Clinical management and outcomes for retroperitoneal hemorrhage with active extravasation on contrast enhanced computed tomography (CT)

Clinical management and outcomes for retroperitoneal hemorrhage with active extravasation on contrast enhanced computed tomography (CT) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Clinical management and outcomes for retroperitoneal hemorrhage with active extravasation on contrast enhanced computed tomography (CT) Rui Dai, Vincent Wu, Ryan Adams, Sara Zhao, Alexis Cahalane, Shams Iqbal, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9260434/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: To assess patient characteristics, clinical management, and outcomes in patients with retroperitoneal hematoma that demonstrate active extravasation on contrast enhanced computed tomography (CT). Methods A retrospective comparative study examining 49 patients with active extravasation on CT over a 5-year period was performed. Patients were stratified into those managed conservatively (n = 32) versus those that underent angiography and embolization (n = 17). Primary endpoints included 30-day mortality, length of hospitalization, and requirement for additional intervention. Secondary endpoints included transfusion requirement, vitals, renal injury, and procedure-related complications. Results Interventional radiology was consulted in 33/49 patients with retroperitoneal hematomas demonstrated active contrast extravasation on CT. Of these patients, 17/33 were taken for angiographic intervention. Patients that required angiography had significantly larger hematomas (p < 0.001), higher heart rates (p = 0.014), lower systolic blood pressure (p = 0.001), lower hemoglobin levels (p = 0.003), and required more transfusions (p = 0.004) compared to those managed conservatively. Patients managed with angiography had significantly longer hospital stays (p = 0.002) and higher 30-day all-cause mortality (p = 0.007). There was no significant difference in hemorrhage-associated mortality or complication rates between groups. Conclusion The majority of patients in this study were successfully managed without angiographic intervention. However, patients with larger hematoma size, clinical deterioration, or increased transfusion requirement were significantly more likely to require angiography and embolization. A tailored approach that integrates imaging findings and clinical status is essential in determine which patients would most benefit from intervention. Retroperitoneal hematoma arterial angiography arterial embolization Computed tomography angiography Interventional radiology Active extravasation Figures Figure 1 Figure 2 Figure 3 Introduction Retroperitoneal hemorrhage is a serious and potentially fatal condition that can occur secondary to trauma, anticoagulation, and/or in the postoperative setting. Because the retroperitoneal space can accommodate large volumes of blood before clinical symptoms manifest, diagnosis is frequently delayed. Computed tomography (CT) serves as the primary diagnostic tool for evaluating suspected retroperitoneal hemorrhage, and active contrast extravasation on CT can prompt urgent intervention ( 1 ). Management of retroperitoneal hemorrhage remains challenging ( 2 ). Prior studies have found that conservative therapy with fluid resuscitation, blood transfusion, and reversal of anticoagulation can be sufficient in most hemodynamically stable patients. Meanwhile, embolization has emerged as an effective and minimally invasive method for controlling active retroperitoneal bleeding and is widely used in clinical practice ( 3 ). Surgical intervention is typically reserved for patients who fail embolotherapy or who develop complications such as significant neural compression or compartment syndrome ( 4 ). The optimal criteria for proceeding with embolization are not well defined. Not all patients with active extravasation on contrast enhanced CT exhibit ongoing bleeding at time of angiography, and some hemodynamically unstable patients with spontaneous retroperitoneal hemorrhage do not benefit from embolization ( 5 ). Conversely, delayed intervention can result in hemodynamic decompensation and hemorrhagic shock. Mortality rates from traumatic retroperitoneal hematomas treated conservatively or surgically have historically been approximately 20% ( 6 ), underscoring the importance of establishing clear indications for intervention. This study seeks to evaluate patient characteristics and clinical outcomes in patients with CT-demonstrated active extravasation who were managed conservatively or with angiography. Methods Study Design This was a retrospective cohort study at a single academic interventional radiology practice assessing the clinical management and outcomes for patients with retroperitoneal hematomas that demonstrated active active contrast extravasation on CT. Institutional review board approval was obtained, and the requirement for informed consent was waived due to the retrospective nature of the study. Patient Selection An institutional imaging database was queried for all adult patients (≥ 18 years old) who underwent contrast enhanced CT between January 1, 2018 and December 31, 2023 with findings of retroperitoneal hematoma and evidence of active contrast extravasation. Active extravasation on contrast enhanced CT was defined as foci of extra-vascular contrast within the