Abstract
Background
Retroperitoneal hemorrhage is traditionally associated with femoral access during cardiac catheterization. However, with the increased use of transradial access, the incidence of retroperitoneal hemorrhage has decreased.
Case Summary
A 62-year-old man with chest pain underwent an elective coronary angiography via right radial artery. During recovery, he developed abdominal pain with hypotension and tachycardia. Abdominal contrast-enhanced computed tomography revealed a grade 4 subcapsular hematoma in the right kidney, which was managed conservatively. Further history revealed he had undergone an uneventful right kidney lithotripsy 2 weeks before the elective coronary angiography.
Discussion
To our knowledge, this is the first documented case of a retroperitoneal hemorrhage after a transradial cardiac catheterization in a patient with recent history of extracorporeal shock wave lithotripsy for kidney stones.
Take-Home Message
This case underscores the importance of a detailed history, particularly when patients have undergone recent renal procedures, including extracorporeal shock wave lithotripsy, that could predispose them to complications.
Key words: coronary angiography, hemorrhage, x-ray fluoroscopy
Graphical Abstract
Case Presentation
A 62-year-old man with a medical history of non–insulin-dependent diabetes mellitus, essential hypertension, and obstructive sleep apnea was evaluated for exertional chest pain. He was scheduled for elective coronary angiography and left heart catheterization after experiencing recurrent retrosternal discomfort. His preprocedural vital signs were stable, with a blood pressure of 160/80 mm Hg, heart rate of 84 beats/min, and oxygen saturation of 96%. Laboratory work-up revealed a hemoglobin level of 12.3 g/dL and a platelet count of 317,000/μL, with normal renal function (glomerular filtration rate: 85 mL/min). The patient's urinalysis was negative for hematuria.
Take-Home Messages
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Retroperitoneal hemorrhage after transradial cardiac catheterization is rare but should be considered in patients who develop hypotension with abdominal pain shortly after the procedure.
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Stable patients may be managed conservatively with observation, fluids, and blood products, if needed.
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In patients with recent extracorporeal shock wave lithotripsy or other renal procedures, it may be prudent to delay elective catheterization by 4 to 6 weeks to allow healing, or alternatively to perform renal imaging before the procedure.
The procedure was performed via the right radial artery with a 5-F sheath and 5,000 U of intravenous heparin. Coronary angiography revealed mild intimal irregularities in the left anterior descending and circumflex arteries, with no angiographic evidence of obstructive epicardial coronary artery disease. Hemostasis was achieved, and the patient was transferred to the recovery unit in stable condition. Approximately 30 minutes postprocedure, he began experiencing severe abdominal pain radiating to the right lumbar and back areas. His blood pressure dropped to 120/80 mm Hg, and he developed tachycardia with a heart rate of 110 beats/min and diaphoresis. However, he denied chest pain or any other discomfort.
Given the clinical picture of abdominal pain, hypotension, and tachycardia, a contrast-enhanced abdominal computed tomography (CT) scan was ordered. The scan revealed a right kidney fracture with a 7.5 × 4.8 cm grade 4 subcapsular hematoma extending into the right retroperitoneal space (Figures 1, 2, and 3). Further history revealed that the patient had undergone a clinically uneventful right kidney lithotripsy approximately 2 weeks prior, without gross hematuria during the days following, using a lithotripter that created high-energy shock wave with electromagnetic generation; this was likely the contributing factor to his renal injury, which was exacerbated by the use of anticoagulation during the catheterization.
Figure 1.
Computed Tomography Angiography Transverse Plane View of the Abdomen and Pelvis
The green arrow indicates the right renal kidney fracture, and the yellow arrow indicates the subcapsular hematoma.
Figure 2.
Computed Tomography Angiography Coronal Plane View of the Abdomen and Pelvis
The yellow arrow indicates the right inferior perirenal hemorrhage.
Figure 3.
Computed Tomography Angiography Sagittal Plane View of the Abdomen and Pelvis
The yellow arrow indicates the right renal subcapsular hematoma extending into the inferior perirenal space and the retroperitoneal hemorrhage.
Management and Outcome
The patient was transferred to the intensive care unit for further observation. He was started on intravenous fluids, antibiotics, and pain management. His hemoglobin level dropped to 8 g/dL, prompting multiple blood transfusions. Upon consultation with the urology team, the decision was made to manage the retroperitoneal hemorrhage conservatively, as the patient remained hemodynamically stable. Serial CT scans showed slow resolution of the hematoma, without any evidence of organ compromise.
The patient's condition gradually improved, and he was discharged home in stable condition. The cause of the hemorrhage was attributed to a combination of recent renal trauma from lithotripsy and the anticoagulation administered during the cardiac catheterization.
