Abdominal Compartment Syndrome with Anticoagulation tion and control of the bleeding site, and transcatheter arte- rial embolization (TAE) can not relieve a compressive mani- festation such as femoral neuropathy (FN). This case suggests that TAE followed by surgical decompression is an effective and, safe method to treat a SRH complicated with FN or abdominal compartment syndrome (ACS) to prevent permanent nerve damage or a catastrophic event. Fig. 1. Computed tomography showing a large retroperitoneal hematoma with contrast extravasation (arrows) consistent with active bleeding. A B Fig. 2. (A) The angiography showing active extravasation from the right in- ternal iliac artery (arrows). (B) The post-embolization angiography showing complete occlusion of the bleeding (arrows) from the right internal iliac ar- tery. CASE REPORT A 48-year-old woman presented with a sudden onset of lower abdominal pain, dizziness and a palpable abdominal mass after prolonged straining to defecate. She had been started on warfarin and aspirin after an artificial aortic valve replacement. The level of anticoagulation was stable. A large, tender lower abdominal mass was palpated on the physical examination. Her arterial blood pressure was 75/40 mmHg, and heart rate was 118 beat/min. The hemo- globin, hematocrit, and international normalized ratio (INR) were 4.6 g/dL, 14.6% and 4.25, respectively. Transfusion of 5 units of fresh frozen plasma and 4 units of packed red cells was followed by a fluid overload and 10 mg of vita- min K. An emergency CT scan demonstrated a large right- sided retroperitoneal hematoma that extended into the pel- vis with active contrast extravasation (Fig. 1). In the view of active bleeding, an angiography was immediately per- formed to control the bleeding vessel. Active contrast ex- travasation was noted from the right proximal internal iliac artery and this bleeding focus was successfully embolized with a mixture of metallic coil, gelform and lipiodol. The subsequent angiography showed that the right internal iliac artery was completely occluded and any contrast leakage was no longer visible (Fig. 2). However, the symptoms worsened during the next 8 hours. She developed severe pain in the right side of her groin and anterior thigh with associated paresthesia over the anterior thigh. She became anuric. The intra-abdominal pressure (IAP), as measured by the urinary bladder pres- sure, was 32 mmHg and the intra-abdominal perfusion pressure (IAPP) was 28 mmHg. Under the diagnosis of ACS and FN, she underwent an exploratory laparotomy. 4,000 mL of hematoma was removed and she immediately produced urine after the evacuation. Anticoagulation was restarted on the 2nd postoperative day. She was discharged in good condition on the 12th postoperative day. DISCUSSION A SRH is defined as bleeding without any known inciting trauma or underlying retroperitoneal pathology. A SRH is uncommon and is almost exclusively seen in association with anticoagulation states, coagulopathy, and hemodialy- sis.5,6 The exact mechanism is unknown, but several hy- Yonsei Med J http://www.eymj.org Volume 52 Number 2 March 2011 359