CardioVascular and Interventional Radiology

, Volume 42, Issue 3, pp 335–343 | Cite as

Transcatheter Arterial Embolization of Spontaneous Soft Tissue Hematomas: A Systematic Review

  • Lahoud Touma
  • Sarah Cohen
  • Christophe Cassinotto
  • Caroline Reinhold
  • Alan Barkun
  • Vi Thuy Tran
  • Olivier Banon
  • David Valenti
  • Benoit Gallix
  • Anthony DohanEmail author
Clinical Investigation Arterial Interventions
Part of the following topical collections:
  1. Arterial Interventions



Severe spontaneous soft tissue hematomas (SSTH) are usually treated with transcatheter arterial embolization (TAE) although only limited retrospective studies exist evaluating this treatment option. The aim of this study was to systematically assess the efficacy and safety of TAE for the management of SSTH.


Medline, EMBASE, PubMed and Cochrane Library were searched from inception to July 2017 using MeSH headings and a combination of keywords. Eligibility was restricted to original studies with patients suffering from SSTH treated with TAE. Patients with traumatic hematomas or who were treated with solely conservative or surgical management were excluded. For each publication, clinical success based on the control of the bleed, rebleeding rates and complications (including mortality) was collected, as well as technical details.


Sixty-three studies met the inclusion criteria, with an aggregate total of 267 patients. Follow-up extended from 1 day to 10 years. Bleeding was mainly localized to the iliopsoas (n = 113/267, 42.3%) and anterior abdominal wall (n = 145/266, 54.7%). When information was available, 81.0% (n = 158/195) of patients were on anticoagulant therapy prior to the bleeding episode. Initial stabilization with control of the bleed was obtained in 93.1% (n = 242 patients, n = 60 studies). The most common embolic materials were coils (n = 129, 54.4%). Rebleeding was reported in 25 patients (9.4%). Only two embolization complications were reported (0.7%). The 30-day mortality was 22.7% (n = 42/1857).


TAE represents a safe and effective procedure in the management of SSTH. We present a management algorithm based on these data, but further studies are needed to address the knowledge gap.


Interventional radiology Embolization Abdominal wall hemorrhage Anticoagulant therapy Psoas hemorrhage 



We acknowledge the Librarian of our institution, Tara Landry, for her help for the literature search, and the PRISMA chart.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

This article does not contain any studies with human participants or animals performed by any of the authors.

Informed Consent

For this type of study informed consent is not required.

Consent for Publication

For this type of study consent for publication is not required.

Supplementary material

270_2018_2086_MOESM1_ESM.docx (20 kb)
Supplementary material 1 (DOCX 19 kb)


