Scott

0. Trerotola,

#{149} Janet

MD

E. Kuhlman,

Bleeding Complications Catheterization: CT Computed and clinical

tomographic data were

21 patients

with

(CT) scans reviewed in

significant

hemato-

ma occurring after catheterization. The procedures included percutaneous transluminal coronary angioplasty (n = 15), cardiac catheterization (n = 2), peripheral angioplasty (n = 2), valvuloplasty (n = 1), and venous access catheterization (n 1). Clinical data including medications, transfusion requirements, and sequelae were obtained by reviewing the patients’ charts. Four distinct types of postcatheterization bleeding were identified at CT: retropenitoneal,

intraperitoneal,

groin

in

17 patients

(mean

5 units of blood in each patient ceiving transfusion) and surgery two patients for vessel repair.

1990;

H

EMATOMA

and

causes

is the most common complication of femoral arterial or venous catheterization (1-5). In most cases, the hematoma is small

only

occasionally

local

the

monitoring,

transfusion,

bly

surgery

vascular

Percutaneous plasty luminal

(PTA) and coronary

with

(PTCA),

of

rein

the

of the and

Radiology

and

Radiological

Sciences,

angiography

use

of

bleeding

size and location may help identify

have

literature 21 patients

of

The

report CT

of

in the a series was used

postcatheterization On

tion on

appeared

(6,7). We in whom

evaluate

Johns Hopkins Hospital, 600 N Wolfe St. Baltimore, MD 21205. From the 1989 RSNA annual meeting. Received August 7, 1989; revision requested September 7; revision received and accepted September 13. Address reprint requests to SOT. RSNA, 1990

c

trans-

patients who will require further therapy, including surgical intervention. Scattered reports of CT of retropenitoneal hematomas occurring after

the

basis

of the these

of to

hemato-

of this

various

series,

scans

were

sequelae,

the

obtained

patients’

with

a Sie-

125

kVp,

310

mAs,

and

8-mm

collimation.

All patients were scanned from the diaphragm to 5 cm below the inguinal ligament; in patients in whom an abnormality was

was

detected

continued

the abnormality trast material

at that

until

level,

the

scanning

inferior

extent

was determined. was administered

of

Conorally

in

10 patients and intravenously in two. Ten scans were obtained without contrast material. In seven patients, contrast material from

the

still

present.

arteniographic

Hematomas

were

procedure divided

was

into

four

according to anatomic location. Retroperitoneal hematoma included bleeding in the anterior and posterior pararetypes

nal spaces, as well as the muscles. Intraperitoneal

iliacus

and

psoas

bleeding was designated as a separate category. The third category included hematomas of the groin and thigh. Hematomas involving the

fourth

abdominal

wall

and

flank

were

in

the

category.

RESULTS

by

occur

AND

patients suggestive

bleeding CT

is pre-

scans

and were

Retroperitoneal seen in 12 patients

METHODS

tients, tenor

with clinical of postcatheteriza-

with

positive

findings

retrospectively

studied.

The patients ranged in age from 41 to 83 years (mean, 65 years); 14 were women, and seven were men. Patients referred for CT with suspected bleeding but with negative CT findings ing (inflammation

tissues

CT

and

by reviewing

a dis-

routes

hematomas

medications,

CT Results

Twenty-one symptoms Department

All

angio-

frequent

including requirements,

mens DR3 or DRH scanner (Iselin, NJ). Scanning parameters were either 3 saconds, 125 kVp, and 230 mM or 4 seconds,

be needed.

percutaneous angioplasty

data,

were obtained charts.

(5). Computed tomography (CT) in patients suspected of having significant bleeding complications of PTCA or femoral catheterization enables

mas.

H. Morgan

may

near the puncture site were The procedures in these patients included PTCA (n 15), peripheral angioplasty (n 2), cardiac catheterization (n = 2), valvuloplasty (n 1), and catheterization for venous access (n 1). transfusion

possi-

intraabdominal

detection hematomas

174:37-40

Russell

and

collection) excluded.

Clinical

When bleedintensive

transluminal

PATIENTS

the

but

of hemor-

decrease in hematocrit. ing occurs to this degree,

which sented.

