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Management of spontaneous soft-tissue hemorrhage secondary to anticoagulant therapy: A cohort study

Published:March 26, 2018DOI:https://doi.org/10.1016/j.ajem.2018.03.061

      Abstract

      Study objective

      The optimal management of patients receiving heparin, warfarin or direct anti-coagulant therapy who experience spontaneous, severe, life-threatening soft-tissue hemorrhage (SSTH) is unclear. The purpose of this study is to investigate efficacy and safety of the interventional protocol implemented in our department.

      Methods

      In this retrospective cohort study, we analyzed data from 80 consecutive patients with SSTH secondary to anticoagulation therapy diagnosed by the appropriate computed tomography scan. All patients received a structured clinical pathway, including aggressive resuscitation, reversal of coagulopathy when indicated, Interventional Radiology procedures by transcatheter embolization (TE), clinical observation and repeated laboratory controls.

      Results

      We enrolled 80 patients from 2013 to 2017. Angiography was performed in 60 patients (75%). It revealed the bleeding site in 46 cases, and a TE was performed in all. The rates of technical success of TE, primary clinical success and bleeding control were 98% (45/46), 91% (73/80) and 89% (71/80) respectively. In 5 patients (6%) the control of the bleeding was obtained with a second TE. Short-term and 30-day mortality was 5% (4 patients) and 11% (9 patients), respectively. No adverse events were observed.

      Conclusion

      A structured clinical pathway, including TE seems to be an effective and safe method to manage the patients with SSTH due to anticoagulant treatment.
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      References