Discussion
Extracorporeal shock wave lithotripsy (ESWL) is a commonly used noninvasive technique for treating nephrolithiasis, but it carries the risk of renal parenchymal injury due to cavitation effects from the shock waves.1, 2, 3 This can lead to vascular damage, resulting in subclinical or symptomatic perinephric hematomas. The reported incidence of symptomatic perinephric hematoma after ESWL is between 0.5% and 4%, while subclinical bleeding may be seen in up to 30% of patients when assessed with CT or magnetic resonance imaging.4, 5, 6
Retroperitoneal hemorrhage is a rare but well-known complication after femoral artery access during coronary interventions.7,8 However, its occurrence after transradial access is exceedingly rare given the anatomical separation between the radial artery and the retroperitoneal space.9 This case demonstrates that retroperitoneal hemorrhage can still occur in patients who have undergone recent renal procedures such as lithotripsy, where subcapsular hematomas or renal fractures may predispose them to hemorrhage, especially when anticoagulation is used during the procedure.
Although there are no class indications or, to our knowledge, any prior documented cases such as ours to help guide an operator on how long to delay an elective coronary angiography after ESWL, the multidisciplinary discussion and consensus held between the urology and cardiology teams was that the ideal delay between renal lithotripsy and an elective coronary angiography should be 6 weeks to allow enough time for healing in case the shock wave–induced microtrauma in a kidney potentially leads to a subclinical grade 1 or grade 2 subcapsular hematoma, as classified by the American Association for the Surgery of Trauma (Table 1), that could destabilize with the use of anticoagulation.10
Table 1.
2025 American Association for the Surgery of Trauma Kidney Injury Scale
| Grade I: A subcapsular hematoma less than 3.5 cm without active bleeding, or a parenchymal contusion without any laceration. |
| Grade II: A perirenal hematoma confined within the perirenal fascia with a parenchymal laceration <2.5 cm and hematoma rim distance (HRD) <3.5 cm, without active bleeding or collecting system involvement. |
| Grade III: A parenchymal laceration ≥2.5 cm or HRD ≥3.5 cm, partial kidney infarction, vascular injury without active bleeding, or a laceration extending into the urinary collecting system and/or urinary extravasation. |
| Grade IV: Active renal bleeding, hematoma extending into the pararenal space, complete or near-complete kidney infarction without active bleeding, a multifragmented kidney (MFK) without bleeding, or complete or near-complete disruption of the ureteropelvic junction. |
| Grade V: A main renal artery or vein is lacerated or transected with active bleeding, or there is complete or near-complete kidney infarction with active bleeding, or a multifragmented kidney (MFK) with active bleeding. |
From Keihani et al.10
The key to this case was recognizing the patient's history of right kidney lithotripsy and considering it as a possible factor contributing to the retroperitoneal hemorrhage. The anticoagulation used during the catheterization procedure likely exacerbated the existing renal injury, disrupting the fragile yet healing renal vasculature.
Conclusions
This case highlights a rare but clinically significant complication—retroperitoneal hemorrhage—after transradial cardiac catheterization. The likely precipitating factors were a recent history of renal lithotripsy and the anticoagulation used during the procedure. Prompt recognition, imaging, and a multidisciplinary approach were key to managing the patient's condition effectively. Clinicians should be aware of this rare complication, particularly in patients with recent renal trauma or procedures such as ESWL, and consider delaying elective catheterization or performing renal imaging before proceeding with intervention.
Funding Support and Author Disclosures
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Visual Summary.
Timeline of the Case
| Preprocedure | A 62-year-old man with a prior ESWL owing to right nephrolithiasis presented for an elective coronary angiography via right transradial access. He received anticoagulation with unfractionated heparin during the procedure. There were no immediate postprocedural complications in the catheterization laboratory. |
| Postprocedure | While in the recovery unit, the patient developed acute abdominal and right flank pain, hypotension, and tachycardia. His hemoglobin dropped from 12.3 to 8 g/dL. |
| Diagnosis and management | A CT of the abdomen and pelvis revealed a right kidney grade 4 subcapsular hematoma managed conservatively with intravenous fluids, antibiotics, and transfusion of 2 units of PRBCs, with close hemodynamic monitoring in the intensive care unit. No surgical or interventional radiology procedures were required. |
| Multidisciplinary discussion | Multidisciplinary discussion between the cardiology and urology teams concluded that the patient's recent ESWL likely predisposed his right renal parenchyma to hemorrhage. The urology team recommended a minimum 6-week delay after ESWL before future catheterization. |
CT = computed tomography; ESWL = extracorporeal shock wave lithotripsy; PRBC = packed red blood cells.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
References
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