Salvage ultrasound-guided percutaneous gelatin sponge embolization for refractory abdominal wall hemorrhage after paracentesis: a case description

Introduction

Paracentesis, first introduced in the 19th century, remains a cornerstone procedure for evaluating and managing ascites. Although generally safe, with an overall complication rate of approximately 1%, potential complications can lead to severe outcomes, necessitating heightened clinical vigilance (1). Common complications include ascites leakage, localized infection, and hemorrhage. Hemorrhagic complications are further categorized into abdominal wall hemorrhage, pseudoaneurysms, and hemoperitoneum, with abdominal wall hemorrhage being the most frequently encountered type in clinical practice. Herein, we report a case of refractory abdominal wall hemorrhage following ultrasound-guided paracentesis that did not respond to sequential interventions—initial compression bandaging, ultrasound-guided percutaneous thrombin injection, and endovascular digital subtraction angiography (DSA) embolization. Ultimately, hemostasis was achieved using salvage ultrasound-guided percutaneous gelatin sponge embolization.

Case presentation

A 66-year-old woman with progressive lung adenocarcinoma was admitted for chemotherapy, having undergone right upper lobectomy with mediastinal lymph node dissection for invasive adenocarcinoma 4 years prior. Admission computed tomography (CT) revealed metastases involving the lungs, liver, bones, and pleuroperitoneum, with associated pleural and peritoneal effusions. Laboratory tests were normal, including complete blood count and coagulation profiles (hemoglobin: 124 g/L). The patient had not been receiving any anticoagulants or antiplatelet agents prior to admission or during the hospitalization. For ascites management, ultrasound-guided percutaneous catheter drainage was performed. Ultrasound revealed that bowel loops interfered with the intended puncture site at the junction of the lateral and middle thirds along the line from the left anterior superior iliac spine to the umbilicus. An alternative site lateral to this was chosen, and an 8-French catheter was successfully placed (Figure 1). Postprocedural monitoring of drainage output was initiated.

Figure 1 2D ultrasound image obtained during paracentesis, with the arrow indicating the position of the drainage catheter. 2D, 2-dimensional.

On postprocedural day 2, drainage ceased. Physical examination revealed extensive purple subcutaneous ecchymosis on the left flank, likely related to the puncture procedure, with a maximum diameter of approximately 20 cm. Ultrasound showed abdominal wall swelling without significant intraperitoneal fluid collection. The catheter was removed, and compression bandaging was applied. On postprocedural day 3, physical examination revealed subcutaneous ecchymosis with a maximum diameter increased by 1–2 cm compared to the previous day. Hemoglobin declined to 97 g/L and coagulopathy developed [prothrombin time (PT): 14.6 s; international normalized ratio (INR): 1.15]. Color Doppler ultrasound revealed abnormal blood flow signals along the needle tract (Figure 2A), with spectral Doppler confirming the presence of arterial flow (Figure 2B). The hemorrhage artery (approximately 1 mm in diameter) originated from the deep abdominal wall; however, ultrasound could not delineate its proximal or distal course due to obscuration by tissue swelling. On postprocedural day 3, an ultrasound-guided percutaneous thrombin (Leiyunshang, Changchun, China) injection (800 units) was administered into the needle tract (Figure 3A). Post-treatment Doppler ultrasound demonstrated an attenuated but persistent blood flow signal along the needle tract (Figure 3B). Compression bandaging was maintained.

Figure 2 Ultrasound images showing active hemorrhage within the needle tract. (A) Color Doppler ultrasound image showing active hemorrhage within the needle tract. (B) Spectral Doppler ultrasound image showing arterial blood flow signals.

Figure 3 Ultrasound images during the first thrombin injection. (A) 2D ultrasound image during thrombin injection, with the arrows indicating the position of the puncture needle. (B) Color Doppler ultrasound image after thrombin injection showing active hemorrhage within the needle tract. 2D, 2-dimensional.

