J. Coloproctol. (Rio J.) vol.35 número2

jcoloproctol(rioj).2015;35(2):120–123

w w w . j c o l . o r g . b r

Journal

of

Coloproctology

Case

Report

Enterorrhagia

due

to

pelvic

hematoma

after

femoral

catheterization

夽

Sérgio

Silveira

Júnior

,

Kaiser

de

Souza

Kock

,

Diego

Machado

Silvano

,

Mariana

Soares

_,

_Daniel

_Rufato

_Delgado

a_{UniversidadedoSuldeSantaCatarina(UNISUL),Florianópolis,SC,Brazil} b_{HospitalNossaSenhoradaConceic¸ão,Tubarão,SC,Brazil}

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Articlehistory:

Received23January2014 Accepted11August2014 Availableonline20April2015

Keywords:

Catheterism Enterorrhagia Hematoma

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Arterialpuncture,betterknownascatheterization,hasbecomeanimportantdiagnostic toolinrecentyears. Foritsrealization,generallytheoptionistheSeldingertechnique, whichisconsideredtodaythesafestandmostoftenusedprocedure.Thistechniqueallows theinsertionoflarge-caliberormultiple-lumencathetersinthevessel.Arterial catheter-izationhelpsinseveralexams,forinstance,mesentericangiographyandcardiacoutput assessment,andcontributesincineangiocoronariographyprocedures.Wereportthecase ofa67-year-oldmalepatientwhowassubmittedtocineangiocoronariographyandevolved withenterorrhagiaduetopelvichematoma.Throughoutthepatient’scare,aconservative treatmentwaschosen.Theprogressionofthepatientwasuneventfulandthenthepatient wasdischarged.Itisveryhardtodeterminewhicharterialsegmentwasinjured;however,as thehematomawaslocatedpredominantlyinthepelvicregion,itisbelievedthataninjury occurredattheinternaliliacartery,ordirectlyatthebifurcationofthecommoniliacartery. Furthermore,itisassumedthatacatheterkinkingoccurredduringitsprogression,dueto anytortuosityortothepresenceofanatheromatousplaque,thusfavoringtheoccurrenceof themoredistallesion,ratherthantheproximalone.Wedecidedtoreportthiscasebecause ofitshighdegreeofrarity,withascarcenumberofpapersintheliteraturerelatedtothe topic.Thus,withthedescriptionofthisreportwebelievethatothermedicalteamswillhave facilitatedtheirdecision-makingprocess,whenfacingasimilarcase.

©2015SociedadeBrasileiradeColoproctologia.PublishedbyElsevierEditoraLtda.All rightsreserved.

Enterorragia

por

hematoma

pélvico

após

cateterismo

femoral

Palavras-chave:

Cateterismo

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e

s

u

m

e

n

Apunc¸ãoarterial,maisconhecidacomocateterizac¸ão,tornou-seumaimportante ferra-mentadiagnósticanosúltimosanos.Parasuarealizac¸ãogeralmenteopta-sepelatécnica

夽

StudyconductedatHospitalNossaSenhoraDaConceic¸ão,Tubarão,SC,Brazil.

∗ _{Correspondingauthor.}

E-mail:silveirasergiojr@gmail.com(S.SilveiraJúnior).

http://dx.doi.org/10.1016/j.jcol.2015.04.001

jcoloproctol(rioj).2015;35(2):120–123

121

Enterorragia Hematoma

deSeldingerqueéconsideradaamaisseguraeutilizadanaatualidade.Estatécnicapermite ainserc¸ãodecateteresdegrossocalibreeoudemúltiploslúmensemvasos.

