Treatment of Inferior Epigastric Pseudoaneurysm and Rectus Sheath Hematoma through Percutaneous Direct Sac Puncture and Embolization with N-Butyl Cyanoacrylate
In a recent medical case, 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) status post endovascular aneurysm repair (EVAR), complicated by Type 2 endoleak, presented with worsening abdominal pain and swelling.
Upon examination, the 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 (Figs. 1 and 2). The patient was subsequently discharged from an outside hospital after conservative treatment, but re-bleeding occurred, necessitating further intervention.
The patient presented to the ED with worsening abdominal swelling and pain. On presentation, the patient was hemodynamically stable with a hemoglobin level of 8.5, which subsequently downtrended to 6.3. Given the complex vascular anatomy and body habitus, an intra-arterial approach was limited.
Interventional Radiology (IR) was consulted for embolization (Fig. 3). The left inferior epigastric pseudoaneurysm was treated by percutaneous direct sac puncture with N-butyl cyanoacrylate (NBCA) glue. This method offers several advantages, including high effectiveness, rapid hemostasis, and a minimally invasive nature.
NBCA, a liquid embolic agent, polymerizes quickly on contact with blood, allowing prompt embolization even in complex, difficult-to-access vascular territories where conventional methods might fail or be risky. Its strong and rapid occlusion provides fast and permanent sealing of bleeding vessels, which is crucial in pseudoaneurysms and hematomas where bleeding control must be definitive.
Moreover, NBCA can be precisely delivered via microcatheters into small or tortuous vessels such as the inferior epigastric artery, which is often anatomically challenging. Its minimally invasive treatment avoids open surgery, thus reducing patient morbidity, shortening hospital stays, and lowering complication risks compared to surgical options.
The rectus sheath has additional vascular supply from the superficial epigastric artery and, rarely, the deep circumflex iliac artery. Superficial pseudoaneurysms with challenging vascular anatomy may benefit from direct percutaneous approaches, often treated with thrombin. However, NBCA embolization offers an alternative to conventional thrombin injection or Transcatheter Arterial Embolization (TAE).
Re-bleeding remains a problem with TAE due to retrograde flow from collaterals, vessel recanalization, and loss of tamponade effect. NBCA's effectiveness in complex anatomy and applicability in refractory cases makes it an ideal embolic agent for controlling bleeding in vascular territories with challenging anatomy, such as inferior epigastric pseudoaneurysms and rectus sheath hematomas.
While no direct, dedicated study on NBCA specifically for inferior epigastric pseudoaneurysm or rectus sheath hematoma was found, the evidence for NBCA's effectiveness in complex vascular embolization and gastrointestinal bleeding refractory to conventional treatment strongly supports these advantages.
This case highlights the use of NBCA for direct sac puncture and embolization of an inferior epigastric pseudoaneurysm, providing an alternative to conventional methods in challenging vascular anatomy cases.
- Science has made significant strides in treating medical-conditions like heart failure and chronic kidney disease.
- Chronic diseases such as cancer and respiratory conditions require continuous monitoring and frequent medical check-ups.
- Digestive health is essential, and conditions like Alzheimer's disease and autoimmune disorders can affect it indirectly.
- Climate change impacts not just the environment but also the manufacturing industry, with potential effects on cardiovascular health.
- Psoriasis is a common skin condition, and understanding its causes and treatments falls within the realm of dermatology and environmental science.
- The industry is increasingly focusing on neurological-disorders research, given their complex nature and debilitating effects.
- Energy production and consumption, influenced by environmental-science, play a crucial role in managing climate change and promoting sustainable living.
- Personal-finance plays a significant role in affording medical treatment and managing health expenses, especially for chronic diseases.
- Investing and wealth-management strategies can help individuals build resilience against financial hardships caused by medical-conditions.
- Home-and-garden maintenance, including gardening, contributes to a healthier living environment and sustainable living.
- Home-improvement projects can help address energy efficiency and lower carbon footprints, aiding in climate change mitigation.
- Baking and cooking require understanding food-and-drink ingredients and global cuisines for nutritious and healthy meals, contributing to cardiovascular health.
- The retail sector, including fashion-and-beauty and food-and-drink outlets, can promote healthy living through product offerings and education.
- Transportation choices, such as walking, cycling, or using public transit, contribute to personal health and sustainability.
- Wearables and smart home-devices can monitor health conditions and create more energy-efficient homes, integrating various aspects of lifestyle.
- Cybersecurity is crucial in ensuring the safety and protection of personal data stored in medical records and health-related apps.
- Outdoor living can boost mental-health, reducing the risk of certain neurological-disorders and offering an essential escape from indoor living.
- Fashion-and-beauty choices can contribute to overall well-being and self-confidence, especially for those dealing with skin-conditions.
- Food-and-drink options catering to dietary restrictions, such as gluten-free or vegan, can help manage certain chronic diseases like Celiac disease or diabetes.
- Dining experiences, especially those focusing on healthy-cooking and global cuisines, can create enjoyable and nutritious opportunities for social interaction.
- Investing in banking-and-insurance institutions that prioritize ethical and sustainable practices can contribute to a more robust, resilient financial future.
- Fintech companies can facilitate easier access to financial resources for healthcare, making treatments more affordable.
- Gadgets like smartphones and smartwatches enable remote medical consultations and monitoring, improving healthcare accessibility.
- Data-and-cloud-computing technologies enable the storage and analysis of vast amounts of health-related data, leading to better disease understanding and treatment.
- Space-and-astronomy research can potentially lead to breakthroughs in medical technology, improving the detection and treatment of various chronic diseases.
- Industrial design, including interior design and product innovation, plays a role in creating more efficient and sustainable living spaces, contributing to a healthier environment and lifestyle.