From postprocedural days 4–6, physical examination revealed further enlargement of subcutaneous ecchymosis by approximately 2 cm in maximum diameter. Serial ultrasound examinations confirmed persistent hemorrhage with hemoglobin fluctuating between 94 and 105 g/L. Given the high risk of chemotherapy-induced myelosuppression potentially exacerbating cytopenia, aggressive hemostasis was pursued. On postprocedural day 6, a repeat ultrasound-guided thrombin (Leiyunshang) injection (1,000 units) was administered (Figure 4A). Persistent flow signals were confirmed by post-treatment Doppler ultrasound (Figure 4B). Ultrasound-guided radiofrequency ablation was planned as salvage therapy.

Figure 4 Ultrasound images during the second thrombin injection. (A) 2D ultrasound image during thrombin injection, with the arrows indicating the position of the puncture needle. (B) Color Doppler ultrasound image after thrombin injection showing active hemorrhage within the needle tract. 2D, 2-dimensional.

During pre-ablation preparation, the patient developed chills with hemodynamic instability (tachycardia, hypotension, and oxygen desaturation). After emergency resuscitation achieving hemodynamic stabilization, she was transferred to the intensive care unit. Multidisciplinary consultation recommended urgent angiographic intervention. Endovascular DSA of the iliac arteries revealed no definitive contrast extravasation (Figure 5A). Based on the bleeding site being located within the distribution of the deep circumflex iliac artery (DCIA) and distant from the inferior epigastric artery (IEA) territory, selective angiography of the IEA was not performed, and empirical embolization was performed using gelatin sponge particles (Alicon, Hangzhou, China) to occlude the DCIA (Figure 5B). Post-embolization, the proximal segment of the DCIA remained patent, and the distal segment was successfully occluded (Figure 5C). Post-treatment Doppler ultrasound confirmed the presence of ongoing active hemorrhage along the needle tract.

Figure 5 Endovascular DSA images. (A) No definitive contrast extravasation in the iliac artery. (B) The DCIA before embolization. (C) The DCIA after embolization. DCIA, deep circumflex iliac artery; DSA, digital subtraction angiography.

On postprocedural days 7–8, physical examination revealed subcutaneous ecchymosis with a maximum diameter of approximately 25 cm. Ultrasound showed persistent hemorrhage with hemoglobin levels ranging from 87 to 96 g/L and worsening coagulopathy (PT: 16.2 s; INR: 1.31). Multidisciplinary consensus favored ultrasound-guided percutaneous gelatin sponge embolization. Using manually fashioned gelatin sponge pledgets (1×10 mm) (Fukangsen, Guilin, China) (Figure 6A), a total of 20 pledgets were deployed under real-time ultrasound guidance through an 18-gauge percutaneous transhepatic cholangiography (PTC) needle, with each pledget being delivered by rapid injection of 1 mL of saline to achieve embolization. The pledgets were distributed both in the tissue near the bleeding point and within the needle tract (Figure 6B). Immediate post-embolization ultrasound confirmed the mechanical occlusion of the bleeding point and needle tract, evidenced by complete filling with hyperechoic pledgets exhibiting posterior acoustic shadowing (Figure 6C).

Figure 6 Gross appearance of gelatin sponge materials and ultrasound images of gelatin sponge embolization. (A) Gross appearance of gelatin sponge materials, with the short arrows indicating gelatin sponge sheets cut into strips and the long arrows indicating gelatin sponge pledgets manually formed by rolling the cut sheets. (B) 2D ultrasound image during gelatin sponge embolization, with the arrows indicating the position of the puncture needle. (C) 2D ultrasound image showing the needle tract plugged with hyperechoic gelatin sponge pledgets. (D) Color Doppler ultrasound image on postprocedural day 14 showing the absence of flow signals within the needle tract. 2D, 2-dimensional.

From postprocedural days 9–14, physical examination showed gradual resolution of subcutaneous ecchymosis, and the patient’s hemoglobin level stabilized. Serial ultrasound surveillance documented progressive sonographic evolution, showing the initial hyperechoic sponge-like material transforming into a homogeneous anechoic area, indicating advanced liquefaction. Concomitant color Doppler persistently showed the absence of flow signals within the needle tract (Figure 6D). The patient was discharged on postprocedural day 14, with near-complete resolution of subcutaneous ecchymosis.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was provided by the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

