An 81-year old female underwent percutaneous coronary intervention (PCI) because of atrial fibrillation on current anticoagulation with 100 mg aspirin/d. 48-hours following the procedure, the patient became hypotensive. Signs of hematoma at the puncture site in the right groin were recoded on general physical examination. The abdomen was distended with tenderness in the right iliac fossa. Additionally the patient suffered from stabbing pain in the right lower abdomen. The hemoglobin level fell from 13 to 8 g/dl.

An abdominal CT scan performed with administration of intravenous contrast media revealed a large, biphasic right retroperitoneal hematoma (zone II) with a craniocaudal dimension of 22 cm (Figure 1). An active bleeding from the right external iliac artery was demonstrated by an ascending contrast extravasation (arrow) between the hematoma layers (serum/corpuscular part).

The patient was managed by exploratory laparotomy. Intraoperative findings were significant for a retroperitoneal hematoma (RPH) with an injured right external iliac artery due to puncture wound and diffuse bleeding. These could be surgically controlled by running suture reconstruction of the artery lesion and subtly, retroperitoneal hemostasis.

The incidence of RPH occurs in approximately 1% of patients who sustain PCI. Features of RPH include hypotension (92%), diaphoresis (58%), groin pain (46%), abdominal pain (42%) and back pain (23%). From the clinical point of view, the vast majority of RPH can be managed nonoperatively. Indication for operative management of RPH includes hemodynamic instability related to the injury. [1]

RPH with PCI is rare. Laparotomy may be required in unstable patient with RPH after PCI.

1. Farouque HM, Tremmel JA, Raissi Shabari F, Aggarwal M, Fearon WF, Ng MK, et al. Risk factors for the development of retroperitoneal hematoma after percutaneous coronary intervention in the era of glycoprotein IIb/IIIa inhibitors and vascular closure devices. J Am Coll Cardiol 2005;45:363-8.   [CrossRef]   [Pubmed]