We report a unique method using transcatheter Onyx embolization in a bleeding due to morphine injection in the gluteal region. A 47-year-old man with a rare blood type presented a painful gluteal hematoma due to iatrogenic injury. A computed tomographic angiography verified bleeding from a suspected branch of the deep femoral artery. Because of the unbearable pain, the hematoma was evacuated by means of computed tomography (CT)-guided puncture and the insertion of a pigtail catheter combined with the injection of a human plasminogen activation agent (t-PA). The initial result was positive. To stop the bleeding, angiographic embolization with Onyx was successfully used. Onyx can be used in small vessel bleedings and might offer the advantage of selective embolization in cases where the access to the bleeding vessel is challenging or time-consuming.
From the Department of Surgery, Örebro University Hospital, Örebro, Sweden.
Accepted for publication March 15, 2011.
Disclosures: Thomas Larzon receives compensation as a lecturer/trainer for ev3, Inc., Plymouth, MN USA. Tal Horer, MD, and Asko Toivola, MD, declare no conflict of interest.
Address for correspondence and reprint requests to Tal Hörer, MD, Department of Surgery, Örebro University Hospital, SE-701 85 Örebro, Sweden. E-mail: firstname.lastname@example.org.
Acute iatrogenic or traumatic bleeding can be managed by either open or endovascular methods. Transcutaneous catheter embolization is widely used in the treatment of acute massive hemorrhage.1 The clear disadvantage of an endovascular procedure would be in not solving a potential compartment syndrome in the bleeding area, as the hematoma is not evacuated; thus, the risk for tissue damage remains.
Different embolization agents are in use as coils, polyvinyl alcohol particles (PVA) particles, alcohol, and gelfoam.1,2 Onyx (Micro Therapeutics Inc., Irvine, CA USA) is a biocompatible liquid embolic agent consisting of ethylene-vinyl-alcohol copolymer dissolved in dimethyl sulfoxide, containing tantalum powder to make it radiopaque. Originally, Onyx had been initially used for intracranial arteriovenous malformations and intracranial aneurysms. In recent times, Onyx embolization has been reported in endoleaks, pseudoaneurysms, and experimental aorta models.3–13 Recently, a successful internal sealing of acute aortic bleeding with Onyx, by filling the entire aneurysm sac with Onyx, has been reported.14
We describe a case of acute bleeding due to iatrogenic injury in the deep gluteal region, following intramuscular morphine injection and successful embolization with Onyx. To our best of knowledge, this is the first case that Onyx is used as an embolizing agent in acute bleeding.
The subject is a 47-year-old man who had been treated with warfarin due to a mechanical aortic valve and had a rare blood type. Three days before admission, he was given an injection of morphine in the gluteal region after a minor surgical procedure due to a traumatic finger fracture. He was admitted because of an extremely painful hematoma in the region where the injection had been administered. Upon admission, a hard and painful hematoma was palpated in the lateral gluteal thigh area. No neurologic deficit was found, and the distal status of the leg was normal.
Computed tomographic angiography revealed a 12 × 6 cm hematoma with extravasation in the gluteal region (Fig. 1). The patient's international normalized ratio value was 1.63, and his warfarin treatment was replaced with low-molecular heparin as the patient had a mechanical aortic valve. Diagnostic angiography with selective catheterization revealed no source of bleeding. The patient was admitted to the intensive care unit due to his agonizing pain. Direct pressure measurement by puncture of the hematoma revealed an intramuscular pressure of 70 mm Hg. An ultrasound-guided puncture was carried out, and a 12-F multipurpose pigtail catheter (William COOK Europe, Bjaereskov, Denmark) was inserted; 300 mL of blood came out immediately. The patient experienced momentary pain relief, but later on in the same day the pain increased again. The patient's hemoglobin was 80 g/L. He received only 3 blood transfusions of packed red blood cells and 2 units of fresh frozen plasma, which was available at that time, and the international normalized ratio normalized at 1.1. At this stage, it seemed like there was no need to further reverse the warfarin effect and that low-molecular heparin (5000 IU per day) would be the optimal compromise between the bleeding risk and the risk of thromboembolic event due to the artificial valve.
