Bleeding complications from paracenteses are rare, occurring 1% of the time (Runyon 1986). However, these can result in life-threatening hemorrhage and carry significant morbidity and mortality. Patients are frequently coagulopathic due to intrinsic liver disease, as with the majority of the patients in our report.
Proceduralists have been taught to minimize the bleeding risk and maximize fluid acquisition by preferentially targeting the left lower abdominal quadrant based on anatomic landmarks 2–4 cm cephalad and medial to the anterior superior iliac spine which is sufficiently lateral to the rectus sheath to avoid the risk of injury to the IEA (Sakai et al. 2005). Several factors may distort the normal anatomy, thus making these landmarks difficult to determine in everyday practice: 1) In patients with ascites, the abdominal musculature and IEA are stretched laterally (Sharzehi et al. 2014), and 2) With obesity, the body habitus may also obscure anatomic landmarks such as the anterior superior iliac spine, as with many of the patients in our report. However, the increased utilization of ultrasound has allowed proceduralists to target the largest pocket of fluid regardless of anatomic location. It is worth noting that while the supra-pubic, midline approach is still performed by some so as to minimize risk of injury to the IEA, the majority of patients undergoing paracentesis have cirrhosis related portal hypertension, and lacerated varices along the peritoneal surface are relatively common in the peri-umbilical region; approximately one third of hemorrhagic complications from paracentesis may be due to these mesenteric varices (Sharzehi et al. 2014).
Injuries to the IEA have a relatively early presentation compared to injuries of other abdominal wall vessels (such as the DCI and varices) given the formation of a hematoma within the rectus muscle sheath compared to the lateral abdominal wall and the peritoneal cavity (Day et al. 2014; Rimola et al. 2007). Therefore, DCIA bleeding may be more difficult to identify compared to inferior epigastric bleeding, as it less likely to form a palpable abdominal wall hematoma (Day et al. 2014). When this happens, occult hemoperitoneum rather than visible abdominal wall hematoma is the main hemorrhagic feature, and delayed presentation of clinically significant bleeding up to 4 days later may occur and present a diagnostic and management challenge (Arnold et al. 1997). In our series, only 9 of the 16 patients developed hematomas by physical exam or by cross-sectional imaging, and 4 of the 8 patients with angiographically documented injured DCIAs presented with hemoperitoneum alone. Traditionally it has been recommended to follow patients at risk for bleeding after paracentesis closely including serial daily hemoglobin checks for several days (Arnold et al. 1997; Katz et al. 2013). However, this may not be pragmatic in contemporary outpatient practice, as patients are routinely scheduled as outpatients for large volume paracenteses.
The mainstay of treatment is first recognition, followed by medical management, and then embolization for patients not responding to conservative management. To date, the largest report of embolization for post paracentesis bleeding described 19 patients with the IEA as the bleeding source in the majority of their patients, none of whom had evidence of injury to the DCIA (Sobkin et al. 2008). If an infraumbilical approach was taken and an injury to the recannalized paraumbilical vein occurs, arteriography will be negative. In a review of the literature, we were only able to identify five definitive cases of injury to the DCIA from paracentesis (Day et al. 2014; Satija et al. 2012; Kang et al. 2012; Rimola et al. 2007), of which four necessitated embolization procedures (one patient responded to conservative management alone). Other investigators have referenced the DCIA as an unusual culprit in abdominal wall hemorrhage from a variety of etiologies; these include Park et al. (Park et al. 2011) who reported embolizations in 12 patients for abdominal wall hemorrahge, including 11 IEAs and only 1 DCIA, though the authors made no mention as to the etiologies of the bleeds, and Mukind et al. (Mukund et al. 2018) who had 23 patients post paracentesis with mostly IEA injuries, but at least one patient with injury to the DCIA documented at angiography. However, in our experience, DCIA injury is the most commonly injured artery (50%) from paracentesis identified at angiography. As many hemorrhages are managed non-operatively, it is almost certain that the true incidence of injury to the DCIA is significantly underreported.
We hypothesize that in consciously avoiding the IEA, practitioners choose a puncture site that is too lateral along the iliac crest which often cannot be easily palpated through a distended abdomen, and where the DCIA courses, resulting in injury to this vessel. While ultrasound evaluation of the peritoneum is primarily utilized to find the largest fluid pocket, mapping out the IEA with the highest frequency ultrasound transducer possible and palpating the iliac crest prior to paracentesis may help to select an appropriate “middle ground” between the two at-risk arteries (Stone and Moak 2015; Sekiguchi et al. 2013). Additionally, portal-systemic varices should be attempted to be identified and avoided. On thinner patients, the DCIA may even sometimes be identified on ultrasonography (Figs. 2 and 3). However, as both Sobkin (Sobkin et al. 2008) and Mukin (Mukund et al. 2018) have noted, as well as in our own experience, the injured artery is typically a small branch rather than the parent artery.
Limitations of our report included its retrospective nature, small patient group, and bias that only the most symptomatic patients were likely referred to IR with lack of more information regarding the patients with post paracentesis hemorrhage managed only conservatively at our institution over the reported time period.
