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, atrial fibrillation on Eliquis, abdominal aortic aneurysm, and a previous endovascular aneurysm repair, presented with abdominal pain and swelling. CTA of the abdomen and pelvis revealed a large left rectus shemathe hematoma and a left inferior epigastric pseudoaneurysm, but no active extravasation (Figs. 1 and 2).
Given the complex vascular anatomy and body habitus that limited an intra-arterial approach, interventional radiology was consulted for embolization. The embolization procedure, depicted in Fig. 3, employed the use of N-butyl cyanoacrylate (NBCA) for direct sac puncture and embolization of the inferior epigastric pseudoaneurysm. This method offers some advantages over conventional treatments.
NBCA rapidly solidifies on contact with blood, allowing for fast and permanent vessel occlusion. It can penetrate distal vessels and complex vascular anatomy better than coil embolization, reducing the risk of recanalization. Unlike thrombin injection, which may allow some recanalization or incomplete thrombosis, NBCA creates a permanent mechanical barrier.
Re-bleeding remains a problem in rectus sheath hematoma (RSH) management due to retrograde flow from collaterals, vessel recanalization, and loss of tamponade effect. In comparison, NBCA's advantages for conditions like RSH and inferior epigastric pseudoaneurysms likely include rapid and durable vessel occlusion, suitability for complex or small vessels, and potentially fewer complications related to incomplete embolization compared to thrombin or transcatheter arterial embolization (TAE).
However, without direct comparative studies specifically addressing these conditions, these conclusions rely on extrapolation from general embolization principles rather than specific evidence.
Most rectus sheath hematomas are managed conservatively, but those with vascular complications or hemodynamic instability may require embolization. Vascular injury, especially involving the inferior epigastric artery, is more common below the arcuate line due to the absence of a posterior sheath. Several studies have demonstrated the safety and efficacy of liquid embolic agents such as NBCA for RSH treatment.
In conclusion, this case demonstrates the use of NBCA for direct sac puncture and embolization of an inferior epigastric pseudoaneurysm as an alternative to conventional thrombin injection or TAE. The advantages of NBCA, including its rapid polymerization and effectiveness in small and tortuous vessels, make it a promising option for complex vascular conditions like RSH and inferior epigastric pseudoaneurysms.
- Given the patient's complex medical-conditions, chronic-diseases like heart failure with preserved ejection fraction and atrial fibrillation, her particular health-and-wellness requirements must be taken into consideration when evaluating fitness-and-exercise options and therapies-and-treatments.
- The treatment for the patient's chronic-kidney-disease, if present, would likely involve a comprehensive approach that includes dietary modifications, medications, and regular monitoring of kidney function as part of the overall health-and-wellness plan.
- As NBCA shows promising results in treating complex vascular conditions like rectus sheath hematoma and inferior epigastric pseudoaneurysms, it might be an effective option for addressing similar vascular issues that could arise during the course of her manageable medical-conditions or chronic-diseases.