retroperitoneal hematoma with progressive enlargement on delayed images (if available). All CTs performed with contrast with images acquired in the arterial phase, portal venous phase, and/or venous delayed phase imaging were included in this study. Inclusion criteria included contrast enhanced CT report text containing the term(s): “contrast extravasation”, “active extravasation”, and/or “active bleeding”. All CT images and reports were retrospectively reviewed by two radiologists blinded to clinical outcomes. Exclusion criteria included incomplete imaging or clinical follow-up, and hemorrhage arising from non-retroperitoneal sources. Data Collection Clinical, imaging, and procedural data were extracted from the electronic medical record and picture archiving and communication system (PACS). Variables collected included the following data. Demographics: age, sex, comorbidities, indication for initial contrast enhanced CT. Clinical parameters: cause of bleeding, blood pressure, heart rate, hemoglobin (Hgb) level, platelet (plt) level, INR, medications (anticoagulation, antiplatelet, antihypertensive), length of hospital stay. Imaging characteristics: reason for study, exam time, location and size of hematoma, hematoma enlargement compared to prior exam, additional sites of bleeding. Clinical management and outcomes: presence or absence of IR consultation, active bleeding identified on angiography, whether embolization was performed, embolization in the absence of active bleeding (prophylactic embolization) or in the presence of active bleeding (therapeutic embolization) on angiography, embolic used, vessels embolized, procedural time, time to angiography from CT, sedation level during procedure, surgical or conservative management, need for repeat intervention, transfusion requirements, intensive care unit admission, pressor requirement, complications, all-cause 30-day mortality, and hemorrhage-associated mortality. Embolization Protocol Embolization Protocol Embolization was performed by fellowship-trained interventional radiologists independently or with interventional radiology trainees under direct supervision. Procedural technique typically involved arterial access via the common femoral artery, with insertion of a 5- or 6-French (Fr) vascular sheath, base catheter selection of a lumbar, iliolumbar, and/or deep circumflex iliac artery catheter selection, and digital subtraction angiography for evaluation of active contrast extravasation. Embolic materials used included a combination of gelatin sponge hemostatic slurry, coils, and/or microparticles at the discretion of the operator. Empiric embolization was typically performed during angiography procedures even when active bleeding was not identified. Statistical Analysis Descriptive statistics were used to summarize baseline demographic, clinical, and imaging characteristics. Continuous variables were reported as mean ± standard deviation or median with interquartile range, depending on distribution. Categorical variables were presented as frequencies and percentages. A p-value of < 0.05 was considered statistically significant. Results A total of 49 patients met the inclusion and exclusion criteria following a query of the institutional imaging database. 65.3% of the patient cohort was male, and the mean age was 62.4 years with a standard deviation (SD) of 19.3. 51.0% (n = 25/49) of retroperitoneal hematomas were spontaneous, and the remaining were associated with trauma or iatrogenic causes, such as following lumbar puncture or paracentesis. Interventional radiology was consulted in 67.3% of patients (n = 33/49). Of the patients that had interventional radiology consultation, 51.5% (n = 17/33) underwent angiography with or without embolization (Fig. 1). 67.3% of the patient cohort had received anticoagulation (n = 33/49) and 36.7% antiplatelet therapy (n = 18/49) within 72 hours prior to contrast enhanced CT (Table 1 ). 65.3% of patients were on antihypertensive therapy (n = 32), with 36.7% on more than one agent (n = 18). Patients that underwent angiography had significantly larger hematomas (1182.5 ± 909.7 cm³) compared to those managed conservatively (314.2 ± 737.6 cm³; p < 0.001). They also exhibited higher heart rates (114.2 ± 13.4 bpm vs. 98.1 ± 24.1 bpm, p = 0.014), lower systolic blood pressure (91.1 ± 12.9 mmHg vs. 111.4 ± 22.8 mmHg, p = 0.001), and lower hemoglobin levels (7.1 ± 1.2 g/dL vs. 9.4 ± 2.9 g/dL, p = 0.003). Additionally, patients who underwent angiography were more likely to require transfusions (88.2% vs. 46.9%, p = 0.004) and a higher volume of packed red blood cells (6.2 ± 5.8 units vs. 2.7 ± 2.1 units, p = 0.04). There was no significant difference in diastolic blood pressure, international normalized ratio (INR), or estimated glomerular filtration rate (eGFR) (Table 2 ). Of patients who were managed with angiography, 17.6% (3/17) of patients were on chronic warfarin and 1 patient had a supratherapeutic INR (> 3) at time of contrast enhanced CT. 25% (8/32) of patients managed conservatively were on chronic warfarin and 2 of those patients had a supratherapeutic INR (> 3). The average time from initial CT to angiography was 18.7 ± 22.6 hours, with 35.3% of patients undergoing angiography within six hours of CT. One patient was monitored conservatively for approximately 4 days after the initial CT prior to angiography due to persistent hemoglobin downtrend. Of all patients who underwent angiography, 29.4% of patients demonstrated active extravasation on angiography (n = 5/17), and 88.2% were embolized (n = 15/17). 