Managing severe iodinated contrast extravasation: a case report highlighting the role of invasive intervention

BMC Surgery Hu et al. BMC Surgery (2025) 25:531 https://doi.org/10.1186/s12893-025-03304-x Open Access CASE REPORT Managing severe iodinated contrast extravasation: a case report highlighting the role of invasive intervention Jingjing Hu1, Tingai Ge1, Yuteng Du1, Jia Wang1 and Yidan Zhou1* Abstract Although the incidence of contrast media extravasation (CME) is low and severe complications are rarer, when it occurs, it can lead to serious complications and patient dissatisfaction. In most cases, CME resolves with conservative treatment. However, some cases require invasive interventions for treatment. We report a case of CME in which the patient developed skin ulcers, necrosis, and hematoma after conservative treatment. Ultimately, the patient was successfully treated with manual compression, saline irrigation, and sharp debridement. Thus, a tiered strategy that combines preventive measures, vigilant clinical and imaging monitoring, proactive escalation of treatment, and transparent communication offers the best approach to minimize CME complications, accelerate recovery, and reduce the risk of medico-legal conflicts. Keywords Contrast extravasation, Conservative treatment, Skin ulcers, Case report Introduction The use of multidetector computed tomography has expanded rapidly, with approximately 76 million examinations performed worldwide each year. Notably, about half of these examinations require intravenous contrast administration, most commonly with iodinated contrast agents [1]. Subcutaneous extravasation of contrast media (CME), a recognized complication of intravenous iodinated contrast administration [2], has been reported to occur in 0.11% to 0.23% of computer tomography (CT) examinations, with a steady decline in the annual incidence from 0.18% in 2017 to 0.07% in 2023[3, 4]. However, the true incidence of CME may be underestimated. The clinical manifestations of CME extends from *Correspondence: Yidan Zhou 1 Department of Emergency Medicine, Hangzhou Third People’s Hospital, Hangzhou, China frequent, mild symptoms [2], such as local discomfort, swelling, pain, numbness, and blisters, to uncommon but severe complications, including hematomas, skin ulcers, tissue necrosis, and compartment syndrome [2, 5–9]. In most cases, CME resolves with conservative management, including limb elevation, cold compresses, and analgesia. However, some patients develop complications that necessitate invasive treatment [8]. Moreover, even CME that is clinically classified as mild may be perceived as significant by patients, who may feel that care was inadequate, potentially leading to medical litigation [8]. We report a case of CME in which the patient developed skin ulcers, necrosis, and hematoma despite conservative management. The patient was ultimately successfully treated with invasive interventions, including bedside incision-free drainage with irrigation, sharp debridement, and regular dressing changes. We present this case to remind clinicians of the importance of invasive treatment for CME, highlighting not only a rare instance of severe CME but also a practical management © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creati vecommons.org/licenses/by-nc-nd/4.0/. Hu et al. BMC Surgery (2025) 25:531 strategy. While conservative therapy remains first-line, invasive interventions should be promptly considered in cases of progressive necrosis, hematoma, or failure of conservative management. This case report was conducted and reported following the guidelines of the Consensus Surgical Case Report (SCARE) criteria [10]. Case reports A 53-year-old woman presented with chest tightness and shortness of breath, prompting CT pulmonary angiography. She had a medical history of intellectual disability, diabetes mellitus, chronic obstructive pulmonary disease, and pulmonary embolism, with no known allergies to food or medications. After performing a saline flush test, intravenous iohexol, was injected through an antecubital fossa vein using a rapid infusion pump. During the injection, the patient did not experience any pain, and no contrast extravasation was observed on the pulmonary images. We observed marked swelling at the injection site, along with extravasation of approximately 75 mL of iodinated contrast medium (Fig. 1A). She initially received conservative treatment, which included stopping the infusion, retaining the intravenous cannula, Fig. 1 Extravasation of Iodine Contrast (A. Day 1; B. Day 3; C. Day 7; D. Day10) Page 2 of 6 and aspirating as much of the extravasated contrast as possible. Additional measures included elevation of the right upper limb, application of local cold compresses, and topical administration of polysulfated glycosaminoglycans, magnesium sulfate, and dexamethasone. Over the following days, the extravasation site developed progressive bruising, skin blisters, necrotizing ulcers, and subcutaneous hematoma (Fig. 1B–C). On day 10, the necrotic ulcer began discharging dark purulent material, prompting a surgical consultation. At the bedside, a general surgeon performed the procedure. Because the dark purulent drainage could be expressed through the existing necrotic site, no additional incision was required. The surgeon applied repeated manual compressions to evacuate approximately 30 mL of purulent fluid, followed immediately by irrigation with 250 mL of normal saline to remove residual contrast and necrotic debris. Sharp debridement was then performed to excise the necrotic skin. This approach resulted in a marked reduction in swelling. (Fig. 1D). However, skin ulceration persisted. As further skin graft surgery was declined by the patient’s guardian, conservative measures were applied, including topical epidermal growth factor and Vaseline to promote Hu et al. BMC Surgery (2025) 25:531 epithelial regeneration. Sixty days later, the skin ulcer and necrotic area demonstrated signs of scar formation and healing (Fig. 2A–B). Discussion Although CME is uncommon and severe outcomes are rare, its oc (...truncated)