  1. 1.
    Neumayer B, Hassler E, Petrovic A, Widek T, Ogris K, Scheurer E. Age determination of soft tissue hematomas. NMR Biomed. 2014;27(11):1397–402.Google Scholar
  2. 2.
    Investigators TC. Low-molecular-weight heparin in the treatment of patients with venous thromboembolism. N Engl J Med. 1997;337(10):657–62.Google Scholar
  3. 3.
    Rimola J, Perendreu J, Falco J, Fortuno JR, Massuet A, Branera J. Percutaneous arterial embolization in the management of rectus sheath hematoma. AJR Am J Roentgenol. 2007;188(6):W497–502.Google Scholar
  4. 4.
    Llitjos JF, Daviaud F, Grimaldi D, et al. Ilio-psoas hematoma in the intensive care unit: a multicentric study. Ann Intensive Care. 2016;6(1):8.Google Scholar
  5. 5.
    Milutinovich J, Follette WC, Scribner BH. Spontaneous retroperitoneal bleeding in patients on chronic hemodialysis. Ann Intern Med. 1977;86(2):189–92.Google Scholar
  6. 6.
    Pieri S, Agresti P, Buquicchio GL, Di Giampietro I, Trinci M, Miele V. Endovascular management of the rectus muscle hematoma. Radiol Med. 2015;120(10):951–8.Google Scholar
  7. 7.
    Dohan A, Sapoval M, Chousterman BG, Di Primio M, Guerot E, Pellerin O. Spontaneous soft-tissue hemorrhage in anticoagulated patients: safety and efficacy of embolization. Am J Roentgenol. 2015;204(6):1303–10.Google Scholar
  8. 8.
    Maleux G, Van Sonhoven F, Hofkens PJ, et al. Soft tissue bleeding associated with antithrombotic treatment: technical and clinical outcomes after transcatheter embolization. J Vasc Interv Radiol. 2012;23(7):910–6.Google Scholar
  9. 9.
    Popov M, Sotiriadis C, Gay F, et al. Spontaneous intramuscular hematomas of the abdomen and pelvis: a new multilevel algorithm to direct transarterial embolization and patient management. Cardiovasc Interv Radiol. 2017;40(4):537–45.Google Scholar
  10. 10.
    Ozyer U. Transcatheter arterial embolization with N-butyl-2-cyanoacrylate in the management of spontaneous hematomas. Cardiovasc Interv Radiol. 2017;40(1):41–9.Google Scholar
  11. 11.
    Dohan A, Darnige L, Sapoval M, Pellerin O. Spontaneous soft tissue hematomas. Diagn Interv Imaging. 2015;96(7–8):789–96.Google Scholar
  12. 12.
    Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. J Clin Epidemiol. 2009;62(10):e1–34.Google Scholar
  13. 13.
    Surani S, Estement B, Manchandan S, Sudhakaran S, Varon J. Spontaneous extraperitoneal lumbar artery hemorrhage. J Emerg Med. 2011;40(6):e111–4.Google Scholar
  14. 14.
    Wada Y, Yanagihara C, Nishimura Y. Bilateral iliopsoas hematomas complicating anticoagulant therapy. Intern Med. 2005;44(6):641–3.Google Scholar
  15. 15.
    Choo IW, Sproat IA, Cho KJ. Transcatheter embolization of the marginal artery of Drummond as treatment for life-threatening retroperitoneal hemorrhage complicating heparin therapy. Cardiovasc Interv Radiol. 1994;17(3):161–3.Google Scholar
  16. 16.
    Isokangas JM, Perala JM. Endovascular embolization of spontaneous retroperitoneal hemorrhage secondary to anticoagulant treatment. Cardiovasc Interv Radiol. 2004;27(6):607–11.Google Scholar
  17. 17.
    Katsumori T, Nakajima K. A case of spontaneous hemorrhage of the abdominal wall caused by rupture of a deep iliac circumflex artery treated by transcatheter arterial embolization. Eur Radiol. 1998;8(4):550–2.Google Scholar
  18. 18.
    Levy JM, Gordon HW, Pitha NR, Nykamp PW. Gelfoam embolization for control of bleeding from rectus sheath hematoma. Am J Roentgenol. 1980;135(6):1283–4.Google Scholar
  19. 19.
    Qanadli SD, El Hajjam M, Mignon F, Bruckert F, Chagnon S, Lacombe P. Life-threatening spontaneous psoas haematoma treated by transcatheter arterial embolization. Eur Radiol. 1999;9(6):1231–4.Google Scholar
  20. 20.
    Kastan DJ, Burke TH. Retroperitoneal hemorrhage. N Engl J Med. 2000;342(10):702.Google Scholar
  21. 21.
    Pathi R, Voyvodic F, Thompson WR. Spontaneous extraperitoneal haemorrhage: computed tomography diagnosis and treatment by selective arterial embolization. Australas Radiol. 2004;48(2):123–8.Google Scholar
  22. 22.
    Pieri S, Agresti P, Buquicchio GL, Di Giampietro I, Trinci M, Miele V. Endovascular management of the rectus muscle hematoma. Radiol Med (Torino). 2015;120(10):951–8.Google Scholar