80% of embolizations were performed in the absence of active extravasation on DSA. Of the patients who underwent embolization, 40% used more than one embolic agent (n = 6/15), with gelatin hemostatic slurry and coils being the most popular combination. 88.2% of the procedures were performed with anesthesia (n = 15/17) and 2/17 procedures were performed with moderate sedation. The average procedure time of 173.1 minutes and standard deviation of 48.2 minutes (Table 3 ). Patients managed with angiography were clinically sicker at baseline, and were associated with significantly longer hospital stays (29.5 ± 29.0 days vs. 10.4 ± 11.3 days, p = 0.002) and higher 30-day all-cause mortality (47.1% vs. 12.5%, p = 0.007). There was no significant difference in hemorrhage-associated mortality or complication rates between groups. There was no significant difference in complications requiring additional interventions or hemorrhage-associated mortality between the two groups (Table 4 ).. Discussion This study highlights the complexity of managing retroperitoneal hematomas with active extravasation on contrast enhanced CT and determining the appropriateness of angiography and embolization. In our cohort, the majority of patients were successfully managed with conservative therapy despite CT evidence of active extravasation. However, patients with larger hematoma size, clinical deterioration, or increased transfusion requirement were significantly more likely to undergo angiography and intervention. There was no significant difference in hemorrhage-associated mortality or complication rates between patients managed conservatively or with angiography. These findings are consistent with prior literature suggesting that many patients with retroperitoneal hemorrhage may be managed conservatively. Lukies et al. reported successful conservative management of spontaneous retroperitoneal hemorrhage in 38 of 54 patients (70.3%), including 13.2% of patients who were initially hemodynamically unstable ( 5 ). Similarly, Warren et al. assessed 99 patients with spontaneous retroperitoneal or rectus sheath hematomas and 82 of 99 patients (82.8%) were successfully managed conservatively ( 4 ). However, both studies emphasize that angiography and embolization remain critical components of management for patients who continue to deteriorate or remain hemodynamically unstable despite conservative therapy. The success of conservative management for retroperitoneal hemorrhage may be attributed to several factors. The anatomy of the retroperitoneal space may facilitate a tamponade effect that helps limit ongoing hemorrhage, especially in the instance of low pressure venous bleeding ( 7 ). Additionally, many patients with spontaneous retroperitoneal hemorrhage present while therapeutically anticoagulated, and reversal of anticoagulation alone may be sufficient to achieve hemostasis. The findings in this study support a management approach that considers hemodynamic status, transfusion requirement, hematoma size, need for continued anticoagulation/antiplatelet therapy, and contrast enhanced CT findings of active extravasation in determining which patients would benefit most from angiography and embolization. Notably, patients who underwent angiography in this study demonstrated greater hemodynamic instability, higher transfusion needs, and larger hematoma size, suggesting appropriate triage of embolization to patients with a higher level of acuity. The risks of embolization, including contrast-induced nephropathy, can be relevant in elderly or critically ill patients who may derive limited benefit from intervention ( 8 ). Furthermore, contrast enhanced CT may overestimate clinically significant bleeding due to imaging artifacts or identification of venous extravasation that may resolve spontaneously following anticoagulation reversal or tamponade ( 9 ). Reliance on imaging findings alone may therefore lead to unnecessary procedures. Decisions regarding appropriateness of embolization should incorporate both imaging and clinical considerations. In summary, active extravasation within retroperitoneal hemorrhage on contrast enhanced CT is an important factor in determining the benefit of angiography and intervention. A tailored approach that integrates both imaging findings and clinical condition is essential. Future prospective studies should aim to define precise thresholds and clinical parameters that guide embolization decisions, balancing intervention risks against the consequences of delayed treatment. Declarations Author Contribution R.D. and T.A. wrote the main manuscript text, figures, and tables. All authors reviewedthe manuscript. References Daly KP, Ho CP, Persson DL, Gay SB. Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings. RadioGraphics. Radiological Society of North America; 2008;28(6):1571–1590. doi: 10.1148/rg.286075141 . Tiralongo F, Toscano S, Mosconi C, et al. Spontaneous retroperitoneal hematoma treated with transarterial embolization: a systematic review and metanalysis. CVIR Endovascular. 2024;7(1):50. doi: 10.1186/s42155-024-00462-6 . Klausenitz C, Kuehn J-P, Noeckler K, et al. Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma. Clinical Radiology. 