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Plastic & Reconstructive Surgery:
doi: 10.1097/PRS.0b013e3181ead13d
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Massive Spontaneous Hematoma from Chronic Enoxaparin (Lovenox) Use

Mir, Tansar M.D.; Layliev, John M.D.; Glickman, Laurence T. M.D.

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Long Island Plastic Surgical Group; Garden City, N.Y., and Department of Surgery; Division of Plastic Surgery; North Shore University Hospital; Manhasset, N.Y. (Mir, Glickman)

Department of Surgery; Division of Plastic Surgery; North Shore University Hospital; Manhasset, N.Y. (Layliev)

Correspondence to Dr. Glickman; Long Island Plastic Surgical Group; 999 Franklin Avenue; Garden City, N.Y. 11530; lglickman@lipsg.com

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Sir:

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A 55-year-old woman was referred for management of a massive left abdominal wall hematoma that she developed spontaneously secondary to enoxaparin (Lovenox; sanofi-aventis, Bridgewater, N.J.) use. Several weeks before her presentation, she developed a hematoma that led to hemorrhagic shock and acute renal failure, requiring 13 units of packed red blood cell transfusion and intensive care unit management. At that time, she underwent angiography and embolization of a branch of the left inferior epigastric artery.

Her comorbid conditions included multiple cerebrovascular accidents secondary to atrial fibrillation, diabetes, hypertension, and hyperlipidemia. She developed skin necrosis to warfarin and was placed on enoxaparin for thrombotic prophylaxis, which she had been taking for many years. Her medications included digoxin, fosinopril, metoprolol, atorvastatin, niacin, and furosemide; the enoxaparin had been discontinued since her admission for hemorrhagic shock.

Physical examination revealed a very large, firm hematoma involving the entire left lower abdominal quadrant and extending toward the back (Fig. 1). It was felt that, given her left lower extremity pain, edema, and significantly limited mobility, evacuation of the hematoma was indicated.

Fig. 1
Fig. 1
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The operative procedure was evacuation of the hematoma with flap reconstruction. A 15-cm transverse lower abdominal skin incision was made. Intraoperative findings revealed a liquefied hematoma in the subcutaneous plane above the level of the rectus fascia. No active bleeding was present. Twelve liters of liquefied hematoma was evacuated in the subcutaneous plane. After copious pulse irrigation with bacitracin solution, multiple quilting sutures of 0 polydioxanone were used to maintain apposition of the superior and inferior flaps. Two no. 10 Jackson-Pratt drains were placed. Tisseel fibrin sealant was then placed throughout the cavity to allow for additional adherence. The incision was closed in three layers using polydioxanone and Monocryl sutures in the standard fashion.

The patient's postoperative course was uncomplicated, and she was discharged on postoperative day 1. Figure 2 shows the operative site at postoperative week 4. Mobility, lower extremity edema, and comfort were much improved.

Fig. 2
Fig. 2
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A review of the literature reveals numerous reports of spinal hematomas, retroperitoneal hematomas, and rectus sheath hematomas secondary to Lovenox use, but massive subcutaneous hemorrhages remain uncommon. There are seven reported cases of massive subcutaneous hemorrhage, only two of which were spontaneous in nature. Both patients incurring spontaneous abdominal wall bleeding were on prophylactic enoxaparin and developed an unexplained fall in the hematocrit and abdominal pain.1 Other reported cases of massive subcutaneous hemorrhage involve trauma. Specifically, there are two cases of life-threatening subcutaneous hemorrhage in patients with neurofibromatosis attributed to microtrauma to abdominal wall vascular malformations; neither of these two patients was on anticoagulant medication.2,3

Our patient is unique in that chronic enoxaparin therapy led to life-threatening spontaneous subcutaneous abdominal wall hemorrhage; this is the third case of such an incident. Physicians should be aware that, although extremely rare, anticoagulant therapy can cause severe spontaneous subcutaneous bleeding. Furthermore, surgical management following initial angiography and embolization to control bleeding can yield an excellent cosmetic and functional result.

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DISCLOSURE

The authors have no conflicts of interest to disclose.

Tansar Mir, M.D.

Long Island Plastic Surgical Group

Garden City, N.Y., and

Department of Surgery

Division of Plastic Surgery

North Shore University Hospital

Manhasset, N.Y.

John Layliev, M.D.

Department of Surgery

Division of Plastic Surgery

North Shore University Hospital

Manhasset, N.Y.

Laurence T. Glickman, M.D.

Long Island Plastic Surgical Group

Garden City, N.Y., and

Department of Surgery

Division of Plastic Surgery

North Shore University Hospital

Manhasset, N.Y.

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REFERENCES

1.Antonelli D, Fares L II, Anene C. Enoxaparin associated with huge abdominal wall hematomas: A report of two cases. Am Surg. 2000;66:797–800.

2.Lo BM, Pennell KN, Lipscomb RM. Life-threatening subcutaneous hematoma. Am J Emerg Med. 2008;26:522.e1–522.e2.

3.Lin YC, Chen HC. Rare complication of massive hemorrhage in neurofibromatosis with arteriovenous malformation. Ann Plast Surg. 2000;44:221–224.

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