  23. 23.
    Basile A, Medina JG, Mundo E, Medina VG, Leal R. Transcatheter arterial embolization of concurrent spontaneous hematomas of the rectus sheath and psoas muscle in patients undergoing anticoagulation. Cardiovasc Interv Radiol. 2004;27(6):659–62.Google Scholar
  24. 24.
    Sharafuddin MJ, Andresen KJ, Sun S, Lang E, Stecker MS, Wibbenmeyer LA. Spontaneous extraperitoneal hemorrhage with hemodynamic collapse in patients undergoing anticoagulation: management with selective arterial embolization. J Vasc Interv Radiol. 2001;12(10):1231–4.Google Scholar
  25. 25.
    Smithson A, Ruiz J, Perello R, Valverde M, Ramos J, Garzo L. Diagnostic and management of spontaneous rectus sheath hematoma. Eur J Intern Med. 2013;24(6):579–82.Google Scholar
  26. 26.
    Akpinar E, Peynircioglu B, Turkbey B, Cil BE, Balkanci F. Endovascular management of life-threatening retroperitoneal bleeding. ANZ J Surg. 2008;78(8):683–7.Google Scholar
  27. 27.
    Cherfan A, Arabi Y, Al Askar A, Al Shimemeri A. Recombinant activated factor VII treatment of retroperitoneal hematoma in a patient with renal failure receiving enoxaparin and clopidogrel. Pharmacotherapy. 2007;27(5):755–9.Google Scholar
  28. 28.
    Donaldson J, Knowles CH, Clark SK, Renfrew I, Lobo MD. Rectus sheath haematoma associated with low molecular weight heparin: a case series. Ann R Coll Surg Eng. 2007;89(3):309–12.Google Scholar
  29. 29.
    Fortina M, Carta S, Del Vecchio EO, Crainz E, Urgelli S, Ferrata P. Retroperitoneal hematoma due to spontaneous lumbar artery rupture during fondaparinux treatment. Case report and review of the literature. Acta Biomedica de l’Ateneo Parmense 2007;78(1):46–50 + 80–81.Google Scholar
  30. 30.
    Goldin AR, Walker WJ, Goldblatt M. Therapeutic embolisation for spontaneous retroperitoneal and other extravisceral haemorrhage. Australas Radiol. 1978;22(2):158–64.Google Scholar
  31. 31.
    Isik A, Peker K, Soyturk M, Firat D, Yoruker U, Yilmaz I. Diagnostic evaluation and treatment of patients with rectus abdominis hematoma. Cir Esp. 2015;93(9):580–8.Google Scholar
  32. 32.
    Kalinowski EA, Trerotola SO. Postcatheterization retroperitoneal hematoma due to spontaneous lumbar arterial hemorrhage. Cardiovasc Interv Radiol. 1998;21(4):337–9.Google Scholar
  33. 33.
    Kim YH, Kim CK, Park CB, Jeon HW, Moon MH, Choi SY. Spontaneous rupture of internal iliac artery secondary to anticoagulant therapy. Ann Thorac Cardiovasc Surg. 2013;19(3):228–30.Google Scholar
  34. 34.
    Limberg RM, Dougherty C, Mallon WK. Enoxaparin-induced bleeding resulting in compartment syndrome of the thigh: a case report. J Emerg Med. 2011;41(1):e1–4.Google Scholar
  35. 35.
    Maruyama T, Abe M, Furukawa T, et al. Retroperitoneal hematoma in a patient with advanced chronic kidney disease receiving warfarin therapy. Intern Med. 2016;55(9):1153–8.Google Scholar
  36. 36.
    Park SH, Lee SW, Jeon U, et al. Transcatheter arterial embolization as treatment for a life-threatening retroperitoneal hemorrhage complicating heparin therapy. Korean J Intern Med. 2011;26(3):352–5.Google Scholar
  37. 37.
    Riera C, Deroover Y, Marechal M. Embolization of a rectus sheath hematoma in pregnancy. Int J Gynecol Obstet. 2009;104(2):145–6.Google Scholar
  38. 38.
    Schmalzried TP, Eckardt JJ. Spontaneous gluteal artery rupture resulting in compartment syndrome and sciatic neuropathy. Report of a case in Ehlers–Danlos syndrome. Clin Orthop. 1992;275:253–7.Google Scholar
  39. 39.
    Mitsogiannis IC, Chatzidarellis E, Skolarikos A, Papatsoris A, Anagnostopoulou G, Karagiotis E. Bilateral spontaneous retroperitoneal bleeding in a patient on nimesulide: a case report. J Med Case Rep. 2011;5:568.Google Scholar
  40. 40.
    Pai S, Payne C. Life threatening retroperitoneal haemorrhage due to therapeutic fondaparinux. BMJ Case Rep. 2009. Scholar
  41. 41.
    Shokoohi H, Boniface K, Reza Taheri M, Pourmand A. Spontaneous rectus sheath hematoma diagnosed by point-of-care ultrasonography. Can J Emerg Med. 2013;15(2):119–22.Google Scholar
  42. 42.
