Treatment of inferior epigastric pseudoaneurysm and rectus sheath hematoma through percutaneous direct sac puncture and embolization with NBCA
In a recent case, interventional radiology (IR) was consulted for embolization of a complex vascular issue involving an inferior epigastric pseudoaneurysm and rectus sheath hematoma. The patient, a 72-year-old female with a history of heart failure with preserved ejection fraction (HFpEF), atrial fibrillation on Eliquis, and an abdominal aortic aneurysm (AAA), presented with abdominal pain and swelling.
Upon presentation, the patient was hemodynamically stable with a hemoglobin level of 8.5, but it subsequently downtrended to 6.3. The patient's complex vascular anatomy and body habitus limited an intra-arterial approach, making the case particularly challenging.
Fortunately, N-butyl cyanoacrylate (NBCA) was employed for direct sac puncture and embolization of the pseudoaneurysm. This liquid embolic agent offers significant advantages for treating rectus sheath hematomas and pseudoaneurysms, especially in cases with complex vascular anatomy.
NBCA's rapid polymerization enables quick vessel occlusion and bleeding control, minimizing procedural time and reducing the risk of glue migration or non-target embolization. Its mechanical occlusion causes effective and durable closure, and it can penetrate and embolize complex, small, or tortuous vessels via microcatheters, even in anatomically difficult areas.
These properties allowed precise and durable embolization in this case, even with the challenging vascular territory. NBCA provides durable vessel closure and has been successfully used in endovascular treatments of vascular malformations and hemorrhages with complex anatomy, achieving high technical success rates.
The case involved the use of NBCA instead of conventional thrombin injection or transcatheter arterial embolization (TAE), which is a well-documented method for RSH management. However, re-bleeding remains a problem with TAE due to retrograde flow from collaterals, vessel recanalization, and loss of tamponade effect.
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. This meant that the case did not involve the re-bleeding issues associated with TAE.
Additional vascular supply to the rectus sheath includes the superficial epigastric artery and rarely the deep circumflex iliac artery. NBCA offers advantages including controlled penetration into both afferent and efferent feeders, reducing recanalization risk, and maintaining its effectiveness regardless of coagulopathic status.
This case demonstrates the safety and efficacy of liquid embolic agents such as NBCA for rectus sheath hematoma treatment, especially in scenarios where vascular anatomy is complex and precise embolization is required to manage bleeding safely and effectively. Some rectus sheath hematomas may require embolization, especially when accompanied by vascular injury or hemodynamic instability.
- Given the patient's complex medical-conditions, including heart failure with preserved ejection fraction (HFpEF), atrial fibrillation, and chronic-kidney-disease due to an abdominal aortic aneurysm, it's crucial to prioritize health-and-wellness and consider fitness-and-exercise for managing chronic-diseases.
- In light of the success of NBCA in treating complex vascular issues, such as rectus sheath hematomas and pseudoaneurysms, further research investigating its applications in science could lead to advancements in medical-conditions management.
- During fitness-and-exercise routines, monitoring for symptoms like abdominal pain and swelling is essential, as they may be indicative of vascular conditions that require immediate medical attention, like chronic-kidney-disease or rectus sheath hematomas.
