Spontaneous Intramuscular Hematomas

Transcription

1 Spontaneous Intramuscular Hematomas Endovascular Management Salah D. Qanadli, MD, PhD, FCIRSE Cardio-Thoracic and Vascular Unit Department of Radiology University of Lausanne, CHUV, Lausanne, Switzerland Service de Radiodiagnostic et Radiologie Interventionnelle Quantitative Medical Université Imaging de Lau International Institute London, UK

2 Rare entity Management Conservative Embolization Surgery

3 Rare entity Q1 What? Management Conservative Embolization Q2 How? Q3 When? Surgery

4 Definition Pathophysiology Anatomic considerations Clinical considerations Management

5 Definition Pathophysiology Anatomic considerations Clinical considerations Management

6 Definition Muscular hematomas are defined as bleeding collected into a muscle (contained or uncontained) Intra-muscular hematomas can be either Spontaneous or secondary to trauma injury, tumors

7 Definition Muscular hematomas are defined as bleeding collected into a muscle (contained or uncontained) Intra-muscular hematomas can be either Spontaneous or secondary to trauma injury, tumors

8 History First report by Richardson in 1857 Incidence: rare entity? - Klingler et al. :1.8% in 1257 pts admitted to hospital w/ abdominal pain who had an abdominal US

9 Definition Pathophysiology Anatomic considerations Clinical considerations Management

10 Pathophysiology Microangiopathy Microtrauma Rectus abdominis: tearing/shearing of small vessels - Isometric contraction, Coughing, Valsava Dissecting hematoma * - Secondary vascular lesions

11 Anatomic considerations SIMH distribution (CT fidings)* 13% 8% Recrus Psoas 21% 58% Iliaque Others *Qanadli SD et al., CIRSE 2012

12 Anatomic considerations

13 Risk Factors Coagulopathies Age Women(sex ratio 1.8) CRI and hemodialysis Hypertension Cardiac and hepatic insufficiency Anticoagulation and APT

14 Role of ACT/APT ACT-induced immune microangiopathy Overdose (<35%) ACT bleeding related complication: 5% Incidence of SIMH: 0.6%

15 Role of ACT/APT

16 Definition Pathophysiology Clinical considerations Management

17 Clinical Considerations

18 Imaging US CTA Se/Sp: %/65-100% (<5 dys) ICC: >95% (?) MRA TCA

19 Woman 75 years, acute abdominal pain, Clopidogrel, INR 1, PTT 21, Hb 87 Unenhanced Early phase Late phase

20 Imaging CT based Classifications Berna et al. Osinbowale et al.

21 Imaging Multilevel classification

22 Definition Pathophysiology Clinical considerations Management

23 Management Conservative Embolization* Surgery Evacuation/drainage Vessel ligation

24 Conservative approach

25 Conservative approach

26 Conservative approach

27 Conservative approach

28 Conservative approach

29 Conservative approach

30 Interventional approach Patients Data Value (%) Patients 27 Mean Age (years old +/-SD) 73 +/-9.34 Female/Male 21/6 (=3.5/1) Clinical profile: - Haemodynamic instability or shock - Abdominal pain - Abdominal mass - Neurologic signs Laboratory: - TP - INR - PTT - HB 18 (67) 20 (74) 19 (70) 2 (7) 64 +/-25 (17-100) /-0.62 (1-3.4) 43 +/-29 (21-150) 85 +/-25 (36-120) Anticoagulation and/or antiaggregant treatment: No AC treatment: (2x cirrhosis, 1x factor XI deficit) 24 (89) 3 (11) n=27 (100)

31 Embolization Safety/Efficacy Technical success: 75 to 100% (96%) Clinical success: 57 to 88% (88%) Complications: <5% 30-day mortality: 15 to 36% (15%, all Type III) Recurrences: 16-25% (90% different arteries)

32 Embolization Target vessels/embolic agents

33 Woman 75 years, acute abdominal pain, Clopidogrel, INR 1, PTT 21, Hb 87 Unenhanced Early phase Late phase

34 Woman 75 years, acute abdominal pain, clopidogrel, INR 1, PTT 21, Hb 87

35 Woman 71 years, acute abdominal pain, shock AVK, Heparin + clopidogrel for atrial fibrilation INR 3.4, PTT 49, Hb 84 1a 1b c Native Early time Late time 4 5 6

36 Woman 71 years, acute abdominal pain, shock AVK, Heparin + clopidogrel for atrial fibrilation INR 3.4, PTT 49, Hb 84 1a 1b c

37 Woman 76 years abdominal pain and shock, AVK + Heparin for pulmonary embolism Native 1a 1b c 3 Early time Late time 5 6

38 Woman 76 years abdominal pain and shock, AVK + Heparin for pulmonary embolism 1a 1b c Hematoma of the rectus R Active bleeding R inferior Epigastric artery and R ilio-lombar artery 4 5 6

39 Embolization

40 Patient s selection CT based Classifications

41 Patient s selection

42 Proposal

43 Rare entity R1: 1% (ACT/APT) Management Embolization R2: resorbable/coils/nbca R3: Multilevel decision (Type IIa?)