From

discomfort,

extent

rhage is sufficient to result in hypotension, acute abdominal pain, and

cussion

I

MD

of Femoral Evaluation’

particularly

Index terms: Abdomen, CT, 796.1211 #{149} Abdomen, hemorrhage, 796.458 #{149} Catheters and catheterization, complications, 95.441, 98.441 Peritoneum, hemorrhage, 95.441 #{149} Retroperitoneal space, CT, 87.121 1 #{149} Retroperitoneal space, hemorrhage, 98.441

Radiology

K. Fishman,

heparin and thrombolytic agents, increase the risk of hemorrhage (1). Examination of the patient is unreliable for detecting significant hematomas,

and thigh, and abdominal wall hematomas. CT scans contributed to treatment in all patients by helping indicate the need for more intensive monitoring and by helping predict the potential need for surgery. Sequelae included the need for blood transfusions

#{149} Elliot

MD

of the

or only in the

groin,

without

minimal subcutaneous

bleed-

a defined

blood pararenal

was

hematoma was (Fig 1). In two

pa-

evident in both anspaces after unilater-

al puncture. Intraperitoneal bleeding was demonstrated on CT scans in three patients (Fig 1). All patients

Abbreviations: minal angioplasty, luminal coronary

PTA

percutaneous

PTCA angioplasty.

percutaneous

translutrans-

37

with intraperitoneal bleeding had concurrent retroperitoneal bleeding.

Eight patients had groin and hematomas (Fig 2). Although groin hematoma was clinically, one patient and thigh hematoma

strated

thigh the

usually obvious with a groin also demon-

a retroperitoneal

hematoma

at

CT, a finding that was unsuspected clinically. Hematomas involving abdominal wall were also usually

clinically

evident.

However,

the b.

of the

five patients with this type of hematoma (Fig 3), two had unsuspected concurrent retroperitoneal bleeding. Overall, seven patients had hematomas

in two

Clinical

locations.

Data

Nineteen patients received heparin, and nine received thrombolytic therapy. One patient was taking warfarm. Two patients did not receive

anticoagulants

or thrombolytic

agents. Puncture eral artery and

of both vein was

for PTCA.

routine

The

a.

the ipsilatperformed

sheath

c.

1. (a) CT topogram (b) CT scan in same patient Figure

fluid-fluid same patient

sizes

used at our institution for PTCA are F for the artery and 6-8 F for the vein. The mean hematocrit decrease was 9 points (range, 0-19 points) at

8

Note

level, involving at T-12 level

anterior

obtained

after

at L3-4 level

PTCA

shows

the psoas muscle reveals concurrent

displacement

of right

kidney

demonstrates

massive

right

and posterior intraperitoneal

a large

right

retroperitoneal pararenal blood

by retroperitoneal

abdominal

mass.

hematoma

with

space. (c) CT scan in in the subhepatic space.

bleeding.

12 hours after the procedure, but many patients received intercurrent transfusions, so the actual hematocrit decrease

was

likely

higher.

included

the

need

for blood

Sequelae

transfu-

sion in 17 patients, with a mean requirement of 5 units of blood for each patient (range, 0-10 units) re-

quiring derwent

transfusion. surgery.

was prompted of intraperitoneal

Two In both,

by

patients surgery

una.

the demonstration blood on CT

scans.

tion

the had

just

ment, found. retro-

inguinal a femoral

below

the

ligament, venous

inguinal

and no iliac vessel Both patients had and intraperitoneal

just

and lacera-

the

In another

delayed

patient,

for several

was

hematoma.

tients pital

sufficiently although

stay

recovered discharge, was

PTCA

months

retroperitoneal

lengthened

due All

the

in most

was

to a pa-

for hoshospital patients.

DISCUSSION Hematoma is a complication of femoral arteniography in 0.5%-5.7% of cases (1-5). Massive hematoma occurs more rarely, in approximately 0.9% of cases (5). Many risk factors 38

#{149} Radiology

groin and thigh hematoma from venous was obvious clinically. CT scan at level of proximal

tire thigh

the

hematoma toma

adductor

from

longus

PTCA

predominantly

and

adductor

in a different involving

magnus,

patient.

the

adductor

as well

CT scan

catheterization. femur shows as the

at proximal

Swelling hematoma

sartorius.

(b)

femoral

level

Right

shows

of eninthigh

hema-

longus.

ligadamage concurrent hemato-

mas. One of these patients had an intraoperative myocardial infarction; both patients made an uneventful necovery.

(a) Right

2

volving

At surgery, one patient had two holes in the external iliac artery above other

b.

Figure

for hematoma been identified,

patient catheters, poor

age,

groin

development including

hypertension, large-bore operator inexperience, compression

removal,

high

and PTCA large series

site,

in

series,

catheter

abnor-

and anticoagutherapy (1-5).

have been shown to cause hematomas

surgery

(1). In our

after

puncture

mal vessel or graft, lant-thrombolytic

quiring

have advanced

1.6%

PTCA

of patients

was

the

cedure leading to hematoma in 21 patients. This is not surprising

cause

many

risk factors procedure, tients,

and and

of the

administration thrombolytic

catheters

pro15 of be-

aforementioned

are common specifically,

large

PTA

in one ne-

with older (8-F

this pa-

arterial),

of anticoagulants agents.

Figure 3. Left CT scan obtained

shows transversus

abdominal wall hematoma. after PTCA at L-5 level

hematoma

involving

left rectus

and

muscles.