2021;76(2):157.e 11-157.e18 . doi: 10.1016/j.crad.2020.10.003. Warren MH, Bhattacharya B, Maung AA, Davis KA. Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas. The American Journal of Surgery. 2020;219(4):707–710. doi: 10.1016/j.amjsurg.2019.05.002 . Lukies M, Gipson J, Tan SY, Clements W. Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation. CardioVascular and Interventional Radiology. Springer; 2023;46(4):488–495. doi: 10.1007/s00270-023-03359-4 . Selivanov V, Chi H, Alverdy J, Morris J, Sheldon G. Mortality in retroperitoneal hematoma. Journal of Trauma: Injury, Infection & Critical Care. 1984;21(12):1022–1027. Ishikawa K, Nakao S, Nakamuro M, Huang T-P, Nakano H. The retroperitoneal interfascial planes: current overview and future perspectives. Acute Medicine & Surgery. 2016;3(3):219–229. doi: 10.1002/ams2.188 . Lopera JE. Interventional Radiology: Understanding the Complex Mechanisms of Complications. RadioGraphics. Radiological Society of North America; 2025;45(8):e240138. doi: 10.1148/rg.240138 . Ramin S, Hermida M, Millet I, et al. Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives. Journal of Trauma and Acute Care Surgery. 2018;85(3):527–535. doi: 10.1097/TA.0000000000002001 . Tables Tables are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9260434","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617338032,"identity":"8c0f3952-2e19-4e4c-bf19-9a3defbbcc65","order_by":0,"name":"Rui Dai","email":"","orcid":"","institution":"Massachusetts General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Rui","middleName":"","lastName":"Dai","suffix":""},{"id":617338042,"identity":"049c0a62-f716-4262-b7fe-8cc2f4398255","order_by":1,"name":"Vincent Wu","email":"","orcid":"","institution":"Massachusetts General 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Hospital","correspondingAuthor":true,"prefix":"","firstName":"Thomas","middleName":"","lastName":"An","suffix":""}],"badges":[],"createdAt":"2026-03-29 18:08:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9260434/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9260434/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106382818,"identity":"97edada5-3c60-4e7d-8ef2-13d27253c989","added_by":"auto","created_at":"2026-04-08 05:30:58","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":33505,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eStudy Schema\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSummary flowchart of patients with retroperitoneal hematoma associated with evidence of active extravasation on contrast enhanced CT report.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9260434/v1/ddf43c76d9c93ded7930ae4c.png"},{"id":106382821,"identity":"87843cda-e67b-4809-8f6c-f767104b35c9","added_by":"auto","created_at":"2026-04-08 05:30:58","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":2132573,"visible":true,"origin":"","legend":"\u003cp\u003e63-year-old male with history significant for aortic heart valve replacement and atrial fibrillation on chronic xarelto, found to have \u003cstrong\u003e(A)\u003c/strong\u003e a spontaneous large left retroperitoneal hematoma measuring approximately 12.9 x 10.2 x 24.4 cm with multiple foci of contrast extravasation (arrows) and hemodynamic instability in the setting of septic shock from COVID-19 infection. \u003cstrong\u003e(B)\u003c/strong\u003eThe patient was taken urgently to angiography and was found to have multiple foci of active extravasation (arrows) on digital subtraction angiography (DSA), which were \u003cstrong\u003e(C)\u003c/strong\u003e embolized with gelfoam to stasis.\u003c/p\u003e","description":"","filename":"image1.png","url":"https://assets-eu.researchsquare.com/files/rs-9260434/v1/cdf935a464a256e8ab8686d5.png"},{"id":106382820,"identity":"089aac71-3a81-45fc-bbc7-7a4cdaca32ac","added_by":"auto","created_at":"2026-04-08 05:30:58","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1138962,"visible":true,"origin":"","legend":"\u003cp\u003e89-year-old male with history significant for hypertension and hyperlipidemia on low-dose aspirin therapy, found to have a spontaneous right psoas hematoma measuring 8.1 x 4.5 x 9.1 cm with foci of active contrast extravasation (arrows) but no significant hemodynamic instability, who was treated conservatively with hemodynamic monitoring and discharged one day after presentation.\u003c/p\u003e","description":"","filename":"image2.png","url":"https://assets-eu.researchsquare.com/files/rs-9260434/v1/050514b9038ff08229749b04.png"},{"id":106960195,"identity":"45920149-a01a-4d38-95b1-03a5b13d5f60","added_by":"auto","created_at":"2026-04-15 09:19:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5188108,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9260434/v1/32679241-7e1c-4139-b7fa-edb91673e99d.pdf"},{"id":106404633,"identity":"95821430-9486-4cb7-85de-05f4f053ea9f","added_by":"auto","created_at":"2026-04-08 09:16:25","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":18327,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9260434/v1/b5500628205b30c3cba57f06.