Treatment of Inferior Epigastric Pseudoaneurysm and Rectus Sheath Hematoma through Percutaneous Direct Sac Puncture and Embolization using NBCA
A 72-year-old female, with a history of heart failure with preserved ejection fraction (HFpEF), atrial fibrillation on Eliquis, abdominal aortic aneurysm (AAA) status post endovascular aneurysm repair (EVAR), and a Type 2 endoleak, presented with abdominal pain and swelling.
Initially, the patient was diagnosed with an abdominal wall hematoma and treated conservatively. However, she subsequently presented with worsening abdominal swelling and pain. Upon further investigation, a computed tomography angiography (CTA) of the abdomen and pelvis revealed a large left rectus sheath hematoma with a left inferior epigastric pseudoaneurysm. Thankfully, there was no evidence of active extravasation.
Most rectus sheath hematomas are managed conservatively, but those with vascular complications or hemodynamic instability may require more aggressive intervention. In this case, the complex vascular anatomy and the patient's body habitus made an intra-arterial approach challenging. As a result, the large left rectus sheath hematoma and left inferior epigastric pseudoaneurysm were treated by direct sac puncture with N-butyl cyanoacrylate (NBCA) glue.
Figure 1 and 2 show the CTA images of the large left rectus sheath hematoma and left inferior epigastric pseudoaneurysm. Figure 3 illustrates the interventional radiology (IR) procedure for embolization of the left inferior epigastric pseudoaneurysm.
The use of NBCA for direct sac puncture and embolization provided an alternative to conventional thrombin injection or transcatheter arterial embolization (TAE). Transcatheter arterial embolization is commonly used for RSH management, with microcoils and gelfoam being the most frequently used embolic agents.
NBCA offers advantages including controlled penetration into both afferent and efferent feeders, reducing recanalization risk, and maintaining its effectiveness regardless of coagulopathic status. This makes it particularly advantageous in cases where time is critical and when accessing the lesion via catheter is challenging.
The rapid polymerization of NBCA upon contact with blood leads to efficient occlusion of the bleeding vessel, providing rapid hemostasis, especially when catheterization of the pseudoaneurysm or its distal branches is technically difficult.
The patient's hemoglobin level improved after the IR procedure, indicating successful treatment of the hematoma and pseudoaneurysm. The advantages of using NBCA for the treatment of inferior epigastric pseudoaneurysms and rectus sheath hematomas primarily include its ability to provide rapid hemostasis and its minimally invasive nature, potentially reducing morbidity compared to surgical options.
In summary, NBCA offers a technically feasible, fast-acting, and minimally invasive embolization option for managing difficult-to-access bleeding pseudoaneurysms and hematomas in the abdominal wall region. Several studies have demonstrated the safety and efficacy of liquid embolic agents such as N-butyl cyanoacrylate for RSH treatment.
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