    Sullivan LE, Wortham DC, Litton KM. Rectus sheath hematoma with low molecular weight heparin administration: a case series. BMC Res Notes. 2014;7:586.Google Scholar
  43. 43.
    Sun PL, Lee YC, Chiu KC. Retroperitoneal hemorrhage caused by enoxaparin-induced spontaneous lumbar artery bleeding and treated by transcatheter arterial embolization: a case report. Cases J. 2009;2(12):9375.Google Scholar
  44. 44.
    Takamura M, Watanabe J, Sakamaki A, et al. Alcoholic liver disease complicated by deep bleeding into the muscles or retroperitoneum: report of three cases and a review of the literature. Intern Med. 2014;53(16):1763–8.Google Scholar
  45. 45.
    Hama Y, Iwasaki Y, Kawaguchi A. Spontaneous rupture of the lumbar artery. Intern Med. 2004;43(8):759.Google Scholar
  46. 46.
    Tseng GS, Liau GS, Shyu HY, Chu SJ, Ko FC, Wu KA. Expanding refractory rectus sheath hematoma: a therapeutic dilemma. Diagn Interv Radiol. 2012;18(1):139–41.Google Scholar
  47. 47.
    Won DY, Kim SD, Park SC, Moon IS, Kim JI. Abdominal compartment syndrome due to spontaneous retroperitoneal hemorrhage in a patient undergoing anticoagulation. Yonsei Med J. 2011;52(2):358–61.Google Scholar
  48. 48.
    Wong JHM, Ng SSM, Ho SSM, Lee JFY. Transcatheter arterial embolization of spontaneous rectus sheath haematoma in a Chinese woman. Asian J Surg. 2008;31(1):36–9.Google Scholar
  49. 49.
    Yamada Y, Ogawa K, Shiomi E, Hayashi T. Images in cardiovascular medicine: bilateral rectus sheath hematoma developing during anticoagulant therapy. Circulation. 2010;121(15):1778–9.Google Scholar
  50. 50.
    Yamamura H, Morioka T, Yamamoto T, Kaneda K, Mizobata Y. Spontaneous retroperitoneal bleeding: a case series. BMC Res Notes. 2014;7:659.Google Scholar
  51. 51.
    Zissin R, Gayer G, Kots E, Ellis M, Bartal G, Griton I. Transcatheter arterial embolisation in anticoagulant-related haematoma—a current therapeutic option: a report of four patients and review of the literature. Int J Clin Pract. 2007;61(8):1321–7.Google Scholar
  52. 52.
    Fernandez-Ruiz M, Guerra-Vales JM. Enoxaparin-induced retroperitoneal haematoma in patients with renal insufficiency. Swiss Med Wkly. 2010;140(7–8):122–3.Google Scholar
  53. 53.
    Hwang NK, Rhee H, Kim IY, et al. Three cases of spontaneous lumbar artery rupture in hemodialysis patients. Hemodial Int. 2017;21(1):E18–21.Google Scholar
  54. 54.
    Halak M, Kligman M, Loberman Z, Eyal E, Karmeli R. Spontaneous ruptured lumbar artery in a chronic renal failure patient. Eur J Vasc Endovasc Surg. 2001;21(6):569–71.Google Scholar
  55. 55.
    Lee KS, Jeong IS, Oh SG, Ahn BH. Subsequently occurring bilateral iliopsoas hematoma: a case report. J Cardiothorac Surg. 2015;10:183.Google Scholar
  56. 56.
    Murena L, Vulcano E, Salvato E, Marano M, D’Angelo F, Cherubino P. Bilateral iliopsoas intramuscular bleeding following anticoagulant therapy with heparin: a case report. Cases J. 2009;2(7):7534.Google Scholar
  57. 57.
    Nakayama T, Ishibashi T, Eguchi D, et al. Spontaneous internal oblique hematoma successfully treated by transcatheter arterial embolization. Radiat Med Med Imaging Radiat Oncol. 2008;26(7):446–9.Google Scholar
  58. 58.
    Omoto K, Tanabe K, Tokumoto T, Kondo T, Yamanouchi E, Toma H. Spontaneous retroperitoneal bleeding caused by rupture of an iliolumbar artery in a renal transplant patient [10]. Transplantation. 2003;76(1):273–4.Google Scholar
  59. 59.
    Pace F, Colombo GM, Del Vecchio LR, et al. Low molecular weight heparin and fatal spontaneous extraperitoneal hematoma in the elderly. Geriatr Gerontol Int. 2012;12(1):172–4.Google Scholar
  60. 60.
    Park JK, Kim SH, Kim HJ, Lee DH. Spontaneous lumbar artery bleeding and retroperitoneal hematoma in a patient treated with continuous renal replacement therapy. Korean J Crit Care Med. 2015;30(4):318–22.Google Scholar
  61. 61.
    Rao SV, Jacob GG, Raju NA, Ancheri S. Spontaneous arterial hemorrhage as a complication of dengue. Indian J Crit Care Med. 2016;20(5):302–4.Google Scholar
  62. 62.
    Sandoval O, Kinkead T. Spontaneous rectus sheath hematoma: an unusual cause of gross hematuria. Urology. 2013;82(6):e35–6.Google Scholar
