We report a case of bilateral iliopsoas hematomas that occurred during postoperative therapy after coronary artery bypass grafting (CABG). An 81-year-old woman receiving anticoagulant and antiplatelet therapies under sedation after CABG developed sudden anemia and went into shock. Abdominal ultrasonography showed a right retroperitoneal hematoma. She improved gradually with conservative treatment. Many patients with an iliopsoas hematoma complain of low-abdominal pain or femoral neuropathy, but such local signs may be absent under sedation. In anticoagulant and antiplatelet therapies under sedation, when the cause of anemia and shock is not clear, we should suspect peritoneal hematoma and examine the peritoneal space.</p

Nakanishi, Koji

Shimizu, Shuji

Une, Dai

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Bilateral Iliopsoas Hematomas under Sedation:A Complication of Postoperative Therapy after Coronary Artery Bypass Grafting

Okayama University Scientific Achievement Repository

Acta Medica OkayamaVolume 64, Issue 1 2010 Article 11FEBRUARY 2010Bilateral Iliopsoas Hematomas underSedation:A Complication of PostoperativeTherapy after Coronary Artery BypassGraftingDai Une∗ Shuji Shimizu†Koji Nakanishi‡∗Department of Cardiovascular Surgery, Saiseikai Imabari Hospital,†Department of Cardiovascular Surgery, Saiseikai Imabari Hospital,‡Department of Cardiovascular Surgery, Saiseikai Imabari Hospital,Copyright c©1999 OKAYAMA UNIVERSITY MEDICAL SCHOOL. All rights reserved.Bilateral Iliopsoas Hematomas underSedation:A Complication of PostoperativeTherapy after Coronary Artery BypassGraftingDai Une, Shuji Shimizu, and Koji NakanishiAbstractWe report a case of bilateral iliopsoas hematomas that occurred during postoperative ther-apy after coronary artery bypass grafting (CABG). An 81-year-old woman receiving anticoag-ulant and antiplatelet therapies under sedation after CABG developed sudden anemia and wentinto shock. Abdominal ultrasonography showed a right retroperitoneal hematoma. She improvedgradually with conservative treatment. Many patients with an iliopsoas hematoma complain oflow-abdominal pain or femoral neuropathy, but such local signs may be absent under sedation. Inanticoagulant and antiplatelet therapies under sedation, when the cause of anemia and shock is notclear, we should suspect peritoneal hematoma and examine the peritoneal space.KEYWORDS: iliopsoas, hematoma, coronary artery bypass graftingBilateral Iliopsoas Hematomas under Sedation: A Complication of Postoperative Therapy after Coronary Artery Bypass GraftingDai Une＊,  Shuji Shimizu,  and Koji NakanishiDepartment of Cardiovascular Surgery,  Saiseikai Imabari Hospital,  Imabari,  Ehime 799-1592,  JapanWe report a case of bilateral iliopsoas hematomas that occurred during postoperative therapy after coronary artery bypass grafting (CABG).  An 81-year-old woman receiving anticoagulant and anti-platelet therapies under sedation after CABG developed sudden anemia and went into shock.  Abdominal ultrasonography showed a right retroperitoneal hematoma.  She improved gradually with conservative treatment.  Many patients with an iliopsoas hematoma complain of low-abdominal pain or femoral neuropathy,  but such local signs may be absent under sedation.  In anticoagulant and anti-platelet therapies under sedation,  when the cause of anemia and shock is not clear,  we should suspect peritoneal hematoma and examine the peritoneal space.Key words: iliopsoas,  hematoma, coronary artery bypass graftingnticoagulant and antiplatelet therapies are asso-ciated with various haemorrhagic complications.  Some cases of iliopsoas hematoma have been reported,  but bilateral hematomas are very rare [1].  Sponta-neous iliopsoas hematoma may occur even after heart surgery,  because anticoagulant and antiplatelet thera-pies are widely used in the perioperative care of patients undergoing heart surgery.　 In most cases,  iliopsoas hematoma is associated with femoral palsy,  lumbar pain or groin pain as early local signs [1].  However,  local signs may be absent under sedation.  During perioperative therapy for coronary artery bypass grafting (CABG) under seda-tion,  anemia and shock are sometimes the only signs of iliopsoas hematoma.  Even in muscular hematomas in hemiplegic patients,  it has been reported that local signs were not obvious,  while general signs of hypov-olemia and anemia were more frequent [2].  