Management of spontaneous abdominal wall hematomas: a narrative review with a focus on CTA-negative endovascular cases.

backgroundSpontaneous abdominal wall hematomas (AWH), typically involving the iliopsoas or rectus sheath, are most often seen in elderly or anticoagulated patients. Their nonspecific presentation can mimic other acute abdominal conditions, delaying diagnosis and management. Computed tomography angiography (CTA), particularly when performed in a multiphasic manner, including venous and delayed phases, provides high sensitivity and specificity in detecting active bleeding. Although subtle arterial bleeding may not always be detectable on arterial-phase imaging alone, this can potentially result in false-negative findings. Treatment options include conservative management, endovascular embolization, and surgical intervention. Identification of the bleeding source on CTA guides targeted embolization during digital subtraction angiography (DSA). In cases where CTA fails to identify the bleeding source, DSA is employed for further assessment and potential embolization. There is no standardized approach in the literature for planning DSA in patients with negative active bleeding signs on preprocedural CTA. This narrative review discusses the clinical presentation, pathophysiology, imaging characteristics, and endovascular treatment options for AWH, with particular emphasis on our procedural approach in patients with negative preprocedural CTA findings.

methodsWe conducted a literature search in PubMed and Google Scholar from inception to December 2024, including studies on spontaneous AWH treated with endovascular embolization. Traumatic hematomas and cases managed exclusively with conservative or surgical methods were excluded. Data from four publications (two systematic reviews and two retrospective studies, totaling 460 patients) were synthesized, and our institutional approach to managing CTA-negative AWH was also summarized.

resultsA total of 460 patients were identified across 4 publications, including 2 systematic reviews (accounting for 408 patients) and 2 retrospective studies. Technical success rates were 100%. In retrospective studies, clinical success rates ranged from 77 to 100%, whereas in two systematic reviews, the reported rates were 56.3% to 89.5% and 93.1%, respectively. Bleeding detection rates were 47% to 82% for CTA and 79% to 85% for DSA. Targeted arteries for embolization were reported, in order of frequency, as follows: lumbar artery, iliolumbar artery, and deep circumflex iliac artery for posterior AWH and deep inferior epigastric artery for anterior AWH.

conclusionEndovascular embolization is an effective and safe treatment for spontaneous AWH. DSA remains essential for localization and embolization. In cases with negative CTA, catheterization of arteries anatomically supplying the hematoma is recommended for both diagnostic and therapeutic purposes. Our stepwise, experience-based protocol for CTA-negative cases offers a practical roadmap for interventional radiologists performing embolization in both anterior and posterior AWH.