Endovascular management of the rectus muscle hematoma

Non-traumatic spontaneous hematoma of the rectus abdominal muscle is not considered a critical condition. Nevertheless, it can be a serious complication in some patients due to continuous and/or consistent bleeding. The most frequent cause of spontaneous rectus muscle hematoma is the anticoagulation therapy. The natural history of rectus muscle hematoma usually leads to a positive outcome and can be spontaneously self-limited only by conservative therapy. Nevertheless, in some patients, despite a correct and early medical therapy, the continuous bleeding requests a more radical handling. Up to now, the surgical hematoma evacuation and the bonding of blood vessels were considered the most appropriate treatment, while at present, the percutaneous management by means of selective catheters and embolization of the bleeding vessel is considered to be the most used option. Our purpose is to report our experience in the endovascular spontaneous rectus muscle bleeding treatment in the elderly patients.

From the data base and medical reports of the hospital, we selected 144 medical reports. We focused on those cases that showed the following criteria: patients with rectus muscle hematoma undergoing anticoagulation therapy and/or non-traumatic spontaneous hematoma and with persistent bleeding revealed on CT examination despite a pharmacological treatment aimed to timely reverse coagulopathy. These criteria were found in 18 patients: 15 females and 3 males, with a median age of 73 (range 64–81). In all patients, the diagnosis had been confirmed by an abdominal CT in emergency setting, performed before and after contrast medium intravenous administration. Because of clinical conditions, all patients had been moved on the angiographic room for diagnostic arteriography and embolization. The criteria for this treatment were hemodynamic instability and the continuous bleeding despite the correct medical therapy.

CT imaging detected rectus muscle hematoma in 18/18 patients and active bleeding in 7/18 patients. Selective catheterization was applied to all 18 patients; arteriographic study confirmed the information of the CT study in all of the seven patients. The inferior epigastric artery was the main cause of the bleeding in all 18 patients. In 14 patients, one single vessel was responsible for the bleeding, while in the other four patients, more than one vessel were involved: In two patients, we also found the involvement of the superior epigastric artery; while the other two patients showed also the involvement of the deep iliac circumflex artery. The material for embolization was compatible coils with micro-catheters in 17/18 patients, and glue for 1/18 patient.

Patients with large rectus muscle hematoma, which have not yet recovered with conservative therapy, should then consider undergoing endovascular treatment. This procedure is highly recommended in patients with other coexisting pathologies that could eventually lead to a fatal outcome. It is difficult to determine when surgery is necessary when there is very poor data provided by scientific literature review, so the decision to use surgery can be suggested when embolization is unsuccessful or when it is necessary to evacuate a complex huge fluid mass in peritoneal cavity.