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Arteriocaliceal Fistula from Prolonged Nephrostomy Tube Drainage
0022-534 7 /94/1516-1616$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL ASSOCIATION, !NC.
Vol. 151, 1616-1618, June 1994
Printed in U.S.A.
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE JOHN A. KAUFMAN
AND
ROBERT A. EDELSTEIN
From the Department of Radiology, Massachusetts General Hospital and Department of Urology, Boston University Medical Center, Boston, Massachusetts
ABSTRACT
We report a case of an arteriocaliceal fistula that occurred after 21 months of continuous nephrostomy drainage. Hemorrhage was successfully controlled with selective angiography and embolization. Although unusual, arterial injury should be considered when patients with indwelling nephrostomy tubes present with new onset of bleeding. KEY WORDS: catheters, indwelling; nephrostomy, percutaneous; hemorrhage
Serious vascular injuries are rare in percutaneous nephrostomy tube placement but usually manifest with bleeding that persists for more than 2 to 3 days. 1 The most common causes of hemorrhage associated with chronically indwelling catheters are urothelial inflammation or granulation tissue along the nephrostomy tract. Arterial injury is an unusual complication of chronic nephrostomy drainage. CASE REPORT
A 71-year-old man with severe chronic obstructive pulmonary disease was hospitalized with a 1-week history of hematuria and a left nephrostomy tube that had not been changed in almost 2 years. An 8.3F nephrostomy catheter had been inserted percutaneously 21 months previously for an obstructing left proximal ureteral stone and urosepsis (fig. 1). No unusual bleeding was noted then or during the intervening time. The patient underwent unsuccessful extracorporeal shock wave lithotripsy 16 months before hospitalization. Because chronic obstructive pulmonary disease was severe, more agAccepted for publication October 29, 1993.
gressive therapy was not considered. The patient was subsequently lost to followup. Hematuria had been noted upon voiding and from the nephrostomy tube a week before hospitalization. The family confirmed that the original catheter had not been changed. Physical examination revealed a tachypneic, cachectic elderly man and bloody urine in the left nephrostomy tube bag. Bladder catheterization yielded bloody urine. Creatinine was 1.4 mg./ dl. (normal 0.7 to 1.5), hematocrit was 33.6% (normal 38 to 46) and coagulation studies were normal. Further evaluation was delayed for 2 days by an episode of respiratory decompensation that required endotracheal intubation. During this time hematuria continued and hematocrit decreased to 24.6%, which prompted transfusion of 2 units of packed red blood cells. After stabilization and extubation a nephrostogram revealed that the tube had retracted into a lower pole calix and the stone partially obstructed the proximal ureter (fig. 2). During a tube change over a 0.038-inch 15 mm. J-tipped floppy wire brisk arterial bleeding occurred from the nephrostomy tract. A 10.3F nephrostomy tube was placed but hematuria persisted and an additional 4 units of packed red blood cells were needed in 48 hours to maintain a stable hematocrit. On selective left renal arteriography extravasation of contrast material was noted into the lower pole calix that had contained the loop of the percutaneous nephrostomy tube, which was consistent with an arteriocaliceal fistula (fig. 3). Bleeding originated away from the site of entry of the tube into the collecting system. Supraselective catheterization permitted successful embolization with micro-coils and absorbable gelatin sponge pledgets (fig. 4). Hematocrit stabilized immediately. The patient was discharged home 2 weeks later. Urine was clear and serum creatinine was stable at followup. DISCUSSION
FIG. 1. Nephrostogram from original procedure 21 months before current presentation shows stone partially obstructing proximal ureter (white arrow) and air bubble above stone.
Percutaneous nephrostomy placement is commonly used in the management of obstructed upper urinary systems. The procedure is usually safe and has few complications. Although asymptomatic retroperitoneal hematomas occur in 13% of cases, the incidence of severe arterial injury during percutaneous nephrostomy tube placement is 1 to 2%. 1- 4 Vascular complications usually present within 2 to 3 days after placement as persistent bleeding but bleeding starting as late as 6 weeks after placement has been reported. 2 The most common arterial injury in the acute period is a pseudoaneurysm that is presumably caused by a needle. 1- 3 Transfusion may be required but hemodynamics generally remain stable, although acute hemodynamic collapse has occurred during the procedure due to laceration of a segmental artery. 5 Our case is unusual because arterial injury did not present
1616
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE
1617
FIG. 2. A, abdominal film from original procedure demonstrates position and configuration of nephrostomy loop. B, abdominal film 21 months later reveals deformity and retraction of nephrostomy loop. Ureteral stone is still present (white arrow).