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Clinical management and outcomes for retroperitoneal hemorrhage with active extravasation on contrast enhanced computed tomography (CT)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRetroperitoneal hemorrhage is a serious and potentially fatal condition that can occur secondary to trauma, anticoagulation, and/or in the postoperative setting. Because the retroperitoneal space can accommodate large volumes of blood before clinical symptoms manifest, diagnosis is frequently delayed. Computed tomography (CT) serves as the primary diagnostic tool for evaluating suspected retroperitoneal hemorrhage, and active contrast extravasation on CT can prompt urgent intervention (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eManagement of retroperitoneal hemorrhage remains challenging (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Prior studies have found that conservative therapy with fluid resuscitation, blood transfusion, and reversal of anticoagulation can be sufficient in most hemodynamically stable patients. Meanwhile, embolization has emerged as an effective and minimally invasive method for controlling active retroperitoneal bleeding and is widely used in clinical practice (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Surgical intervention is typically reserved for patients who fail embolotherapy or who develop complications such as significant neural compression or compartment syndrome (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe optimal criteria for proceeding with embolization are not well defined. Not all patients with active extravasation on contrast enhanced CT exhibit ongoing bleeding at time of angiography, and some hemodynamically unstable patients with spontaneous retroperitoneal hemorrhage do not benefit from embolization (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Conversely, delayed intervention can result in hemodynamic decompensation and hemorrhagic shock. Mortality rates from traumatic retroperitoneal hematomas treated conservatively or surgically have historically been approximately 20% (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), underscoring the importance of establishing clear indications for intervention.\u003c/p\u003e \u003cp\u003eThis study seeks to evaluate patient characteristics and clinical outcomes in patients with CT-demonstrated active extravasation who were managed conservatively or with angiography.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003e This was a retrospective cohort study at a single academic interventional radiology practice assessing the clinical management and outcomes for patients with retroperitoneal hematomas that demonstrated active active contrast extravasation on CT. Institutional review board approval was obtained, and the requirement for informed consent was waived due to the retrospective nature of the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePatient Selection\u003c/h3\u003e\n\u003cp\u003eAn institutional imaging database was queried for all adult patients (\u0026ge;\u0026thinsp;18 years old) who underwent contrast enhanced CT between January 1, 2018 and December 31, 2023 with findings of retroperitoneal hematoma and evidence of active contrast extravasation. Active extravasation on contrast enhanced CT was defined as foci of extra-vascular contrast within the retroperitoneal hematoma with progressive enlargement on delayed images (if available). All CTs performed with contrast with images acquired in the arterial phase, portal venous phase, and/or venous delayed phase imaging were included in this study. Inclusion criteria included contrast enhanced CT report text containing the term(s): \u0026ldquo;contrast extravasation\u0026rdquo;, \u0026ldquo;active extravasation\u0026rdquo;, and/or \u0026ldquo;active bleeding\u0026rdquo;. All CT images and reports were retrospectively reviewed by two radiologists blinded to clinical outcomes. Exclusion criteria included incomplete imaging or clinical follow-up, and hemorrhage arising from non-retroperitoneal sources.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eClinical, imaging, and procedural data were extracted from the electronic medical record and picture archiving and communication system (PACS). Variables collected included the following data. Demographics: age, sex, comorbidities, indication for initial contrast enhanced CT. Clinical parameters: cause of bleeding, blood pressure, heart rate, hemoglobin (Hgb) level, platelet (plt) level, INR, medications (anticoagulation, antiplatelet, antihypertensive), length of hospital stay. Imaging characteristics: reason for study, exam time, location and size of hematoma, hematoma enlargement compared to prior exam, additional sites of bleeding. Clinical management and outcomes: presence or absence of IR consultation, active bleeding identified on angiography, whether embolization was performed, embolization in the absence of active bleeding (prophylactic embolization) or in the presence of active bleeding (therapeutic embolization) on angiography, embolic used, vessels embolized, procedural time, time to angiography from CT, sedation level during procedure, surgical or conservative management, need for repeat intervention, transfusion requirements, intensive care unit admission, pressor requirement, complications, all-cause 30-day mortality, and hemorrhage-associated mortality.