Treatment of an inferior epigastric pseudoaneurysm and rectus sheath hematoma through a percutaneous direct sac puncture and embolization with N-butyl cyanoacrylate.
In a recent case, interventional radiology (IR) was consulted for the treatment of a left inferior epigastric pseudoaneurysm in a 72-year-old female patient. The patient, who had 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), presented with abdominal pain and swelling.
Vascular injury, especially involving the inferior epigastric artery, is more common below the arcuate line due to the absence of a posterior sheath. Rectus sheath hematomas, a rare cause of abdominal pain, are often associated with abdominal wall trauma and anticoagulation, particularly in elderly patients.
The patient's CTA images revealed a large left rectus sheath hematoma with a left inferior epigastric pseudoaneurysm, but no evidence of active extravasation. Initially, the patient was treated conservatively for the abdominal wall hematoma and discharged, but later returned with worsening abdominal swelling and pain.
In light of these findings, IR was consulted for embolization of the left inferior epigastric pseudoaneurysm. The case highlights the use of NBCA (N-butyl cyanoacrylate) for direct sac puncture and embolization of the pseudoaneurysm, providing an alternative to conventional thrombin injection or transcatheter arterial embolization (TAE).
NBCA glue offers several advantages over traditional embolic agents. It polymerizes quickly on contact with blood, resulting in an immediate mechanical occlusion of the target vessel or pseudoaneurysm. This rapid action can be critical in controlling active bleeding or high-flow vascular lesions.
Moreover, NBCA can flow into small branches, niduses, or irregular vascular spaces before polymerizing, allowing effective embolization of lesions difficult to reach or treat with coils or thrombin alone. Unlike thrombin, which requires the body's coagulation cascade to induce clotting, NBCA polymerizes independently, making it advantageous in patients with coagulopathy or anticoagulation therapy.
Furthermore, NBCA embolization can be faster and therefore reduce fluoroscopy time compared to other embolic agents, potentially lowering X-ray exposure for patients and operators. Additionally, NBCA forms a permanent, solid cast within the vessel, which may reduce recurrence risk compared to thrombin-induced clots that can dissolve or recanalize.
However, operator expertise with NBCA is crucial to avoid complications such as non-target embolization. Individualized patient and lesion characteristics should guide the choice of embolic agent.
Several studies have demonstrated the safety and efficacy of liquid embolic agents such as NBCA for rectus sheath hematoma (RSH) treatment. While most RSHs are managed conservatively, those with vascular complications or hemodynamic instability may require embolization. Superficial pseudoaneurysms with challenging vascular anatomy may benefit from direct percutaneous approaches, often treated with thrombin.
In conclusion, NBCA glue offers a fast, durable, and effective embolic option, particularly advantageous in complex pseudoaneurysms and hematomas where rapid hemostasis and deep penetration are required. The case presented here underscores the potential benefits of NBCA in the treatment of vascular complications associated with rectus sheath hematomas.
Figure 1: Patient's CTA images Figure 2: Embolization procedure depicted Figure 3: Patient's CTA images after embolization
Science has shown the effectiveness of liquid embolic agents like NBCA in the treatment of medical-conditions such as rectus sheath hematomas (RSH). Particularly in complex cases with vascular complications or hemodynamic instability, chronic-diseases such as chronic kidney disease might require health-and-wellness interventions like therapies-and-treatments involving NBCA for the management of RSHs. The rapid action and deep penetration of NBCA glue make it advantageous in patients with coagulopathy or anticoagulation therapy, reducing the risk of recurrence and providing a faster process, potentially minimizing X-ray exposure. However, the expertise of the operator is vital to avoid non-target embolization.
