A Rare Case of Spontaneous Massive Retroperitoneal Hemorrhage Due to Idiopathic lumbar Artery Bleed.

Dear Editor,

Spontaneous retroperitoneal hemorrhage could present as a rare, life-threatening emergency with sudden onset of massive bleeding. The most common causes being anti-coagulation therapy, postiatrogenic intervention or trauma.[123]

A 24-year-old male came to the emergency department with a history of sudden-onset right flank pain and loss of consciousness. On examination, he was pale with a pulse rate of 120/min and blood pressure of 90/60 mm Hg. The patient had received one packed red-cell transfusion before the presentation. On abdominal examination, a large lump of 20 cm × 10 cm was palpable in the right flank. His hemoglobin was 5.2 g/L, and white blood cells count of 10,800 cells/cumm and platelets of 2.9 lakhs. The patient was resuscitated with crystalloids and two packed red-cell transfusions. There was no significant medical or surgical history. The urgent computed tomography scan was suggestive of massive retroperitoneal bleed with active blush present from lumbar artery [Figure 1]. Transarterial embolization of the bleeding vessel was performed [Figure 2]. Over the next 24 h, pulse rate slowly returned to normal and he maintained blood pressure with adequate urine output. The patient was discharged by day 4. Repeat imaging on follow-up after a month revealed an organized hematoma at the site of bleed and no evidence of tumor or aneurysm [Figure 3].

Figure 1

Massive retroperitoneal bleed with active blush (arrow)

Figure 2

Angiography preembolization showing active blush (arrow in a) and postembolization showing control of bleeding (arrow in b)

Figure 3

Follow-up computed tomography scan showing organized hematoma

Retroperitoneal bleeding resulting from lumbar arteries are most frequently a result of high-velocity trauma or spinal surgical instrumentation.[45] On the other hand, spontaneous bleeding in these arteries, though rare is related to anticoagulant therapy or aneurysm rupture.[6]

Spontaneous lumbar arterial bleeding has been reported before in patients on enoxaparin or with neurofibromatosis. However, there is no reported case of spontaneous lumbar arterial bleed in young adult as in our patient.

The retroperitoneal region has a rich blood supply. The major source being lumbar arteries with numerous anastomoses with branches of intercostal and internal iliac arteries.[7] In case of a lumbar artery bleed achieving hemostasis through open technique is a daunting task with high morbidity. Furthermore, it involves the direct manipulation of an arterial wall that is weakened by a chronic inflammatory process. Endovascular approach is minimally invasive and has significant advantages over conventional surgical approach, namely reduced blood loss and general anesthesia is avoided thus making it feasible in bleeding patients with hemodynamic instability.[8] Hence, the endovascular approach must be attempted first.

Another important concept is the origin of the anterior radiculomedullary artery (T8– L2) or Adamkiewicz artery, which arises from first or second lumbar artery in 19% of patients and supplies the thoracolumbar portion of the spinal cord. Inadvertent manipulation might cause medullary infarction and paralysis.[9] which should be remembered during treatment.

Based on the above data, treatment should be started with aortography, and super-selective embolization should be performed after careful identification of the bleeder using micro-guidewire and micro-catheters.[7] Repeat arteriography should then be performed to record interruption of active bleeding, in addition to the identification of branches that lead to refilling of treated sites.

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