\u003c/p\u003e\n\u003ch3\u003eEmbolization Protocol\u003c/h3\u003e\n\u003cdiv class=\"Heading\"\u003eEmbolization Protocol\u003c/div\u003e \u003cp\u003eEmbolization was performed by fellowship-trained interventional radiologists independently or with interventional radiology trainees under direct supervision. Procedural technique typically involved arterial access via the common femoral artery, with insertion of a 5- or 6-French (Fr) vascular sheath, base catheter selection of a lumbar, iliolumbar, and/or deep circumflex iliac artery catheter selection, and digital subtraction angiography for evaluation of active contrast extravasation. Embolic materials used included a combination of gelatin sponge hemostatic slurry, coils, and/or microparticles at the discretion of the operator. Empiric embolization was typically performed during angiography procedures even when active bleeding was not identified.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics were used to summarize baseline demographic, clinical, and imaging characteristics. Continuous variables were reported as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation or median with interquartile range, depending on distribution. Categorical variables were presented as frequencies and percentages. A p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 49 patients met the inclusion and exclusion criteria following a query of the institutional imaging database. 65.3% of the patient cohort was male, and the mean age was 62.4 years with a standard deviation (SD) of 19.3. 51.0% (n\u0026thinsp;=\u0026thinsp;25/49) of retroperitoneal hematomas were spontaneous, and the remaining were associated with trauma or iatrogenic causes, such as following lumbar puncture or paracentesis. Interventional radiology was consulted in 67.3% of patients (n\u0026thinsp;=\u0026thinsp;33/49). Of the patients that had interventional radiology consultation, 51.5% (n\u0026thinsp;=\u0026thinsp;17/33) underwent angiography with or without embolization (Fig.\u0026nbsp;1). 67.3% of the patient cohort had received anticoagulation (n\u0026thinsp;=\u0026thinsp;33/49) and 36.7% antiplatelet therapy (n\u0026thinsp;=\u0026thinsp;18/49) within 72 hours prior to contrast enhanced CT (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). 65.3% of patients were on antihypertensive therapy (n\u0026thinsp;=\u0026thinsp;32), with 36.7% on more than one agent (n\u0026thinsp;=\u0026thinsp;18).\u003c/p\u003e \u003cp\u003ePatients that underwent angiography had significantly larger hematomas (1182.5\u0026thinsp;\u0026plusmn;\u0026thinsp;909.7 cm\u0026sup3;) compared to those managed conservatively (314.2\u0026thinsp;\u0026plusmn;\u0026thinsp;737.6 cm\u0026sup3;; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They also exhibited higher heart rates (114.2\u0026thinsp;\u0026plusmn;\u0026thinsp;13.4 bpm vs. 98.1\u0026thinsp;\u0026plusmn;\u0026thinsp;24.1 bpm, p\u0026thinsp;=\u0026thinsp;0.014), lower systolic blood pressure (91.1\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9 mmHg vs. 111.4\u0026thinsp;\u0026plusmn;\u0026thinsp;22.8 mmHg, p\u0026thinsp;=\u0026thinsp;0.001), and lower hemoglobin levels (7.1\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 g/dL vs. 9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;2.9 g/dL, p\u0026thinsp;=\u0026thinsp;0.003). Additionally, patients who underwent angiography were more likely to require transfusions (88.2% vs. 46.9%, p\u0026thinsp;=\u0026thinsp;0.004) and a higher volume of packed red blood cells (6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.8 units vs. 2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;2.1 units, p\u0026thinsp;=\u0026thinsp;0.04). There was no significant difference in diastolic blood pressure, international normalized ratio (INR), or estimated glomerular filtration rate (eGFR) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Of patients who were managed with angiography, 17.6% (3/17) of patients were on chronic warfarin and 1 patient had a supratherapeutic INR (\u0026gt;\u0026thinsp;3) at time of contrast enhanced CT. 25% (8/32) of patients managed conservatively were on chronic warfarin and 2 of those patients had a supratherapeutic INR (\u0026gt;\u0026thinsp;3).\u003c/p\u003e \u003cp\u003eThe average time from initial CT to angiography was 18.7\u0026thinsp;\u0026plusmn;\u0026thinsp;22.6 hours, with 35.3% of patients undergoing angiography within six hours of CT. One patient was monitored conservatively for approximately 4 days after the initial CT prior to angiography due to persistent hemoglobin downtrend. Of all patients who underwent angiography, 29.4% of patients demonstrated active extravasation on angiography (n\u0026thinsp;=\u0026thinsp;5/17), and 88.2% were embolized (n\u0026thinsp;=\u0026thinsp;15/17). 80% of embolizations were performed in the absence of active extravasation on DSA. Of the patients who underwent embolization, 40% used more than one embolic agent (n\u0026thinsp;=\u0026thinsp;6/15), with gelatin hemostatic slurry and coils being the most popular combination. 88.2% of the procedures were performed with anesthesia (n\u0026thinsp;=\u0026thinsp;15/17) and 2/17 procedures were performed with moderate sedation. The average procedure time of 173.1 minutes and standard deviation of 48.2 minutes (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePatients managed with angiography were clinically sicker at baseline, and were associated with significantly longer hospital stays (29.5\u0026thinsp;\u0026plusmn;\u0026thinsp;29.0 days vs. 10.4\u0026thinsp;\u0026plusmn;\u0026thinsp;11.3 days, p\u0026thinsp;=\u0026thinsp;0.002) and higher 30-day all-cause mortality (47.1% vs. 12.5%, p\u0026thinsp;=\u0026thinsp;0.007). There was no significant difference in hemorrhage-associated mortality or complication rates between groups. There was no significant difference in complications requiring additional interventions or hemorrhage-associated mortality between the two groups (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)..