FIG. 3. Selective left renal arteriogram. A, early film shows contrast material extravasating from lower pole interlobar artery (white arrow) distinct from path of nephrostomy tube through renal cortex. B, late film reveals that extravasated contrast material conforms to shape of lower pole calix (white arrow).
until 21 months after insertion of the tube. The initial procedure was not complicated by prolonged or excessive blood loss. Angiography clearly demonstrated that bleeding was not related to the course of the tube through the renal parenchyma or the entry point into the collecting system. The presumed mechanism of injury was erosion of the loop portion of the chronically indwelling tube into an interlobar artery. To our knowledge delayed arteriocaliceal fistula caused by erosion of a nephrostomy tube has not been previously described. Morris et al reported a case of caliceal-duodenal fistula due to chronic nephrostomy drainage. 6 Ureteroarterial fistula is a well known severe complication of chronic ureteral stenting, 7- 9 and may also result from trauma, radiation, malignancy and erosion by arterial aneurysms or prosthetic vascular grafts. 8 Angiographic demonstration of the fistula is uncommon. 10 At our facility tubes normally are changed every 4 to 6 months to ensure proper positioning and function of the nephrostomy. Frequent changes and the soft material of most nephrostomy tubes may explain the rarity of arterial injury due to chronic indwelling. In time tubes may become encrusted or
less supple, which increases the risk of trauma to the adjacent urothelium. The catheter in our case functioned for 21 months but to leave a tube indwelling for this long violates protocol. When bleeding from a nephrostomy tube recurs or is not controlled by insertion of a larger diameter catheter, serious arterial injury should be suspected. Angiography with embolization of the bleeding site is the accepted treatment in stable cases. 11 In our case this modality proved diagnostic as well as therapeutic. The use of supraselective catheters makes occlusion of segmental and smaller branches possible, which minimizes injury to the renal cortex. Bleeding complications of nephrostomy catheters may not be limited to acute or subacute cases. In our patient late hemorrhage seems to have been caused by erosion of a chronically indwelling tube into an adjacent artery instead of an injury during placement. Angiography provided the diagnosis and therapy. When bleeding persists in patients who have chronically indwelling urinary devices, arterial injury should be suspected. Careful followup is important in the management of cases of chronic nephrostomy drainage.
1618
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE REFERENCES
FIG. 4. Angiogram after successful embolization of lower pole segmental artery with absorable gelatin sponge pledgets and coils (arrow). Contrast medium is present in small portion of lower pole parenchyma.
1. Cope, C. and Zeit, R. M.: Pseudoaneurysms after nephrostomy. AJR, 139: 255, 1982. 2. Gavant, M. L., Gold, R. E. and Church, J. C.: Delayed rupture of renal pseudoaneurysm: complication of percutaneous nephrostomy. AJR, 138: 948, 1982. 3. Cronan, J. J., Dorfman, G. S., Amis, E. S. and Denny, D. F., Jr.: Retroperitoneal hemorrhage after percutaneous nephrostomy. AJR, 144: 801, 1985. 4. Vehmas, T., Kivisaari, L., Mankinen, P., Tierala, E., Somer, K., Lehtonen, T. and Standertskjiild-Nordenstam, C. G.: Results and complications of percutaneous nephrostomy. Ann. Clin. Res., 20: 423, 1988. 5. Koonings, P. P., Teitelbaum, G. P., Finck, E. J. and Schlaerth, J. B.: Renal artery laceration secondary to percutaneous nephrostomy catheter placement. Gynec. Oncol., 40: 164, 1991. 6. Morris, D. B., Siegelbaum, M. H., Pollack, H. M., Kendall, R. A. and Gerber, W. L.: Renoduodenal fistula in a patient with chronic nephrostomy drainage: a case report. J. Urol., 146: 835, 1991. 7. Kar, A., Angwafo, F. F. and Jhunjhunwala, J. S.: Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J. Urol., 132: 755, 1984. 8. Shetty, S. D., Read, J. R. and Newling, D. W.: Uretero-arterial fistula. Brit. J. Urol., 62: 382, 1988. 9. Cass, A. S. and Odland, M.: Ureteroarterial fistula: case report and review of literature. J. Urol., 143: 582, 1990. 10. Hauenstein, K., Vinee, P., Tanyu, M. 0. and Noldge, G.: Angiographic demonstration of a ureteroarterial fistula. AJR, 161: 212, 1993. 11. Larsen, D. W. and Pentecost, M. J.: Embolotherapy in renal trauma. Sem. Interven. Rad., 9: 13, 1992.
