An Unusual Complication of EVAR, Spontaneous Rectus Sheath Hematoma: A Case Report

To report a successful conservative management in a case of spontaneous rectus sheath hematoma (SRSH) after Endovascular Aneurysmal Repair (EVAR) of infrarenal Abdominal Aortic Aneurysm (AAA).

An 84-year-old woman with a 6 cm in diameter infrarenal AAA underwent EVAR at our hospital. During the procedure, intravenous heparin was administered to keep the activated clotting time around 300 seconds. One hour after the procedure, the patient complained of pain on her right side abdomen. Physical examination revealed a tender mass in the right lower abdominal wall. Laboratory studies showed a fall in hemoglobin from 12.7 g/dl to 9.3 g/dl. Ultrasound (US) examination demonstrated an 8 × 5 cm hematoma within the right rectus muscle. Follow-up US examination revealed that the hematoma had enlarged and a computed tomography (CT) examination of the lower abdomen was performed. CT scan showed a smooth-shaped mass within the layers of the anterolateral abdominal wall leading to enlargement of the right rectus abdominis muscle without signs of active bleeding. A conservative management was considered.

The clinical course was uneventful with a stable hemodynamic state. The patient was discharged 12 days later and was doing well at the 2 week follow-up.

Spontaneous rectus sheath hematoma is an unusual complication of a patient on anticoagulant therapy during EVAR. A prompt radiological investigation may prevent unnecessary surgical procedures in this unusual complication.