A recent study published in the journal CardioVascular and Interventional Radiology has found conservative management may be efficacious in patients with spontaneous retroperitoneal haemorrhage (SRH), with added variable success seen after embolization in a more unstable patient group.
The single-centre retrospective case-control study of patients with SRH included patients who were treated conservatively or with embolization. Enrolled patients aged ≥18 years were identified from computed-tomography (CT) imaging reports which stated a diagnosis of SRH or similar, with images reviewed for confirmation. Exclusion criteria were outlined as recent trauma, surgery, retroperitoneal vascular line insertion and other non-spontaneous aetiology.
Corresponding author Warren Clements (The Alfred Hospital, Melbourne, Australia) and colleagues identified a total of 54 patients who were predominantly anticoagulated (74%), male (72%), older adults (mean age of 69 years), with active haemorrhage on CT-scan (52%).
Overall mortality in this patient cohort was 15%, however clinical success was more likely with conservative management over embolization; all-cause, uncontrolled primary bleeding mortality was higher with embolization. However, embolized patients more commonly had active bleeding, shock, and higher blood transfusion volumes.
In their discussion of the results, Clements et al. note that, while most patients treated conservatively were haemodynamically stable, conservative treatment was successful in 13.2% of unstable groups, 100% of whom were taking therapeutic anticoagulants.
“These findings suggest that embolization in SRH may be best reserved for patients with ongoing bleeding despite adequate reversal of anticoagulation agents, or patients who were not anticoagulated to begin with and are haemodynamically unstable,” the authors state.
Of their study’s limitations, the investigators note that their groups were not congruent—embolized patients were more likely to have been unstable and/or have received high blood resuscitation volume, and were not matched even after propensity score matching, particularly regarding blood transfusion volume. Furthermore, they add that underlying coagulopathy, which has been shown to develop in the setting of major blood loss, likely contributed to the lower success rate in the embolization group.
They also underline that patients with SRH are typically older adults who come with a broader range of significant comorbidities. Due to this, Clements et al add that it can often be difficult to determine a precise cause of death, which perhaps explains variations in mortality attributable to SRH in contemporary published literature.
Although more research is needed in this area to confirm the effectiveness of conservative management of SRH, the authors highlight that their results—alongside the findings of other recent studies—show that mortality in SRH is high, and goals of treatment should include addressing the coagulopathy, and not just arrest of haemorrhage, in this patient population.
