Profound Inferior Epigastric Artery Bleed After Tenckhoff Catheter Implantation

An 88-year-old female on maintenance dialysis underwent a Swan Neck Tenckhoff peritoneal dialysis catheter insertion via a right paramedian incision in the operating theater under local anesthesia by an experienced surgeon.

Post-procedure, the patient developed abdominal pain and tachycardia, with hemoperitoneum and a drop in hemoglobin. A contrast enhanced CT [Figure 1] of the abdomen revealed a large rectus sheath hematoma with active contrast extravasation from the left inferior epigastric artery, indicating an arterial injury likely sustained during catheter placement. The hematoma was evacuated and a drain tube was placed. The patient had a cardiac arrest and succumbed.

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Figure 1:

Contrast enhanced computed tomography (CECT) abdomen showing (a) hematoma and extravasation of contrast from the inferior epigastric artery, and (b) reconstructed CECT image showing the large hematoma.

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This case highlights a rare but potential complication of a left inferior epigastric artery bleed, which was not detected during catheter implantation in 1.2-2% of cases.¹ The patient also had prolonged aPTT and INR, which could be a manifestation of chronic liver disease or previous heparin use in an elderly, frail patient with end-stage kidney disease.² Extreme caution and proactive action during catheter implantation are mandatory to avoid perforation of the inferior epigastric artery, as demonstrated in this patient.