Case Presentation:

A 51–year–old female with end stage renal disease, cirrhosis, tricuspid regurgitation, and portal hypertension undergoes hemodialysis three times per week and receives periodic therapeutic paracenteses. She routinely has 10L or more removed per session, and on two prior occasions her immediate post–procedure course was complicated by profuse abdominal wall bleeding. Both bleeding episodes were controlled with infiltration of the puncture site with lidocaine with epinephrine, 2–0 nylon sutures, and local pressure. The reason for her recurrent misfortune was not clear, however, since no visible varices were apparent at the entry sites. A subsequent incident of post–procedure bleeding while she was an inpatient resulted in a drop in her hematocrit despite the deployment of the standard hemostatic maneuvers. Portable ultrasound of her peritoneum within hours of the procedure demonstrated reaccumulation of fluid. DDAVP and packed red cells were given and her hospitalization was prolonged by 4 days. One month later, she returned for an outpatient paracentesis. This time, in addition to ultrasounding the ascites with a low frequency, phase–array probe, her abdominal wall was also interrogated using a high frequency linear probe. This view revealed significant vasculature a few centimeters deep into the abdominal wall, not visible to the naked eye, and directly adjacent to the peritoneum (Figure 1). An alternative entry site was selected and the procedure was performed without complication (13.2L removed). A subsequent paracentesis with similar mapping occurred without incident (15.4L removed).

Discussion:

While the use of ultrasound for localization of ascites has become routine for many Proceduralists, we found no literature that speaks to the potential value of also using ultrasound to scan the abdominal wall for aberrant vasculature prior to needle entry. We perform ∼1200 paracentesis annually and experience approximately three significant bleeds per year. While this incidence is indeed low (<1%), the occurrences have been both unpredictable and frequently catastrophic, sometimes resulting in ICU admission, transfusion of blood products, prolonged hospitalization, and/or death. The simple yet remarkable discovery of these potential bleeders lurking “subterranean” suggests that the application of ultrasound surveillance may help prevent this dreaded procedural complication.

Conclusions:

Additional study is clearly warranted to determine both the frequency of this vascular pattern in ascitic patients and whether pre–procedural identification can truly prevent unexpected bleeding. Attempts to validate this experience with a larger patient sampling are currently underway, and it is highly likely that this simple maneuver will provide significant benefit to patients (safety) and Proceduralists (risk reduction) with minimal expenditure of additional resources or time.

Figure 1Cross–sectional image of patient’s abdominal wall, with three vessels readily apparent (arrows) that were not visible to the naked eye.