# Haemorrhagic Shock After Iatrogenic Deep Circumflex Iliac Artery Injury During Paracentesis: A Rare Lethal Complication

## TL;DR

A rare but life-threatening complication of abdominal paracentesis is described, involving bleeding from the deep circumflex iliac artery, highlighting the need for vigilance and ultrasound guidance.

## Contribution

This case report highlights a rare iatrogenic injury to the deep circumflex iliac artery during paracentesis and its management via angioembolisation.

## Key findings

- Intraperitoneal haemorrhage from the deep circumflex iliac artery is a rare but lethal complication of paracentesis.
- Angioembolisation is an effective treatment for uncontrolled intraperitoneal haemorrhage from this artery.
- Ultrasound guidance can reduce the risk of such complications during paracentesis.

## Abstract

Abdominal paracentesis is a commonly performed bedside procedure. It serves as a therapeutic and diagnostic tool for a variety of conditions. It is regarded as a safe procedure with a low risk of complications. Rarely, iatrogenic complications such as peritonitis, haemorrhage, and bowel perforation may occur. Intraperitoneal haemorrhage is rare and usually occurs due to bleeding from the intraabdominal venous collateral vessels or mesenteric varices. However, intraperitoneal haemorrhage secondary to injury to the abdominal wall arteries, such as the inferior epigastric artery or deep circumflex iliac artery (DCIA), is very uncommon.

We report on a 64-year-old man with decompensated cardiac failure who underwent paracentesis due to gross ascites. Twenty-four hours post-procedure, he became progressively hypotensive and lethargic. An ecchymosis measuring 3 cm × 2 cm was seen over the puncture site. An urgent CT angiography of the abdomen showed a large left-sided intraperitoneal haematoma with active contrast extravasation from the left DCIA. We performed a successful angioembolisation of the left DCIA.

It is important to note that intraperitoneal haemorrhages secondary to DCIA injury may present as occult intraperitoneal haemorrhage. Angioembolisation is a useful tool in the management of uncontrolled intraperitoneal haemorrhage. The recommended puncture site is in the left lower quadrant, 2-4 cm superior and medial to the anterior superior iliac spine (ASIS).

This case report serves to emphasise the rare but potentially lethal complication of a commonly performed procedure. A high index of suspicion of intraperitoneal haemorrhage is required for patients with unexplained hypotension post-paracentesis, even if overt abdominal signs are absent. The use of ultrasound guidance will aid in reducing the risk of severe complications and increasing the overall success rate.