After CABG,  shock results from various conditions such as myocardial infarction,  low output syndrome,  graft occlusion,  postoperative bleeding,  cardiac tamponade and hypovolemia.  Clinicians must attempt to immedi-ately diagnose a complication and perform appropriate treatment.　 We report a case of bilateral iliopsoas hematomas that occurred during anticoagulant and antiplatelet therapy under sedation after CABG and was associ-ated with anemia and shock.  This report may alert clinicians to be aware of the potential for this rare complication as a diﬀerential diagnosis.Case Report　 An 81-year-old woman was admitted for acute car-diac failure associated with dyspnea.  She had a his-tory of coronary artery bypass grafting (saphenous vein graft (SVG) to right coronary artery and SVG to left anterior descending artery (LAD)) for angina AActa Med.  Okayama,  2010Vol.  64,  No.  1,  pp.  71ﾝ73CopyrightⒸ 2010 by Okayama University Medical School.Case Report http ://escholarship.lib.okayama-u.ac.jp/amo/Received May 25, 2009 ; accepted August 17, 2009. ＊Corresponding author. Phone : ＋81ﾝ86ﾝ225ﾝ7111; Fax : ＋81ﾝ86ﾝ223ﾝ5265E-mail : daune@hotmail.co.jp (D. Une)1Une et al.: Bilateral Iliopsoas Hematomas under Sedation:A Complication of PoProduced by The Berkeley Electronic Press, 2010pectoris 12 years ago.  Since then,  she had received ticlopidine for follow-up of her angina pectoris.  Although angiography showed occlusions of both vein grafts 5 years after surgery,  she had no symptom of cardiac ischemia until this admission.　 Angiography showed unstable angina pectoris,  100ｵ occlusion of the right coronary artery,  75ｵ stenosis in the left main trunk and 90ｵ stenosis in the LAD.  Despite medical management,  the heart failure worsened.  Continuous intravenous infusion of heparin was started because heart failure took a turn for the worse.  CABG was performed again (left internal thoracic artery-LAD,  SVG-right coronary artery,  SVG-circumﬂex on pump) 14 days after admission.  Anticoagulant (heparin) therapy was continued even after CABG.  Activated coagulation time (ACT) was measured every 12h.  ACTs were between 120 and 190sec.  Antiplatelet (aspirin at 100mg/day and cil-ostazol at 200mg/day) therapy was started 5 days after the operation through a gastric tube.  The patient developed anemia and went into shock 8 days after the operation.  A tender mass in the right lower abdominal quadrant was palpable on physical examina-tion.  She had been unconscious from anesthesia when she went into shock.  Perioperative management was not directly related to the iliopsoas muscles.　 Abdominal ultrasonography showed a right retro-peritoneal hematoma,  and computed tomography revealed bilateral iliopsoas hematomas (Fig.  1).  Angiography showed multiple focuses of bleeding through lumbar arteries and iliolumbar arteries (Fig.  2).  On the 8th day after the operation,  the platelet count was 8.6×104/µl,  prothrombin time-interna-tional normalized ratio (PT-INR) was 1.12,  activated partial thromboplastin time (APTT) was 27.3sec and hemoglobin had dropped to a minimum of 7.4g/l.  A blood transfusion was performed.　 We chose conservative therapy and discontinued anticoagulant and antiplatelet therapies.　 The patientʼs hemodynamic condition gradually became stable after a blood transfusion.  On the 21st day after the operation,  she recovered from anesthe-sia soon after anesthesia was stopped.  She had mild weakness in the right quadriceps muscle.Discussion　 Anticoagulant or antiplatelet therapy is widely used in heart surgery.  However,  there have been few reports of an iliopsoas hematoma occurring in the perioperative period of heart surgery.  Spontaneous iliopsoas hematoma has been reported as a complica-tion of anticoagulant therapy or antiplatelet therapy for various diseases [1,  3-6].  Many cases of sponta-neous iliopsoas hematoma due to heparin therapy have been reported [4],  and a few cases of retroperitoneal hemorrhage secondary to antiplatelet therapy have been reported [5].　 Spontaneous hematomas originate from tears in muscle ﬁbers and are rarely bilateral [7].  Small ves-sel arteriosclerosis [8] or a phenomenon related to a thrombotic genesis involving the adrenal glands may or may not correlate with the presence of heparin-72 Acta Med.  Okayama　Vol.  64,  No.  1Une et al.Fig. 1　 A computed tomography scan image showing a right ret-roperitoneal hematoma (1) and hematomas within the bilateral iliop-soas muscles (2 and 3).Fig. 2　 An angiography image showing multiple focuses of bleed-ing through lumbar arteries and iliolumbar arteries.2Acta Medica Okayama, Vol. 64 [2010], Iss. 1, Art. 11http://escholarship.lib.okayama-u.ac.jp/amo/vol64/iss1/11induced immune microangiopathy [9]; they are the most accepted pathogenetic processes [10].　 