obturator, and lateral femoral cutaneous nerves.
      • Sreeram S
      • Lumsden A.B
      • Miller J.S
      • et al.
      Retroperitoneal hematoma following femoral arterial catheterization a serious and often fatal complication.
      Nonspecific symptoms could be the only clue to intraabdominal pathology and recently performed procedures must be considered.
      In cases in which the diagnosis of RPH is suspected, the definitive diagnosis can be made by CT scan. Ultrasound is a useful adjunct because it could demonstrate free fluid in the peritoneal cavity and provide a clue to the diagnosis.

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