\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study highlights the complexity of managing retroperitoneal hematomas with active extravasation on contrast enhanced CT and determining the appropriateness of angiography and embolization. In our cohort, the majority of patients were successfully managed with conservative therapy despite CT evidence of active extravasation. However, patients with larger hematoma size, clinical deterioration, or increased transfusion requirement were significantly more likely to undergo angiography and intervention. There was no significant difference in hemorrhage-associated mortality or complication rates between patients managed conservatively or with angiography.\u003c/p\u003e \u003cp\u003eThese findings are consistent with prior literature suggesting that many patients with retroperitoneal hemorrhage may be managed conservatively. Lukies et al. reported successful conservative management of spontaneous retroperitoneal hemorrhage in 38 of 54 patients (70.3%), including 13.2% of patients who were initially hemodynamically unstable (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Similarly, Warren et al. assessed 99 patients with spontaneous retroperitoneal or rectus sheath hematomas and 82 of 99 patients (82.8%) were successfully managed conservatively (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). However, both studies emphasize that angiography and embolization remain critical components of management for patients who continue to deteriorate or remain hemodynamically unstable despite conservative therapy.\u003c/p\u003e \u003cp\u003eThe success of conservative management for retroperitoneal hemorrhage may be attributed to several factors. The anatomy of the retroperitoneal space may facilitate a tamponade effect that helps limit ongoing hemorrhage, especially in the instance of low pressure venous bleeding (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Additionally, many patients with spontaneous retroperitoneal hemorrhage present while therapeutically anticoagulated, and reversal of anticoagulation alone may be sufficient to achieve hemostasis.\u003c/p\u003e \u003cp\u003eThe findings in this study support a management approach that considers hemodynamic status, transfusion requirement, hematoma size, need for continued anticoagulation/antiplatelet therapy, and contrast enhanced CT findings of active extravasation in determining which patients would benefit most from angiography and embolization. Notably, patients who underwent angiography in this study demonstrated greater hemodynamic instability, higher transfusion needs, and larger hematoma size, suggesting appropriate triage of embolization to patients with a higher level of acuity.\u003c/p\u003e \u003cp\u003eThe risks of embolization, including contrast-induced nephropathy, can be relevant in elderly or critically ill patients who may derive limited benefit from intervention (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Furthermore, contrast enhanced CT may overestimate clinically significant bleeding due to imaging artifacts or identification of venous extravasation that may resolve spontaneously following anticoagulation reversal or tamponade (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Reliance on imaging findings alone may therefore lead to unnecessary procedures. Decisions regarding appropriateness of embolization should incorporate both imaging and clinical considerations.\u003c/p\u003e \u003cp\u003eIn summary, active extravasation within retroperitoneal hemorrhage on contrast enhanced CT is an important factor in determining the benefit of angiography and intervention. A tailored approach that integrates both imaging findings and clinical condition is essential. Future prospective studies should aim to define precise thresholds and clinical parameters that guide embolization decisions, balancing intervention risks against the consequences of delayed treatment.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eR.D. and T.A. wrote the main manuscript text, figures, and tables. All authors reviewedthe manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDaly KP, Ho CP, Persson DL, Gay SB. Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings. RadioGraphics. Radiological Society of North America; 2008;28(6):1571\u0026ndash;1590. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/rg.286075141\u003c/span\u003e\u003cspan address=\"10.1148/rg.286075141\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTiralongo F, Toscano S, Mosconi C, et al. Spontaneous retroperitoneal hematoma treated with transarterial embolization: a systematic review and metanalysis. CVIR Endovascular. 2024;7(1):50. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s42155-024-00462-6\u003c/span\u003e\u003cspan address=\"10.1186/s42155-024-00462-6\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKlausenitz C, Kuehn J-P, Noeckler K, et al. Efficacy of transarterial embolisation in patients with life-threatening spontaneous retroperitoneal haematoma. Clinical Radiology. 2021;76(2):157.e\u003cdiv class=\"ExternalRefDOI\"\u003e11-157.e18\u003c/div\u003e. doi: 10.1016/j.crad.2020.10.003.