vascular complications are the most frequent adverse outcomes associated with percutaneous coronary intervention ( pci ) via the femoral artery .
they contribute to in - hospital morbidity , mortality , and costs ; and furthermore , are associated with increased long - term risk of myocardial infarction and death .
vascular complications include bleeding , pseudoaneurysm formation , hematoma , arterio - venous fistula , retroperitoneal bleeding , and other femoral arterial injuries requiring procedural or surgical intervention .
abdominal wall hematoma is a rare condition that can give rise to an acute abdomen . in this report
, we describe a case of a 73-year - old woman who developed an abdominal wall hematoma , which is a rare but serious complication of a pci via the femoral approach .
a 73-year - old woman , with a past medical history of hypertension , diabetes mellitus for 40 years , and chronic kidney disease stage 5 , because of diabetic nephropathy , presented to the emergency department with dyspnea ( nyha iv ) .
the patient had the following vital signs : blood pressure : 155/63 mmhg ; pulse : 93 beats per minute ; respiratory rate : 28 breaths per minute ; and her body temperature was 36.0. on physical examination , the patient had no notable findings , other than bilateral expiratory rales and neck vein distention .
an electrocardiogram was within normal limits . a chest x - ray revealed marked cardiomegaly and pulmonary edema .
laboratory tests showed the following : white blood cell count : 10300/mm , hemoglobin : 8.3 g / dl , platelet count : 250000/mm , blood urea nitrogen : 63 mg / dl , creatinine : 4.4 mg / dl , brain natriuretic peptide : 483 pg / ml , creatine kinase isoenzyme mb : 2.0 ng / ml , and troponin - i : 0.10 ng / ml .
the patient received emergency hemodialysis because of pulmonary edema refractory to medical therapy , including high - dose furosemide infusion . after stabilizing the patient s volume status by regular hemodialysis
, she received coronary angiography for the evaluation of ischemic heart disease on the 19th day of admission .
the patient took aspirin ( 300 mg ) and clopidogrel ( 300 mg ) loading dose 12 hours before the procedure .
when the 0.025-inch straight guidewire ( 45 cm , terumo , tokyo , japan ) for a 4 french sheath was advanced , some resistance was felt .
we then checked the fluoroscopy and found that the guidewire was introduced into the circumflex iliac artery ( fig .
1a ) . we promptly pulled the guidewire back from the circumflex iliac artery and advanced it into the abdominal aorta under fluoroscopic guidance .
the external iliac artery and circumflex iliac arteries were intact , there were no changes in the patient s vital signs , and no abdominal symptoms were found , therefore , we continued the coronary angiography without incident .
( a ) hydrophilic guidewire is unintentionally introduced into the circumflex iliac artery ( arrow ) .
the circumflex iliac artery is intact and there is no evidence of perforation ( arrow ) .
coronary angiography revealed significant stenosis in the middle and distal segments of the right coronary artery and the middle segment of the left anterior descending artery .
after 7000 iu of heparin was administered intravenously , we performed a pci at the middle and distal right coronary artery and the mid - left anterior descending artery with an activated clotting time ( act ) of more than 300 seconds , without any immediate complications . because the act remained prolonged
fourteen hours after pci , the patient complained of a right abdominal pain , with mild swelling of her right abdomen .
we started hydration with normal saline and performed a transfusion of 2 pints of packed red blood cell because of an abrupt drop of hemoglobin from 9.3 to 7.3 g / dl over 12 hours .
the sheath site was clear with no evidence of bleeding , hence , we performed an abdominal computed tomography angiography to identify other causes of the bleeding , which revealed a right lateral abdominal wall hematoma about 5 cm in diameter ( fig .
the right circumflex iliac artery was located in the hematoma , but there was no evidence of active extravasation of contrast media .
the patient s vital signs remained stable after hydration and transfusion , so we decided to closely observe her .
however , the patient still complained of abdominal pain and ecchymotic patches appeared on her abdomen 3 days after the procedure ( fig .