January

1990

c,’0

4. Figures gram

5. 4, 5. (4) Diagram of pathways of spread of retroperitoneal and shows pathway of spread of abdominal wall hematoma in addition

CT has been shown to be useful in evaluating retroperitoneal hematomas of several different origins, including complication of arteriography (6-8). In the present series, four distinct types of hematoma resulting from femoral catheterization were identified. The routes of spread of blood can be explained in three of these types on the basis of the anatomy of the femoral sheath and trian-

gle.

The routes of spread of extrapenitoneal and thigh hematomas are along anatomic fascial planes, as expected. The anatomy of the femoral triangle and femoral sheath explains the locations of the hematomas seen in this series.

The

femonal

sheath,

with the Anteriorly,

Volume

174

#{149} Number

1

tion with the retropenitoneum. The top of the funnel opens into the prevesical space (7). Bleeding contained in the femoral sheath will therefore spread superiorly into the prevesical space. As demonstrated by Auh et al (7), this space has a capacity of approximately 3 L without

showing

external

evi-

dence of distention. Thus, massive hematomas may collect in this space but may not be visible clinically. Furthermore, this space extends posteni-

may be seen in the cul-de-sac and blood in the posterior extent of the prevesical space, which is retropenitoneal and subperitoneal (10,11).

contain-

tip directthe wall

of the sheath is formed by a continuation of the transversalis fascia and therefore in direct communication with the anterior abdominal wall; posteriorly, it is formed by the iliac fascia and is therefore in communica-

hematomas and groin

only, and large collections in this space may involve the presacral space; it is important to distinguish between intraperitoneal blood that

ing the femoral artery, femoral vein, and a few lymphatic vessels, has the shape of a funnel, ed inferiorly (9).

groin and thigh to retroperitoneal

Blood

in the

ing superiorly the parietal is

spaces

beneath

the for

roperitoneal matomas,

space

and posteriorly peritoneum to the

peritoneal counts

prevesical

and

anteriorly

spread-

along retrojust

transversalis fascia acthe routes of spread of retand abdominal wall herespectively (Figs 4, 5) (7).

from and

Further

femoral thigh

triangle. hematomas.

involvement

(5) Cutaway

of the

dia-

abdomi-

nal wall may occur due to direct extension through areas of thinning in the transversalis fascia into the rectus and other muscles of the abdominal wall, again along fascial planes. An alternative

route

is along

the

epigas-

tric vessel transversalis

sheaths penetrating the fascia. With hematomas

spreading

posteriorly,

volvement

of the

psoas

muscles,

depending bleeding.

and

there

iliacus

is in-

muscles,

pararenal

spaces,

on the extent Interestingly,

of the in two patients in whom puncture was unilateral, hematoma involved both anterior pararenal spaces, findings indicating connection between these spaces. As demonstrated in Figure 1, hematomas in the retroperitoneum may be massive and may displace intraperitoneal and retroperitoneal structures. When bleeding is not confined to the femoral sheath but involves the femoral triangle, the routes of spread may be different. The femoral thangle is a V-shaped trough, bounded medially by the adductor longus and laterally by the sartorius (9). The base Radiology

#{149} 39

of the

triangle

guinal trough iliacus

is formed

ligament. is bounded and psoas

medially tor longus

the

and of the

is directed

medially

infeniorly.

The femoral est portion originating

sheath of this in the

extend

Intraperitoneal

in-

the pectineus (9). The apex

may

by

by

The floor of the laterally by the major muscles and

and

ly thought

ture This tient

adductrough

directly

along

the

iliacus

and psoas muscles to the retroperitoneum to form a retropenitoneal he-

matoma

without

involvement

of the

prevesical space or may directly involve the adjacent muscles (ie, pectineus, adductor longus, sartorius). Most commonly, bleeding spreads medially to involve the adductor lon-

gus

and

pectineus

er medial

muscles

This

is likely

primarily

and

secondarily

due

in part

oth-

(Fig

to the

4).

orien-

only

is usualwith

the

only

other

pa-

peritoneum.

One

patient

can

who

tation of the femoral triangle may also be due in part to the practice of groin compression somewhat medially directed In addition, blood may dissect fascial planes in the thigh and vascular sheaths, particularly the profunda femoris vessels.

but usual in a fashion. along along those of The re-

suit

is clini-

spread of bleeding from femoral puncture. It is believed that puncture

thigh

of the

cally

of this

type

evident

of extension

as an

enlarging

and is visible at CT as a groin and thigh hematoma. It is unclear from this series why large thigh hematomas developed in some patients, while retroperitoneal and anterior abdominal wall hematomas developed in others. Only one patient had both thigh and retroperitoneal bleed-

ing, and nal wall

one had bleeding.

thigh The

and abdomireason for this

lack of overlap could be due to differences in groin compression; although there was no apparent difference in clinical factors among the various groups, differences in compression technique would be impossible to evaluate retrospectively. An alternative, and perhaps more plausible, ex-

planation

is that

bleeding

primarily

contained in the femoral sheath follows the path of least resistance superiorly into the prevesical space and retroperitoneum, while bleeding not contained by the sheath but confined to the femoral triangle involves the groin and thigh of least resistance.

muscles

as the

paths

excluded

with

the third bleeding, en. Thus,

patient with intraperitoneal no surgery was undertakno formal conclusion may

be reached

the

external

by

Meyers, can

iliac

vessels

assess patients postcatheterization the

clinician

rapidly

decide

ing

indicate

1.