Acateterizac¸ãoarterialauxilianarealizac¸ãodeexamescomoarteriografiamesentérica, avaliac¸ãododébitocardíaco,alémdecontribuirnarealizac¸ãodacineangiocoronariografia (CATE).Relata-seumcasodequeumpacientemasculinode67anosquefoisubmetido aoCATEeevoluiucomenterorragiadevidoaohematomapélvico.Emtodomomentofoi optadoportratamentoconservador.Aevoluc¸ãodopacienteocorreusemintercorrências eentãoopacientefoidealta.Dificilmenteépossívelprecisarqualsegmentoarterialfoi lesado,entretanto,comoohematomalocalizou-sepredominantementenaregiãopélvica, acredita-sequeocorreuumalesãodaartériailíacainternaoulogonabifurcac¸ãodaartéria ilíacacomum.Ademais,supõe-sequeaconteceuumadobranocateterduranteasua pro-gressãodevidoaalgumatortuosidadeoumesmopelapresenc¸adeplacasateromatosas. Favorecendo,dessaforma,aocorrênciadalesãomaisdistalenãoproximal.Optou-sepor relatartalcasodevidoaoaltograuderaridade,econsequentemente,nota-sequehápoucos achadosnaliteratura relacionadosaotema.Dessaforma, coma descric¸ãodesterelato podem-seajudarequipesmédicasatomaremcondutasquandodeparadascomumcaso semelhante.

©2015SociedadeBrasileiradeColoproctologia.PublicadoporElsevierEditoraLtda. Todoslosderechosreservados.

Introduction

Arterial puncture, better known as catheterization, has becomeanimportant diagnostictool inrecent years. Usu-allythetechniquechosenistheSeldingertechnique,which nowadaysisconsideredthesafestandmostoftenused pro-cedure.Thistechniqueallowstheinsertionofalarge-caliber ormultiple-lumencatheterinthevessel.

Arterial catheterization helps in several exams, for instance,mesentericangiographyandcardiacoutput assess-ment, and also helps in cineangiocoronariography (CAT) procedures.

Catheterization is a relatively safe technique with less riskof immediatecomplications, sincethe vessel is punc-turedwitharelativelysmallgaugeneedle.Butevenwithits lower riskofcomplications,the techniqueisnotfreefrom suchproblems,oneofwhichistheretroperitonealandpelvic hematoma.Inthisstudy,themechanismofhematoma for-mationanditstreatmentwillbediscussed.1,2

Case

report

Wereportthecaseofamalepatient, 67years,witha his-toryofhypertensionand coronaryartery disease,and who underwentacoronaryarterybypasssurgeryin2010;hewasa chronicuserofanticoagulantmedicationandaspirin.

Thispatientunderwentelectivecoronaryangiographyvia femoralartery.Afewhoursaftertheprocedure,thepatient complainedofsevereandpersistentperianalandsuprapubic pain,withoutrelieffactorsatthattime.Aphysical examina-tionshowednochange,anditwasfoundthathisvitalsigns werepreserved.ItwasdecidedtoperformaCTscanofthe abdomenandpelvis,whichresultedinthefollowingreport: “Noevidenceofabdominalbleeding,iliacvesselsandfemoral regionwithno changes,andwithout retroperitoneal bleed-ing.Presenceofasignificantrectalthickeningtothesigmoid”

(Fig.1).Duetotheimportantpelvicpain,requiringeventhe administrationofparenteralopioids,thepatientwasreferred totheintensive careunit(ICU)onthe sameday, wherehe remainedclinicallystable.

After18h fromthe initialevent,the presenceofa peri-analecchymosiswasobserved,withthefemoralpuncturesite unchanged.Atthat time,the patientreporteda significant tenesmusandsomedegreeofdifficultyinremovinggasesand feces.Digitalrectalexamination(DRE)revealedanimportant, painless,firmbulgingintherightlateralrectalwall, appar-ently withaliquid content and thatbegan roughly3–4cm from the analverge,extending cranially,evenout ofreach ofthefingerand displacingthemucousmembranetoward the contralateralwallandalmost completelyoccludingthe rectallumen.Therewasnobloodintheglove.A6-pointdrop inpatient’shematocritwasalsodemonstrated,but without

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Fig.2–RSCafteranepisodeofintestinalbleeding,where animagecompatiblewithrectalperforationandresidual melenacanbeseen(right).RSC,rectosigmoidoscopy.

hemodynamicinstability.Wedecidedtoadoptanexpectance conduct.