  63. 63.
    Santillan A, Zink W, Patsalides A, Gobin YP. Thoraco-lumbar artery aneurysms associated with a metameric paraspinal lesion presenting with retroperitoneal hemorrhage: endovascular management. Surg Neurol Int. 2011;2:137.Google Scholar
  64. 64.
    Shigematsu Y, Kudoh K, Nakasone Y, Fujisaki T, Uemura S, Yamashita Y. Nontraumatic rupture of lumbar artery causing an intravertebral body pseudoaneurysm: treatment by transcatheter embolization. Cardiovasc Interv Radiol. 2006;29(5):870–4.Google Scholar
  65. 65.
    Tai CM, Liu KL, Chen CC, Lin JT, Wang HP. Lateral abdominal wall hematoma due to tear of internal abdominal oblique muscle in a patient under warfarin therapy. Am J Emerg Med. 2005;23(7):911–2.Google Scholar
  66. 66.
    Tsai CL, Lu TC, Chen WJ. Spontaneous retroperitoneal bleeding in a patient with Evans syndrome [1]. Ann Hematol. 2004;83(12):789–90.Google Scholar
  67. 67.
    Vener C, Artoni A, Boschetti C, et al. An acquired factor VIII inhibitor in a myeloproliferative neoplasm presenting with severe retroperitoneal hemorrhage. Leuk Lymphoma. 2012;53(11):2296–8.Google Scholar
  68. 68.
    Wang ZW, Xue HD, Li XG, Pan J, Zhang XB, Jin ZY. Life-threatening spontaneous retroperitoneal haemorrhage: role of multidetector CT-angiography for the emergency management. Chin Med Sci J. 2016;31(1):43–8.Google Scholar
  69. 69.
    Yang MKW, Hui JYH, Fan WC, Chan JCS. Life-threatening spontaneous extraperitoneal haemorrhage secondary to anticoagulant therapy and its management with transcatheter embolisation. J Hong Kong Coll Radiol. 2006;9(1):36–40.Google Scholar
  70. 70.
    Giugliano RP, Ruff CT, Braunwald E, et al. Edoxaban versus warfarin in patients with atrial fibrillation. N Engl J Med. 2013;369(22):2093–104.Google Scholar
  71. 71.
    Zainea GG, Jordan F. Rectus sheath hematomas: their pathogenesis, diagnosis, and management. Am Surg. 1988;54(10):630–3.Google Scholar
  72. 72.
    Cherry WB, Mueller PS. Rectus sheath hematoma: review of 126 cases at a single institution. Medicine. 2006;85(2):105–10.Google Scholar
  73. 73.
    Bhat KJ, Kapoor S, Watali YZ, Sharma JR. Spontaneous epidural hematoma of spine associated with clopidogrel: a case study and review of the literature. Asian J Neurosurg. 2015;10(1):54.Google Scholar
  74. 74.
    Mayer J, Tacher V, Novelli L, et al. Post-procedure bleeding in interventional radiology. Diagn Interv Imaging. 2015;96(7–8):833–40.Google Scholar
  75. 75.
    Dohan A, Eveno C, Dautry R, et al. Role and effectiveness of percutaneous arterial embolization in hemodynamically unstable patients with ruptured splanchnic artery pseudoaneurysms. Cardiovasc Interv Radiol. 2015;38(4):862–70.Google Scholar
  76. 76.
    Garcia-Blazquez V, Vicente-Bartulos A, Olavarria-Delgado A, et al. Accuracy of CT angiography in the diagnosis of acute gastrointestinal bleeding: systematic review and meta-analysis. Eur Radiol. 2013;23(5):1181–90.Google Scholar
  77. 77.
    Soyer P, Fohlen A, Dohan A. Acute gastrointestinal bleeding: a slowly changing paradigm. Diagn Interv Imaging. 2017;98(6):451–3.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2018

Authors and Affiliations

  • Lahoud Touma
    • 1
  • Sarah Cohen
    • 2
    • 3
  • Christophe Cassinotto
    • 1
    • 4
  • Caroline Reinhold
    • 1
  • Alan Barkun
    • 5
  • Vi Thuy Tran
    • 1
  • Olivier Banon
    • 1
  • David Valenti
    • 1
  • Benoit Gallix
    • 1
  • Anthony Dohan
    • 1
    • 6
    Email author
  1. 1.Department of RadiologyMcGill University Health CentreMontrealCanada
  2. 2.INSERM-UMRS 1138 Team 22, Cordeliers Research CentreParis Descartes UniversityParisFrance
  3. 3.Service de cardiopathies congénitales, Hôpital Marie LannelongueLe Plessis-RobinsonFrance
  4. 4.Department of RadiologySt-Eloi University HospitalMontpellierFrance
  5. 5.Department of GastroenterologyMcGill University Health CentreMontrealCanada
  6. 6.Department of Radiology A, Body and Interventional Imaging, Assistance Publique, Hôpitaux de Paris, Cochin HospitalSorbonne Paris Cité, Paris Descartes UniversityParisFrance

Personalised recommendations