Ultrasound reassessment at day 2 showed no change in the size of the hematoma and the patient continued to suffer severe pain. A decision was made to repuncture the hematoma and combine it with local injection of t-PA (Atlepas, Boehringer Ingelheim, Germany) for evacuation of the hematoma. CT-guided puncture using a 12-F pigtail drainage catheter (Thal-Quick abscess drainage; COOK Europe, Bjaeverskov, Denmark) was performed, but no blood evacuated spontaneously (Fig. 2). After the injection of 10 mg of Atleplas through the catheter, it was clamped for 20 minutes and then reopened; at this point, blood immediately came out. Within the next 12 hours, 2.3 L of blood was evacuated. The patient experienced pain relief and was hemodynamically stable. Considering his clinical status, stable vital parameters, and stable hemoglobin level and due to the assumption that most of the blood evacuated was from the existing hematoma and not ongoing bleeding, a decision was made to continue clinical follow-up in the intensive care unit. Nevertheless, on the morning of day 3 after arrival, the patient's hemoglobin decreased to 65 g/L, and his blood pressure decreased to a systolic value of 80 mm Hg. A decision was made to do an acute angiography aiming at hemostasis by embolization. Imaging revealed a bleeding from a branch of the deep femoral artery (Fig. 3). Selective catheterization with microcatheter (Progreat 0.025 inch; Terumo Somerset, NJ USA) to a minor branch of the bleeding source and Onyx 34 embolization (1 mL) was performed (Fig. 4). The patient's homodynamic status stabilized. He also received additional 3 blood packed red blood cell transfusions that were available after cross matching. The patient developed an acute hemolytic reaction and received steroid treatment with good results. His hemoglobin levels stabilized at 90 g/L.
At day 5, computed tomographic angiography showed that there was still a hematoma of the same size in the gluteal region (Fig. 5); however, the patient had only moderate pain and was hemodynamically stable. After several days at the surgical ward, the clinical status had generally improved and the patient was transferred to the hematological department for further evaluation and rehabilitation. Autoimmune hemolytic anemia was diagnosed as his blood tests showed positive anticardiolipin antibodies, antiphospholipids antibodies, and positive antinuclear antibodies. This reaction was probably due to the transfusions at day 3 and was correlated to his rare blood subtype, but the exact mechanism is unknown after extensive investigation by the hematologists. Two weeks later, an ultrasound examination showed a somewhat decreased size of the hematoma (10 × 5 cm). At 3-month clinical control, the patient had moderate pain and still needed opioid pain medications. He was able to walk about 200 m while experiencing pain in the gluteal region and the thigh. He also had a loss of sensitivity in the lateral side of the foot. The gluteal area was not swollen, but atrophy in the area and a decrease in muscle strength were noted.
In the patient described in this case, bleeding was from a branch of the deep femoral artery and was unfit for open surgery. There was a fear of significant blood loss, and due to his unique blood type, there was a risk of having no available blood for major transfusions. He was suffering extreme pain, and there was a clear indication to stop bleeding as well as evacuating and decompressing the hematoma to achieve pain relief. The first angiography did not reveal a source of bleeding, probably due to a high-pressure compartment in the gluteal region. After decompression using t-PA, angiographic examination revealed a source of bleeding that could be embolized with Onyx.
Embolization with coils and particles is widely used,1,2 and the use of Onyx in neurosurgical diseases has been commonly reported.13 The use of coils and particles is limited by the need to find the target vessel and release them there. It might also be difficult to locate the exact source of bleeding and access it for deployment. Alcohol might be used to overcome this problem, but it does not appear on the angiogram. Onyx, however, does not necessarily have to be deployed in the target vessel, as one can intentionally use the blood stream to transport the substance into the peripheral branches. Onyx is manufactured in different formulas. The low-density formulas, Onyx 18, 20, and 34, have good penetration and are suitable to a case like this. Onyx 500, the high-density formula, has a very low tendency to embolize in the blood stream and is indicated for neurointerventions. The ability of Onyx to transform from a liquid to a solid state makes its application more versatile than coil embolization.
In conclusion, Onyx embolization is feasible in small vessel bleedings and might be used as an alternative to other embolization agents, especially in cases where it is hard to detect the bleeding vessel or where catheterization to the remote vessel is too technically demanding or time-consuming. We describe a unique method to stop an acute bleeding by Onyx embolization after evacuation of the hematoma using t-PA. To the best of our knowledge, this has not been described before and might be applicable in different bleeding scenarios.
The authors thank Ms. Andrianne Prince for language revision of the manuscript.
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