Vol. 151, 1616-1618, June 1994
Printed in U.S.A.
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE JOHN A. KAUFMAN
AND
ROBERT A. EDELSTEIN
From the Department of Radiology, Massachusetts General Hospital and Department of Urology, Boston University Medical Center, Boston, Massachusetts
ABSTRACT
We report a case of an arteriocaliceal fistula that occurred after 21 months of continuous nephrostomy drainage. Hemorrhage was successfully controlled with selective angiography and embolization. Although unusual, arterial injury should be considered when patients with indwelling nephrostomy tubes present with new onset of bleeding. KEY WORDS: catheters, indwelling; nephrostomy, percutaneous; hemorrhage
Serious vascular injuries are rare in percutaneous nephrostomy tube placement but usually manifest with bleeding that persists for more than 2 to 3 days. 1 The most common causes of hemorrhage associated with chronically indwelling catheters are urothelial inflammation or granulation tissue along the nephrostomy tract. Arterial injury is an unusual complication of chronic nephrostomy drainage. CASE REPORT
A 71-year-old man with severe chronic obstructive pulmonary disease was hospitalized with a 1-week history of hematuria and a left nephrostomy tube that had not been changed in almost 2 years. An 8.3F nephrostomy catheter had been inserted percutaneously 21 months previously for an obstructing left proximal ureteral stone and urosepsis (fig. 1). No unusual bleeding was noted then or during the intervening time. The patient underwent unsuccessful extracorporeal shock wave lithotripsy 16 months before hospitalization. Because chronic obstructive pulmonary disease was severe, more agAccepted for publication October 29, 1993.
gressive therapy was not considered. The patient was subsequently lost to followup. Hematuria had been noted upon voiding and from the nephrostomy tube a week before hospitalization. The family confirmed that the original catheter had not been changed. Physical examination revealed a tachypneic, cachectic elderly man and bloody urine in the left nephrostomy tube bag. Bladder catheterization yielded bloody urine. Creatinine was 1.4 mg./ dl. (normal 0.7 to 1.5), hematocrit was 33.6% (normal 38 to 46) and coagulation studies were normal. Further evaluation was delayed for 2 days by an episode of respiratory decompensation that required endotracheal intubation. During this time hematuria continued and hematocrit decreased to 24.6%, which prompted transfusion of 2 units of packed red blood cells. After stabilization and extubation a nephrostogram revealed that the tube had retracted into a lower pole calix and the stone partially obstructed the proximal ureter (fig. 2). During a tube change over a 0.038-inch 15 mm. J-tipped floppy wire brisk arterial bleeding occurred from the nephrostomy tract. A 10.3F nephrostomy tube was placed but hematuria persisted and an additional 4 units of packed red blood cells were needed in 48 hours to maintain a stable hematocrit. On selective left renal arteriography extravasation of contrast material was noted into the lower pole calix that had contained the loop of the percutaneous nephrostomy tube, which was consistent with an arteriocaliceal fistula (fig. 3). Bleeding originated away from the site of entry of the tube into the collecting system. Supraselective catheterization permitted successful embolization with micro-coils and absorbable gelatin sponge pledgets (fig. 4). Hematocrit stabilized immediately. The patient was discharged home 2 weeks later. Urine was clear and serum creatinine was stable at followup. DISCUSSION
FIG. 1. Nephrostogram from original procedure 21 months before current presentation shows stone partially obstructing proximal ureter (white arrow) and air bubble above stone.
Percutaneous nephrostomy placement is commonly used in the management of obstructed upper urinary systems. The procedure is usually safe and has few complications. Although asymptomatic retroperitoneal hematomas occur in 13% of cases, the incidence of severe arterial injury during percutaneous nephrostomy tube placement is 1 to 2%. 1- 4 Vascular complications usually present within 2 to 3 days after placement as persistent bleeding but bleeding starting as late as 6 weeks after placement has been reported. 2 The most common arterial injury in the acute period is a pseudoaneurysm that is presumably caused by a needle. 1- 3 Transfusion may be required but hemodynamics generally remain stable, although acute hemodynamic collapse has occurred during the procedure due to laceration of a segmental artery. 5 Our case is unusual because arterial injury did not present
1616
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE
1617
FIG. 2. A, abdominal film from original procedure demonstrates position and configuration of nephrostomy loop. B, abdominal film 21 months later reveals deformity and retraction of nephrostomy loop. Ureteral stone is still present (white arrow).
