Abstract 4141627: Not The Corona You Wish For After a Successful Atrial Fibrillation Ablation!

Background: Corona mortis artery or ring of death, is a common variant (25-30%) vascular anastomosis between the obturator artery and inferior epigastric or external iliac artery. However, injury to this vessel during EP procedures has not been described. We present a case of an inguinal hematoma secondary to arteriovenous fistula(AVF) and pseudoaneurysm of the corona mortis artery due to puncture injury during atrial fibrillation(AF) ablation. Case: A 71-year-old male underwent pulmonary vein isolation for persistent AF. The right femoral vein was accessed using ultrasound guidance and 3 sheaths were placed after which intravenous heparin was administered. At the end of the case, protamine was given for heparin and a figure of 8 suture was placed after sheath removal. Six hours post procedure, a soft 2.5 cm right groin hematoma was noted, that was treated conservatively with manual pressure and pressure dressing overnight. The patient was discharged home next day but returned one week later with continued groin pain and swelling. Examination revealed a moderate groin hematoma, ecchymosis and a loud right femoral bruit. Duplex ultrasound demonstrated a fistula between the right external iliac artery and vein with potential pseudoaneurysm at the fistula site. CT angiogram of the abdomen and pelvis showed a pseudoaneurysm of a distal branch of the external iliac artery arising from the inferior epigastric artery and an AVF (Fig 1a). Selective arteriogram was performed via left groin access, which confirmed the above findings as a result of injury to the corona mortis (Fig 1b). Coil embolectomy of the right inferior epigastric artery and the obturator branch up to the respective origins was performed with resolution of the fistula (Fig 1c). The patient was discharged home and oral anticoagulation therapy was restarted 24 hours later. He recovered well with no further sequelae. Discussion: The corona mortis artery is a common vascular variant which may be a source of bleeding complications during groin injury or during vascular groin access. Familiarity with this variant allows its consideration in the differential diagnosis of post procedural groin hematoma which ensures rapid diagnosis and appropriate management.