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWarren MH, Bhattacharya B, Maung AA, Davis KA. Contemporary management of spontaneous retroperitoneal and rectus sheath hematomas. The American Journal of Surgery. 2020;219(4):707\u0026ndash;710. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.amjsurg.2019.05.002\u003c/span\u003e\u003cspan address=\"10.1016/j.amjsurg.2019.05.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLukies M, Gipson J, Tan SY, Clements W. Spontaneous Retroperitoneal Haemorrhage: Efficacy of Conservative Management and Embolisation. CardioVascular and Interventional Radiology. Springer; 2023;46(4):488\u0026ndash;495. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00270-023-03359-4\u003c/span\u003e\u003cspan address=\"10.1007/s00270-023-03359-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSelivanov V, Chi H, Alverdy J, Morris J, Sheldon G. Mortality in retroperitoneal hematoma. Journal of Trauma: Injury, Infection \u0026amp; Critical Care. 1984;21(12):1022\u0026ndash;1027.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIshikawa K, Nakao S, Nakamuro M, Huang T-P, Nakano H. The retroperitoneal interfascial planes: current overview and future perspectives. Acute Medicine \u0026amp; Surgery. 2016;3(3):219\u0026ndash;229. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1002/ams2.188\u003c/span\u003e\u003cspan address=\"10.1002/ams2.188\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLopera JE. Interventional Radiology: Understanding the Complex Mechanisms of Complications. RadioGraphics. Radiological Society of North America; 2025;45(8):e240138. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1148/rg.240138\u003c/span\u003e\u003cspan address=\"10.1148/rg.240138\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRamin S, Hermida M, Millet I, et al. Limits of intravascular contrast extravasation on computed tomography scan to define the need for pelvic angioembolization in pelvic blunt trauma: a specific assessment on the risk of false positives. Journal of Trauma and Acute Care Surgery. 2018;85(3):527\u0026ndash;535. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/TA.0000000000002001\u003c/span\u003e\u003cspan address=\"10.1097/TA.0000000000002001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables are available in the Supplementary Files section.\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Retroperitoneal hematoma, arterial angiography, arterial embolization, Computed tomography angiography, Interventional radiology, Active extravasation","lastPublishedDoi":"10.21203/rs.3.rs-9260434/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9260434/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo assess patient characteristics, clinical management, and outcomes in patients with retroperitoneal hematoma that demonstrate active extravasation on contrast enhanced computed tomography (CT).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA retrospective comparative study examining 49 patients with active extravasation on CT over a 5-year period was performed. Patients were stratified into those managed conservatively (n = 32) versus those that underent angiography and embolization (n = 17). Primary endpoints included 30-day mortality, length of hospitalization, and requirement for additional intervention. Secondary endpoints included transfusion requirement, vitals, renal injury, and procedure-related complications.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInterventional radiology was consulted in 33/49 patients with retroperitoneal hematomas demonstrated active contrast extravasation on CT. Of these patients, 17/33 were taken for angiographic intervention. Patients that required angiography had significantly larger hematomas (p \u0026lt; 0.001), higher heart rates (p = 0.014), lower systolic blood pressure (p = 0.001), lower hemoglobin levels (p = 0.003), and required more transfusions (p = 0.004) compared to those managed conservatively. Patients managed with angiography had significantly longer hospital stays (p = 0.002) and higher 30-day all-cause mortality (p = 0.007). There was no significant difference in hemorrhage-associated mortality or complication rates between groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe majority of patients in this study were successfully managed without angiographic intervention. However, patients with larger hematoma size, clinical deterioration, or increased transfusion requirement were significantly more likely to require angiography and embolization. A tailored approach that integrates imaging findings and clinical status is essential in determine which patients would most benefit from intervention.\u003c/p\u003e","manuscriptTitle":"Clinical management and outcomes for retroperitoneal hemorrhage with active extravasation on contrast enhanced computed tomography (CT)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-08 05:30:54","doi":"10.21203/rs.3.rs-9260434/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"ea38745b-fce7-43d6-8ae3-6d613a27ee32","owner":[],"postedDate":"April 8th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T12:13:39+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-08 05:30:54","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9260434","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9260434","identity":"rs-9260434","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}