Patient management algorithms in life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH); experiences from three centres

Purpose: Evaluation of the technical and clinical success of interventional treatments employed in three University medical centers and development of work-flow recommendations for intra-arterial embolizations in patients with life-threatening spontaneous retroperitoneal and rectus sheath hemorrhage (SRRSH).

Materials and Methods: Retrospective evaluation of all patients with contrast-enhanced CT and digital subtraction angiography (DSA) for SRRSH from 01/2018–12/2022 amounted to 91 interventions in 83 patients (45f, 38m) with a mean age of 68.1 ± 13.2 years. Analysis of the amount of bleeding and embolized vessels, choice of embolization material, technical success, and 30-day mortality was performed.

Results: Pre-interventional, contrast-enhanced CT demonstrated active contrast extravasation in 79 cases (87%). DSA identified a mean of 1.4 ± 0.88 active bleeds in all but two interventions (98%), consisting of 60 cases with a singular and 39 cases of >1 bleeding artery, which were consecutively embolized. A total of 82/ 83 patients underwent embolization with either n-Butyl-2-cyanoacrylate (NBCA; n=38), coils (n=21) or a combination of embolic agents (n=23). The technical success rate was 97.8%. Overall, 25 patients (30%) died within 30 days after the initial procedure, with mortality rates ranging from 25-86% between the centers with different treatment algorithms.

Conclusion: Embolotherapy is a safe therapy option with high technical success rates in patients with life-threatening SRRSH. For maximisation of clinical success and survival rates, we propose a standardized approach for angiography as well as a low threshold for re-angiography.