Thepatientprogressedwithimprovementofperinealand pelvic pain and stabilization of perianal ecchymosis. After 8days from catheterization,the patient reported episodes ofapainless enterorrhagiainmoderatequantity,but with-outhemodynamicrepercussion.Atthattime,adigitalrectal examinationwascarriedout,whenadecreaseintherectal wallbulgingwasobserved,butthistimeinassociationwith arectalperforation locatedapproximately 8–9cmfrom the analvergeandinthepresenceofaseeminglyoldbloodon theexaminationglove.Arectosigmoidoscopywasperformed (Fig.2)allowingtheobservationofanapproximately15-mm longperforationintherightsidewalloftherectumwithdark blood coming out in asmall amount,probably due tothe expansionofthepelvichematomaandtheperforationinto therectum,withnobleedingabovetheperforation.

Weoptedforthemaintenanceofaconservativeapproach, sincethiswasanextraperitonealrectalperforationwithout hemodynamicorinfectiousrepercussionsofar.

After a week of expectant treatment, the patient had no further complaints and showed no change at physical examination.Acontrolcolonoscopywasperformed(Fig.3), showingperforationintheintermediaryrectalsegment,but smallerinsizecomparedtotheexamspreviouslyconducted. Finally,afteradoptingaconservativeapproachthroughoutthe treatment, the patientwas discharged, withan uneventful evolution.

Discussion

Thefemoralartery,acontinuationoftheexternaliliacartery distaltotheinguinalligament,isthemainarteryofthelower limb.Itsinitialsegment,proximallytothedeepfemoralartery branching,hasasuperficiallocation,makingthisvessel espe-cially accessible and useful for several clinical procedures. Sucharterycanbecannulatedimmediatelybelowthe mid-pointoftheinguinalligament.InCAT,along,thincatheteris

Fig.3–AsubsequentCRSwhereedemaandrectalwall perforationarestillseen,withnosignsofhealingor bleeding.RSC,rectosigmoidoscopy.

insertedintothearterythroughexternaliliacartery,common iliacarteryandaorta,untilreachingtheleftventricle.3

Percutaneous catheterization of the femoral artery has becomeanimportantdiagnosticadjuvanttool,beingusually performedusingtheSeldingertechnique,describedin1953. Mostofthetimethisisasafetechnique,however,notwithout complications.4

Thecomplicationraterelatedtofemoralartery catheteriza-tionis1–2%.5,6_{Pelvicbleedingisanunusualevent,compared}

tolocalizedhematomas,pseudoaneurysmsandarteriovenous fistulas.Few casesrelatedtopelvichemorrhage havebeen reportedintheliterature.1,7,8

Whenapunctureisperformed,someprecautionsmustbe takentoavoiddamagetothevessel.First,onemustexamine thepatient,observingifhe/sheisobeseorhassome abdom-inal bloating,becausebothconditionsaffectthe procedure. Theneedlepositioningangleforthepunctureisalso impor-tant:ifthisangleistoooblique,apossibleoccurrenceofvessel lacerationbecomesmorelikely.