        • Titone C.
        • Lipsius M.
        • Krakauer J.S.
        “Spontaneous” hematoma of the rectus abdominis muscle: critical review of 50 cases with emphasis on early diagnosis and treatment.
        Surgery. 1972; 72: 568-572
        • Dohan A.
        • Darnige L.
        • Sapoval M.
        • et al.
        Spontaneous soft tissue hematomas.
        Diagn Interv Imaging. 2015; 96: 789-796
        • Sunga K.
        • Bellolio F.
        • Gilmore R.
        • et al.
        Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome.
        J Emerg Med. 2012; 43: e157-61
        • Cherry W.B.
        • Mueller P.S.
        Rectus sheath hematoma: review of 126 cases at a single institution.
        Medicine (Baltimore). 2006; 85: 105-110
        • Hodin E.
        • Dass T.
        Spontaneous retroperitoneal hemorrhage complicating anticoagulant therapy.
        Ann Surg. 1969; 170: 848-851
        • Zidane M.
        • Schram M.T.
        • Planken E.W.
        • et al.
        Frequency of major hemorrhage in patients treated with unfractionated intravenous heparin for deep venous thrombosis or pulmonary embolism: a study in routine clinical practice.
        Arch Intern Med. 2000; 160: 2369-2373
        • Berna J.D.
        • Zuazu I.
        • Madrigal M.
        • et al.
        Conservative treatment of large rectus sheath hematoma in patients undergoing anticoagulant therapy.
        Abdom Imaging. 2000; 25: 230-234
        • Ekici Y.
        • Aydogan C.
        • Yagmurdur M.C.
        • et al.
        Treatment approaches for spontaneous retroperitoneal bleeding.
        Int Surg. 2009; 94: 257-262
        • Zissin R.
        • Ellis M.
        • Gayer C.
        The CT findings of abdominal anticoagulant-related hematomas.
        Semin Ultrasound CT MR. 2006; 27: 117-125
        • Wang Z.W.
        • Xue H.D.
        • Li X.G.
        • et al.
        Life-threatening spontaneous retroperitoneal haemorrhage: role of multidetector CT-angiography for the emergency management.
        Chin Med Sci J. 2016; 31: 43-48
        • Sharafuddin M.J.
        • Andresen K.J.
        • Sun S.
        • et al.
        Spontaneous extraperitoneal hemorrhage with hemodynamic collapse in patients undergoing anticoagulation: management with selective arterial embolization.
        J Vasc Interv Radiol. 2001; 12: 1231-1234
        • Isokangas J.M.
        • Perala J.M.
        Endovascular embolization of spontaneous retroperitoneal hemorrhage secondary to anticoagulant treatment.
        Cardiovasc Intervent Radiol. 2004; 27: 607-611
        • Farrelly C.
        • Fidelman N.
        • Durack J.C.
        • et al.
        Transcatheter arterial embolization of spontaneous life-threatening extraperitoneal hemorrhage.
        J Vasc Interv Radiol. 2011; 22: 1396-1402
        • Wick M.C.
        • Klocker J.
        • Grundtman C.
        • et al.
        Transcatheter embolization for the management of acute active inferior epigastric artery hemorrhages.
        J Endovasc Ther. 2013; 20: 561-567
        • Pode D.
        • Caine M.
        Spontaneous retroperitoneal hemorrhage.
        J Urol. 1992; 147: 311-318
        • Dabney A.
        • Bastani B.
        Enoxaparin-associated severe retroperitoneal bleeding and abdominal compartment syndrome: a report of two cases.
        Intensive Care Med. 2001; 27: 1954-1957
        • Vaya ́ A.
        • Mira Y.
        • Aznar J.
        • et al.
        Enoxaparin-related fatal spontaneous retroperitoneal hematoma in the elderly.
        Thromb Res. 2003; 110: 69-71
        • Antón E.
        • Marti J.
        Enoxaparin-associated spontaneous thigh haematoma.
        Age Ageing. 2004; 33: 641-642
        • Surani S.
        • Estement B.
        • Manchandan S.
        • et al.
        Spontaneous extraperitoneal lumbar artery hemorrhage.
        J Emerg Med. 2011; 40: e111-4
        • Tsai J.L.
        • Yang P.J.
        • Lin H.Y.
        • et al.
        Spontaneous iliopsoas hematoma.
        J Emerg Med. 2016; 51: e53-4
        • Katsumori T.
        • Nakajima K.
        A case of spontaneous hemorrhage of the abdominal wall caused by rupture of a deep iliac circumflex artery treated by transcatheter arterial embolization.
        Eur Radiol. 1998; 8: 550-552
        • Qanadli S.D.
        • El Hajjam M.
        • Mignon F.
        • et al.
        Life-threatening spontaneous psoas haematoma treated by transcatheter arterial embolization.
        Eur Radiol. 1999; 9: 1231-1234
        • Pathi R.
        • Voyvodic F.
        • Thompson W.R.
        Spontaneous extraperitoneal haemorrhage: computed tomography diagnosis and treatment by selective arterial embolization.
        Australas Radiol. 2004; 48: 123-128
        • Zissin R.
        • Gayer G.
        • Kots E.
        • et al.
        Transcatheter arterial embolization of concurrent spontaneous hematomas of the rectus sheath and psoas muscle in patients undergoing anticoagulation.
        Cardiovasc Intervent Radiol. 2004; 27: 659-662
        • Zissin R.
        • Gayer G.
        • Kots E.
        • et al.
        Transcatheter arterial embolisation in anticoagulant-related haematoma-a current therapeutic option: a report of four patients and review of the literature.
        Int J Clin Pract. 2007; 61: 1321-1327
        • Wick M.C.
        • Klocker J.
        • Grundtman C.
        • et al.
        Transcatheter embolization for the management of acute active inferior epigastric artery hemorrhages.
        J Endovasc Ther. 2013; 20: 561-567
        • Kolber M.K.
        • Shukla P.A.
        • Kumar A.
        • et al.
        Ethylene vinyl alcohol copolymer (onyx) embolization for acute hemorrhage: a systematic review of peripheral applications.
        J Vasc Interv Radiol. 2015; 26: 809-815
        • Ozyer U.
        Transcatheter arterial embolization with N‑butyl‑2‑cyanoacrylate in the management of spontaneous hematomas.
        Cardiovasc Intervent Radiol. 2017; 40: 41-49
        • Llitjos J.F.
        • Daviaud F.
        • Grimaldi D.
        • et al.
        Ilio-psoas hematoma in the intensive care unit: a multicentric study.
        Ann Intensive Care. 2016; 6: 8-14
        • von Elm E.
        • Altman D.G.
        • Egger M.
        • et al.
        The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies.
        Lancet. 2007; 370: 1453-1457
        • Olaussen A.
        • Blackburn T.
        • Mitra B.
        • et al.
        Review article: shock index for prediction of critical bleeding post-trauma: a systematic review.
        Emerg Med Australas. 2014; 26: 223-238
        • Ageno W.
        • Gallus A.S.
        • Wittkowsky A.
        • et al.
        Oral anticoagulant therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed.: American College of Chest Physicians Evidence-based Clinical Practice Guidelines.
        Chest. 2012; 141: e44S-e88S
        • Rubboli A.
        • Becattini C.
        • Verheugt F.W.
        Incidence, clinical impact and risk of bleeding during oral anticoagulation therapy.
        World J Cardiol. 2011; 3: 351-358
        • Tornkvist M.
        • Smith J.G.
        • Labaf A.
        Current evidence of oral anticoagulant reversal: a systematic review.
        Thromb Res. 2017; 162: 22-31
        • Dohan A.
        • Sapoval M.
        • Chousterman B.G.
        • et al.
        Spontaneous soft-tissue hemorrhage in anticoagulated patients: safety and efficacy of embolization.
        AJR Am J Roentgenol. 2015; 204: 1303-1310
        • Popov M.
        • Sotiriadis C.
        • Gay F.
        • et al.
        Spontaneous intramuscular hematomas of the abdomen and pelvis: a new multilevel algorithm to direct transarterial embolization and patient management.
        Cardiovasc Intervent Radiol. 2017; 40: 537-545
        • Makris M.
        • Van Veen J.J.
        • Tait C.R.
        • et al.
        Guideline on the management of bleeding in patients on antithrombotic agents.
        Br J Haematol. 2013; 160: 35-46
        • Guzzardi G.
        • Fossaceca R.
        • Cerini P.
        • et al.
        Endovascular treatment of spontaneous extraperitoneal haemorrhage: immediate and long-term clinical efficiency.
        Radiol Med. 2014; 119: 121-127
        • Choo I.W.
        • Sproat I.A.
        • Cho K.J.
        Transcatheter embolization of the marginal artery of Drummond as treatment for life-threatening retroperitoneal hemorrhage complicating heparin therapy.
        Cardiovasc Intervent Radiol. 1994; 17: 161-163
        • Maleux G.
        • Van Sonhoven F.
        • Hofkens P.-J.
        • et al.
        Oft tissue bleeding associated with antithrombotic treatment: technical and clinical outcomes after transcatheter embolization.
        J Vasc Interv Radiol. 2012; 23: 910-916
        • Levy J.M.
        • Gordon H.W.
        • Pitha N.R.
        • et al.
        Gelfoam embolization for control of bleeding from rectus sheath hematoma.
        AJR Am J Roentgenol. 1980; 135: 1283-1284