, the patient underwent intermittent hemodialysis with minimal use of heparin and had her hemoglobin checked daily .
the patient was discharged uneventfully after 26 days of hospitalization ( 7 days after pci ) .
she was discharged on aspirin ( 100 mg ) , clopidogrel ( 75 mg ) , rosuvastatin ( 10 mg ) , losartan ( 50 mg ) , and carvedilol ( 6.25 mg ) .
transverse ( a ) and coronal ( b ) section show right - sided abdominal hematoma and circumflex iliac artery ( arrows ) .
abdominal wall hematoma is a rare but potentially serious vascular complication that may develop after cardiac and peripheral angiographic procedures.1 ) predisposing factors include increased sheath size , repeat or multiple punctures of the artery , concomitant use of anticoagulants , advanced age , being female , and hypertension.2)3 ) there are two types of abdominal wall hematomas : spontaneous and iatrogenic .
iatrogenic hematomas often occur when the circumflex iliac artery is perforated during the insertion of the guidewires , although this is a rare complication.4 ) these hematomas are distinguished from retroperitoneal hematomas , which occur when a physician unintentionally punctures the inferior epigastric artery or cannulates the femoral artery too superiorly .
there have been cases of spontaneous abdominal wall hematomas in patients with some predisposing factors , although the incidence is very low.5)6 ) the common symptoms of abdominal wall hematoma are the sudden onset of abdominal pain and swelling , which usually occurs several hours after the procedure . because of its rarity
, abdominal wall hematoma can be mistaken for several common acute abdominal conditions , such as appendicitis , sigmoid diverticulitis , perforated ulcers , ovarian cyst torsion , tumors , and incarcerated inguinal hernias.7 ) diagnosis can be made clinically by the appearance of an obvious swelling or bruising , or may include non - specific findings , such as anemia and fever .
imaging studies help to confirm the diagnosis and exclude intra - abdominal hemorrhage.8 ) contrast - enhanced ct can detect and evaluate active bleeding from a rupture site . even in patients without contrast extravasation at the bleeding site as observed on a ct , angiography could be a useful imaging technique to identify an active bleeding point.9 ) conservative management , including bed rest and analgesics , is appropriate for most stable patients
. however , when a patient has evidence of sustained bleeding , angiographic interventions or surgery should be considered.10 ) in order to prevent vascular complications , such as abdominal wall hematomas or pseudoaneurysms , puncturing the femoral artery under fluoroscopy guidance may be considered.11 ) after the artery has been successfully punctured , the guidewire must be smoothly advanced through the cannula .
the cornerstone of safe sheath engagement is to stop when resistance is encountered during the insertion of the guidewire .
difficulty in advancing the guidewire may occur when the wire enters a small branch vessel . after confirming the location of a wire by fluoroscopy
, one can then retract the wire , spin it gently , and try advancing it again .
in this situation , one must consider angiography to assess for the occurrence of complications , such as vessel perforation and dissection .
when vascular complications are suspected , pci should be delayed with a discontinuation of antithrombotic agents , as well as close observation of the patient .
because hydrophilic guidewires tend to unintentionally engage small vessels , replacing the straight hydrophilic guidewire with a j - tipped wire can be one strategy for preventing the perforation of small vessels . in general , it can not be overemphasized that it is important to closely observe patients who have undergone pci , especially with those with predisposing factors for bleeding , even without any evidence of immediate vascular complications . in the present case
, there was an unusual development of an abdominal wall hematoma after a pci , in the absence of immediate vascular complications .
thus , we suggest that the following may be causative factors of a delayed abdominal wall hematoma following a pci : injury to the circumflex artery during guidewire insertion and the subsequent prolonged act associated with the use of periprocedural heparin in patients with chronic kidney disease .
this case reminds medical professionals of the importance of close observation and proper evaluation of complications after percutaneous coronary intervention , even if the rates of these complications are very low .
fluoroscopy - guided femoral artery puncture and guidewire insertion may reduce the rate pci - related vascular complications .
when vascular complications are suspected during the procedure , a staged pci should be considered to prevent periprocedural vascular complications and ensure a patient s safety . with more coronary angiographic procedures being performed , it is important for clinicians to consider the possibility of abdominal wall hematoma in this situation , especially when the patient has many predisposing factors .
 abdominal wall hematoma is a rare but potentially serious vascular complication that may develop after coronary angiographic procedures . in particular , 
 an oblique muscle hematoma caused by an injury of the circumflex iliac artery is very rare , yet can be managed by conservative treatment including hydration and transfusion . 
 however , when active bleeding continues , angiographic embolization or surgery might be needed . in this study , we report an uncommon case of injury to the circumflex iliac artery by an inappropriate introduction of the hydrophilic guidewire during the performance of a percutaneous coronary intervention . 