Thepresenceofinstabilityandoscillationatthetimeof puncture alsofacilitatestheonsetofcomplications.During withdrawalofthetransfixedneedle,theexpectedbuffering may not occur, with a difficult-to control bleeding during angiography,resultinginpelvichematomaaccumulation.9

Despitepossiblecomplications,thefemoralartery punc-tureshouldnotbecondemned,becausethisisausefultool inmedicalpractice.Therefore,whenpunctioningthisvessel, theutmostattentionmustbepaidtotheproposedtechnique, inordertoavoidpossiblepitfalls.9

Theindicationofcomputedtomography(CT)isreservedfor patientswithsuspectedpelvichematomaandpresentingwith abdominalpain,hypotensionoradeclineinhemoglobin.CT maydemonstrateanincreasedretroperitonealspace, accom-panied bydistortionorcompressionofadjacentstructures, andawelllocalizedordiffusedabnormaldensityofsofttissue. All these CT findings depend on bleeding location, attenuation,durationandorigin.10_{Allthesehematoma}

jcoloproctol(rioj).2015;35(2):120–123

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Otherdifferentialdiagnosesshouldbeconsidered,for exam-ple,abscess,lymphoceleandcyst.10,11

Thus,the earlytherapy topromotinghemostasisatthe puncturesiteisbymanualpressure.Atthesametime, hema-tocrit and hemoglobin determinations should beobtained, togetherwithintravenousfluidadministrationandacareful monitoring.Itisworthconsideringasurgicaloption, ifthe doctorcannotcontroltheproblemsolelywithconservative measures.9

Inthepresent case,it wasnoted thatprobablyan arte-rialpunctureaccidentoccurred,maybeduetothepresence ofatheromatousplaquesthatweakenthearterialwall, caus-ingthepatienttoevolvewiththepelvichematomamanifested throughintestinalbleeding.Notethatitisnotpossibleto spec-ifytheexactetiologyofthecase.Weadoptedaconservative approachandthepatientprogresseduneventfully.

Hardlyonecould determinewhicharterialsegmentwas injured,butasthehematomawaslocatedpredominantlyin thepelvicregion,ourbetwasinfavorofaninjuryatthe inter-naliliacartery,orjustatthebifurcationofthecommoniliac artery.Furthermore,itisassumedthatakinkofthecatheter hadoccurredduringtheprogressionofthedevice,thanksto sometortuosityorbythepresenceofatheromatousplaques, whichwouldfavortheoccurrenceofamoredistal,ratherthan proximal,lesion.

Ourdecisiontoreportthiscasewasbasedonitsgreatrarity, aswenotedagreatlackoffindingsintheliteraturerelatedto thistopic.Thus,withthedescriptionofthisreportwebelieve thatothermedicalteamswillhavefacilitatedtheir decision-makingprocess,whenfacingasimilarcase.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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1.BergentzSE,HanssonLO,NorbackB.Surgicalmanagementof complicationstoarterialpuncture.AnnSurg.1966;164: 1021–6.

2.SigstedtB,LunderquistA.Complicationsofangiographic examinations.AmJRoentgenol.1978;103:455–60.

3.KeithL,MooreAF.DalleyAnatomiaorientadaparaaclínica. Quintaedic¸ão.RiodeJaneiro:GuanabaraKoogan;2007.p.556.

4.SeldingerSJ.Catheterreplacementoftheneedlein percutaneousarteriography:anewtechnique.ActaRadiol. 1953;39:368.

5.HesselSJ,AdamsDF,AbramsHL.Complicationsof angiography.Radiology.1981;138:273–81.

6.BouhoutsosJ,MorrisT.Femoralarterycomplicationafter diagnosticprocedure.BrModJ(ClinRos).1973;3:396–9.

7.BolasnyBL,KillenDA.Surgicalmanagementofarterial injuriessecondarytoangiography.AnnSurg.1971;174:962–4.

8.LangEK.Asurveyofthecomplicationsofpercutaneous retrogradearteriography.Radiology.1963;81:257–63.

9.KaufmanJL.Pelvichemorrhageafterpercutaneousfemoral angiography.AmJRoentgenol.1984;143:335–6.

10.IllescasFF,BakerME,McCannRCT.evaluationof retroperitonealhemorrhageassociatedwithfemoral arteriography.AmJRoentgenol.1986;146:1289–92.