2.

3.

4.

6.

7.

9.

10.

1 1.

between

these possibilities is obvious, but, as noted, findings at physical examination may be surprisingly benign in patients with massive hematomas. In addition, as noted by Illescas et al (6), CT may help suggest alternative diagnoses that were unsuspected. In our series, CT contributed to the treatment of all patients: in two by the

need

for

is not

sur-

of

possible

to the

in both

planning

and U

and

interpreting

their

signifi-

examining the

radiolCT

the

exami-

CT

References

help

on

This

view

is vital

nation scan.

8.

of distinguishing

and predict

ogist

rather

further therapy. This is particularly important in patients who have undergone PTCA, in whom hypotension and abdominal pain may mdicate coronary thrombosis or spasm rather than hematoma. The impontance

cance

suspected of having bleeding; thus, can

in

matomas

5.

accurately

in-

was identiunsuspected

the capacities of the various intraabdominal spaces. An understanding of the types of he-

In

intrapenitoneal

is needed. quickly and

CT

helping

#{149} Radiology

about

findings.

than the femoral vessels is responsible for intraperitoneal bleeding as a complication of femoral arteniography (3). Further evaluation of the possibility of additional routes, such as the reverse of those demonstrated

gery,

40

CT

in whom

bleeding frequently

on underestimated.

postulate

that the reverse may also be true. In addition, in rare situations such as a patent processus vaginalis or punctune of a femoral hernia, direct spread of blood from the femoral tnangle into the peritoneal cavity could occur. Although the former possibility cannot be excluded, the latter was the

In patients

prising

underwent surgery in this series, who also had intraperitoneal bleeding, had evidence only of active yenous bleeding into the femoral tniangle. This patient also had retropenitoneal bleeding, and Meyers (12) states that intraperitoneal processes may reach the extrapenitoneal spaces through pathologic defects in the parietal

monitoring.

traabdominal fied, it was

punc-

above the inguinal ligament. was surgically proved in one with intrapenitoneal bleeding.

However,

lies in the deeptrough. Bleeding femoral triangle

hematoma to occur

12.

Fraedrich C, Beck A, Bonzel T, Schlosser V. Acute surgical intervention for complications of percutaneous transluminal angioplasty. Eur J Vasc Surg 1987; 1:197203. Garti I, Salinger H. Complications in brachial countercurrent arteriography and in retrograde femoral arteriography. Israel J Med Sci 1969; 5:1192-1197. Lang EK. A survey of the complications of percutaneous retrograde arteriography: Seldinger technique. Radiology 1963; 81:257-263. Redman HC, Reuter SR. Percutaneous transarterial arteriography: complications and their avoidance. Angiology 1970; 21:575-579. Sigstedt B, Lunderquist A. Complications of angiographic examinations. AJR 1978; 130:455-460. Illescas FF, Baker ME, McCann R, Cohan RH, Silverman PM, Dunnick NR. CT evaluation of retroperitoneal hemorrhage associated with femoral arteriography. AJR 1986; 146:1289-1292. Auh YH, Rubenstein WA, Schneider M, Reckler JM, Whalen JP, Kazam E. Extraperitoneal paravesical spaces: CT delineation with US correlation. Radiology 1986; 159:319-328. Sagel 55, Siegel MJ, Stanley RJ, Jost RC. Detection of retroperitoneal hemorrhage by computed tomography. AJR 1977; 129:403-407. Williams PL, Warwick R, eds. Cray’s anatomy. 36th Br ed. Philadelphia: Saunders, 1980; 725. Gaeta M, Pandolfo I, Russi E, Blandino A, Volta 5, Racchiusa S. Pelvic carcinomatous neuropathy: CT findings and implications for radiation treatment planning. Comput Assist Tomogr 1988; 12:811-816. Grabbe E, Lierse W, Winkler R. The penrectal fascia: morphology and use in staging rectal carcinoma. Radiology 1983; 149:241-246. Meyers M. Dynamic radiology of the abdomen: normal and pathologic anatomy. 3rd ed. New York: Springer-Verlag, 1988; 333-345.

sun-

in the remainder by helpthe need for intensive

January

1990