Treatment of spontaneous iliopsoas hematomas depends on the speed of onset,  volume and degree of neurological impairment [11].  For smaller hemato-mas and moderate neurological symptoms,  a conserva-tive approach with bed rest is justiﬁed [12],  whereas large hematomas and severe motor function inhibition require mandatory surgical treatment by decompres-sion and drainage [13].  In addition,  if patients remain hemodynamically unstable,  surgical arrest of bleeding is required.  In most such cases,  however,  patients are not candidates for surgical treatment.  Transcatheter arterial embolization has been reported to be safe and beneﬁcial as an alternative procedure [14].  We chose conservative therapy for our patient because the hematomas were not large,  and our patient recovered soon from shock with blood transfusion.  Conservative treatment resulted in a good outcome.　 Diagnosis of a retroperitoneal hematoma is diﬃcult under perioperative sedation of heart surgery but is not diﬃcult in an awake state.  Under sedation,  patients with an iliopsoas hematoma cannot complain of common early signs such as femoral neuropathy,  lumbar pain and groin pain.  This report may help clinicians to become aware of the possibility of this rare complica-tion as a diﬀerential diagnosis.References 1. Wada Y,  Yanagihara C and Nishimura Y: Bilateral iliopsoas hema-tomas complicating anticoagulant therapy.  Intern Med (2005) 44:  641-643. 2. Galimard N,  Vassilev K,  Chevignard M,  Perrigot M and Mazevet D: Spontaneous muscular haematomas in hemiplegic patients receiving anticoagulation therapy.  Rev Neurol (Paris) (2004) 160:  672-677. 3. Jamjoom ZA,  al-Bakry A,  al-Momen A,  Malabary T,  Tahan AR and Yacub B: Bilateral femoral nerve compression by iliacus hema-tomas complicating anticoagulant therapy.  Surg Today (1993) 23:  535-540. 4. Sasson Z,  Mangat I and Peckham KA: Spontaneous iliopsoas hematoma in patients with unstable coronary syndromes receiving intravenous heparin in therapeutic doses.  Can J Cardiol (1996) 12:  490-494. 5. Nakao A,  Sakagami K,  Mitsuoka S,  Uda M and Tanaka N:  Retroperitoneal hematoma associated with femoral neuropathy: a complication under antiplatelets therapy.  Acta Med Okayama (2001) 55: 363-366. 6. Merrick HW,  Zeiss J and Woldenberg LS: Percutaneous decom-pression for femoral neuropathy secondary to heparin-induced ret-roperitoneal hematoma: case report and review of the literature.  Am Surg (1991) 57: 706-711. 7. Niakan E,  Carbone JE,  Adams M and Schroeder FM:  Anticoagulants,  iliopsoas hematoma and femoral nerve compres-sion.  Am Fam Physician (1991) 44: 2100-2102. 8. Torres GM,  Cernigliaro JG,  Abbitt PL,  Mergo PJ,  Hellein VF,  Fernandez S and Ros PR: Iliopsoas compart ment: normal anatomy and pathologic processes.  Radiographics (1995) 15: 1285-1297. 9. Di Rosa C,  Venora S,  Monterosso N,  La Spada NM and Viola S:  Retroperitoneal hematoma during heparin therapy.  Comments on 3 cases.  Minerva Chir (1997) 52: 493-497.10. Basile A,  Medina JG,  Mundo E,  Medina VG and Leal R: Trans-catheter arterial embolization of concurrent spontaneous hemato-mas of the rectus sheath and psoas muscle in patients undergoing anticoagulation.  Cardiovasc Intervent Radiol (2004) 27: 659-662.11. Marquardt G,  Barduzal Angles S,  Leheta F and Seifert V: Spon-taneous haematoma of the iliac psoas muscle: a case report and review of the literature.  Arch Orthop Trauma Surg (2002) 122:  109-111.12. Maﬀulli N,  So WS,  Ahuja A and Chan KM: Iliopsoas haematoma in an adolescent Taekwondo player.  Knee Surg Sports Traumatol Arthrosc (1996) 3: 230-233.13. Kumar S,  Anantham J and Wan Z: Posttraumatic hematoma of ili-acus muscle with paralysis of the femoral nerve.  J Orthop Trauma (1992) 6: 110-112.14. Qanadli SD,  El Hajjam M,  Mignon F,  Bruckert F,  Chagnon S and Lacombe P: Life-threatening spontaneous psoas haematoma treated by transcatheter arterial embolization.  Eur Radiol (1999) 9:  1231-1234.73Iliopsoas Hematoma after CABGFebruary 20103Une et al.: Bilateral Iliopsoas Hematomas under Sedation:A Complication of PoProduced by The Berkeley Electronic Press, 2010

Bilateral Iliopsoas Hematomas under Sedation:A Complication of Postoperative Therapy after Coronary Artery Bypass Grafting

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