Ultrasound-guided percutaneous catheter drainage is widely used for ascites management due to its precision and minimal invasiveness. Nevertheless, abdominal wall hemorrhage remains a critical complication (1). Although compression bandaging is typically effective for controlling abdominal wall hemorrhage, its failure in this case may be attributed to several factors: (I) anatomic constraints likely contributed—the hemorrhage source, a deep intramuscular micro-artery (approximately 1 mm in diameter), could have impaired pressure transmission due to overlying soft tissue thickness; (II) therapeutic delay possibly played a role—compression initiation 2 days post-hemorrhage onset reduced the hemostatic effect of external pressure, leading to progressive hematoma enlargement; (III) coagulopathy-vascular fragility interplay probably exacerbated the condition—progressive coagulation dysfunction compounded by chemotherapy-induced vascular fragility may have further diminished hemostatic potential (2).

Although DSA is an established effective intervention for achieving hemostasis (3), its failure to identify the hemorrhage source may be attributed to the following: (I) obscuration of the hemorrhage micro-artery by superimposed pelvic vasculature; and (II) hemorrhage volume potentially below the sensitivity threshold of conventional angiography. Regarding ultrasound-guided percutaneous thrombin injection, failure may reflect suboptimal dosing (4). Current evidence suggests a mean thrombin dose of 977 units for pseudoaneurysm embolization (5), yet no consensus exists for active hemorrhage. The regimen we adhered to, although appropriate for thromboembolic safety in pseudoaneurysms, may be insufficient for active hemorrhage due to distinct pathophysiology potentially requiring higher thrombin doses.

Ultrasound-guided percutaneous gelatin sponge embolization achieved hemostasis via two synergistic mechanisms: (I) mechanical occlusion by its three-dimensional scaffold structure, providing immediate physical tamponade of the hemorrhage tract; and (II) biological procoagulant activity, wherein its porous surface promotes platelet adhesion and activates the intrinsic coagulation cascade (6). Although gelatin sponge has been described for needle tract plugging in small series (7-9), its use as salvage therapy for refractory abdominal wall hemorrhage appears to be rarely reported. This case demonstrates the technical feasibility of this approach in complex clinical scenarios.

To facilitate broader clinical implementation, standardizing the technique is warranted, particularly given the labor-intensive nature of manual sponge preparation. Preloaded delivery systems, such as injectable gelatin sponge pledgets, could enhance procedural efficiency and reproducibility (10). In terms of safety considerations, our procedure was performed under real-time ultrasound guidance, ensuring precise placement of gelatin sponge pledgets in the extravascular space. This extravascular approach is a key safety feature of our technique, as it significantly reduces the risk of retrograde migration into the external iliac artery or non-target embolization. Additionally, we deliberately chose gelatin sponge over permanent embolic agents such as N-butyl-2-cyanoacrylate (NBCA), owing to its favorable biocompatibility and gradual absorbability over time.

Under real-time ultrasound guidance, we utilized a substantial volume of gelatin sponge pledgets, distributing them near the bleeding site and within the needle tract, which successfully achieved hemostasis by filling these spaces. Although no complications were observed and satisfactory clinical outcomes were attained, the optimal hemostatic dosage of gelatin sponge remains undefined, representing a limitation of our case. Another limitation relates to the lack of precise imaging measurements for the hematoma size throughout the clinical course, as we relied primarily on physical examination findings rather than serial imaging with objective measurements. Finally, our diagnostic approach was limited to ultrasound and DSA without complementary cross-sectional imaging such as contrast-enhanced CT, which could have provided further anatomical detail about the bleeding site and surrounding structures. Future research should focus on establishing dose-response relationships between embolic volume and hemorrhage severity, as well as evaluating the comparative efficacy of different gelatin formulations (slurry versus pledgets) for needle tract plugging.

Conclusions

Ultrasound-guided percutaneous gelatin sponge embolization may serve as a salvage option for compression-refractory deep abdominal wall hemorrhage when conventional interventions fail.

Acknowledgments

None.

Footnote

Funding: The study was supported by the Talent Introduction Program of China-Japan Friendship Hospital, under the project titled ‘Application of Ultrasound New Technologies in Hormone-Related Diseases’ (No. 2019-RC-2).

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://qims.amegroups.com/article/view/10.21037/qims-2025-1632/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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