FIG. 3. Selective left renal arteriogram. A, early film shows contrast material extravasating from lower pole interlobar artery (white arrow) distinct from path of nephrostomy tube through renal cortex. B, late film reveals that extravasated contrast material conforms to shape of lower pole calix (white arrow).
until 21 months after insertion of the tube. The initial procedure was not complicated by prolonged or excessive blood loss. Angiography clearly demonstrated that bleeding was not related to the course of the tube through the renal parenchyma or the entry point into the collecting system. The presumed mechanism of injury was erosion of the loop portion of the chronically indwelling tube into an interlobar artery. To our knowledge delayed arteriocaliceal fistula caused by erosion of a nephrostomy tube has not been previously described. Morris et al reported a case of caliceal-duodenal fistula due to chronic nephrostomy drainage. 6 Ureteroarterial fistula is a well known severe complication of chronic ureteral stenting, 7- 9 and may also result from trauma, radiation, malignancy and erosion by arterial aneurysms or prosthetic vascular grafts. 8 Angiographic demonstration of the fistula is uncommon. 10 At our facility tubes normally are changed every 4 to 6 months to ensure proper positioning and function of the nephrostomy. Frequent changes and the soft material of most nephrostomy tubes may explain the rarity of arterial injury due to chronic indwelling. In time tubes may become encrusted or
less supple, which increases the risk of trauma to the adjacent urothelium. The catheter in our case functioned for 21 months but to leave a tube indwelling for this long violates protocol. When bleeding from a nephrostomy tube recurs or is not controlled by insertion of a larger diameter catheter, serious arterial injury should be suspected. Angiography with embolization of the bleeding site is the accepted treatment in stable cases. 11 In our case this modality proved diagnostic as well as therapeutic. The use of supraselective catheters makes occlusion of segmental and smaller branches possible, which minimizes injury to the renal cortex. Bleeding complications of nephrostomy catheters may not be limited to acute or subacute cases. In our patient late hemorrhage seems to have been caused by erosion of a chronically indwelling tube into an adjacent artery instead of an injury during placement. Angiography provided the diagnosis and therapy. When bleeding persists in patients who have chronically indwelling urinary devices, arterial injury should be suspected. Careful followup is important in the management of cases of chronic nephrostomy drainage.
1618
ARTERIOCALICEAL FISTULA FROM PROLONGED NEPHROSTOMY TUBE DRAINAGE REFERENCES
FIG. 4. Angiogram after successful embolization of lower pole segmental artery with absorable gelatin sponge pledgets and coils (arrow). Contrast medium is present in small portion of lower pole parenchyma.
1. Cope, C. and Zeit, R. M.: Pseudoaneurysms after nephrostomy. AJR, 139: 255, 1982. 2. Gavant, M. L., Gold, R. E. and Church, J. C.: Delayed rupture of renal pseudoaneurysm: complication of percutaneous nephrostomy. AJR, 138: 948, 1982. 3. Cronan, J. J., Dorfman, G. S., Amis, E. S. and Denny, D. F., Jr.: Retroperitoneal hemorrhage after percutaneous nephrostomy. AJR, 144: 801, 1985. 4. Vehmas, T., Kivisaari, L., Mankinen, P., Tierala, E., Somer, K., Lehtonen, T. and Standertskjiild-Nordenstam, C. G.: Results and complications of percutaneous nephrostomy. Ann. Clin. Res., 20: 423, 1988. 5. Koonings, P. P., Teitelbaum, G. P., Finck, E. J. and Schlaerth, J. B.: Renal artery laceration secondary to percutaneous nephrostomy catheter placement. Gynec. Oncol., 40: 164, 1991. 6. Morris, D. B., Siegelbaum, M. H., Pollack, H. M., Kendall, R. A. and Gerber, W. L.: Renoduodenal fistula in a patient with chronic nephrostomy drainage: a case report. J. Urol., 146: 835, 1991. 7. Kar, A., Angwafo, F. F. and Jhunjhunwala, J. S.: Ureteroarterial and ureterosigmoid fistula associated with polyethylene indwelling ureteral stents. J. Urol., 132: 755, 1984. 8. Shetty, S. D., Read, J. R. and Newling, D. W.: Uretero-arterial fistula. Brit. J. Urol., 62: 382, 1988. 9. Cass, A. S. and Odland, M.: Ureteroarterial fistula: case report and review of literature. J. Urol., 143: 582, 1990. 10. Hauenstein, K., Vinee, P., Tanyu, M. 0. and Noldge, G.: Angiographic demonstration of a ureteroarterial fistula. AJR, 161: 212, 1993. 11. Larsen, D. W. and Pentecost, M. J.: Embolotherapy in renal trauma. Sem. Interven. Rad., 9: 13, 1992.