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Spontaneous Disappearance of Iatrogenic Renal Arteriovenous Fistula: Report of a Case
Vol. 105, Jan. Printed in U.S.A.
THE JouRNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
SPONTANEOUS DISAPPEARANCE OF IATROGENIC RENAL ARTERIOVENOUS FISTULA: REPORT OF A CASE ALAN HERSCHMAN,* MELVIN J. KLEIN
AND
ARNOLD G. BLUMBERG
From the Departments of Radiology and Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
Major complications of percutaneous renal biopsy are rare, occurring in less than 1 per cent of such examinations. 1- 4 We had 1 patient in whom an intrarenal arteriovenous fistula was noted 4 weeks after percutaneous renal biopsy for evaluation of hypertension and proteinuria. Subsequent angiography 2 years later revealed spontaneous healing of the fistula.
Abdominal aortography revealed an arteriovenous fistula in the lower pole of the left kidney (fig. 1). No abdominal bruit was audible. The high blood pressure was medically controlled for 2 years and the patient was then hospitalized for re-evaluation of the left kidney. Aortography and selective left renal arteriography failed to demonstrate the previously identified arteriovenous fistula (fig. 2).
CASE REPORT
S.T., a 29-year-old white woman, was hypertensive with a blood pressure of 180/130. There was no history of renal disease. Urinalysis revealed proteinuria and red cells, white cells and granular and red cell casts were present. Blood urea nitrogen was 15 mg. per 100 cc. Excretory urography with early sequence films was normal. Urinary vanillyl mandelic acid excretion was normal and lupus erythematosus preparations were negative. A left percutaneous renal biopsy was performed with a Vim-Silverman needle. Subsequently the patient complained of severe left flank pain and had transient gross hematuria. Microscopic examination of the biopsy specimen revealed medullary renal tissue with no glomeruli. It was presumed that no cortical tissue had been removed by the biopsy needle. The patient was treated with antihypertensive medications and 4 weeks later was readmitted to the hospital with a blood pressure of 150/95.
DISCUSSI0:'>1
Arteriovenous fistula resulting from renal biopsy was first reported by Boijsen and Kohler 5 and since has been reported by several authors. 6- 12 Of 9 such cases reported by Bennett and Wiener 6 spontaneous disappearance of the fistula was documented in 3 instances and a fourth case demonstrated decrease in size of the lesion. Healing time ranged from 3.5 to 20 months. No change in the clinical course of the hypertension was noted in these patients. The hypertensive patient described by Nilsson and Ross had bilateral renal arteriovenous fistulas 5 Boijsen, E. and Kohler, R.: Renal arteriovenous fistulae. Acta Radiol., 57: 433, 1962. 6 Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965. 7 Blake, S., Heffernan, S. and McCann, P.: Renal arteriovenous fistula after percutaneous renal biopsy. Brit. Med. J., 1: 1458, 1963. 8 Maldonado, J. E. and Sheps, S. G.: Renal arteriovenous fistula. Postgrad. Med., 40: 263, 1966. 9 Fernstrom, I. and Lindblom, K.: Selective renal biopsy using roentgen television control. J. Urol., 88: 709, 1962. 10 Nilsson, C. G. and Ross, R. J.: Bilateral renal arteriovenous fistulas and decreased blood pressure following renal biopsies. J. U rol., 97: 176, 1967. 11 Riley, J.M.: Renal arteriovenous fistula: a complication of percutaneous renal biopsy. J. Urol., 93: 333, 1965. 12 Kaufman, J. J., Gordon, A. and Maxwell, M. H.: Intrarenal arteriovenous fistula following needle biopsy of the kidney. Calif. Med., 103: 350, 1965.
Accepted for publication February 7, 1970. * Current address: Lakeville Medical Center, 2035 Lakeville Road, New Hyde Park, New York 11040.
1 Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L. and Kiefer, J. H.: An analysis of five hundred percutaneous renal biopsies. Arch. Intern. Med., 101: 439, 1958. 2 Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 3 Lee, D. A., Roger, R., Agre, K. M. and Rubini, M.: Late complications of percutaneous renal biopsy. J. Urol., 97: 793, 1967. 4 Muth, R. G.: The safety of percutaneous renal biopsy: an analysis of 500 consecutive cases. J. Urol., 94: 1, 1965.
4
DISAPPEARANCE OF IATROGENIC RENAL ARTERIOVENOUS FISTULA
following percutaneous renal biopsies. The patient became normotcnsive but 3 weeks later hypertension recurred. Repeat angiography failed to demonstrate the previously seen fistulas.
The pathophysiological relationship between intrarenal arteriovenous fistula and hypertension is complex. Although resection of the lesion can result in cure of hypertension,5 patency of the
FIG. 1. A, initial aortogram. B, close-up left kidney, early arterial phase, C, close-up left kidney in later arterial phase demonstrates early filling of large venous structures from lower pole and faint opacification of inferior vena cava.
Fw. 2. A, aortogram and B, selective left renal arteriogram 2 years after initial study. No evidence of arteriovenons fistula demonstrated.
6
HERSCHMAN, KLEIN AND BLUMBERG
fistula was associated with transient remission of hypertension in the case reported by Nilsson and Ross 10 and in case 4 of Boijsen and Kohler. 5 Several mechanisms have been postulated to account for lowered blood pressures during fistula patency but none have been proved. 5 • 10 No change in our patient's hypertension occurred which could be attributed to patency or healing of the renal arteriovenous fistula. Our case and the cases cited suggest that watchful waiting, rather than immediate operation, may suffice when this complication of per-
cutaneous renal biopsy occurs. Repeat angiography after an interval of 4 to 6 months should be performed to ascertain whether any evidence of healing has occurred. SUMMARY
A case of spontaneous disappearance of a postbiopsy intrarenal arteriovenous fistula is described and 5 similar case reports are reviewed. It is suggested that surgical treatment be delayed pending interval repeat angiography when a fistula of this type occurs.
THE JouRNAL OF UROLOGY
Copyright © 1971 by The Williams & Wilkins Co.
SPONTANEOUS DISAPPEARANCE OF IATROGENIC RENAL ARTERIOVENOUS FISTULA: REPORT OF A CASE ALAN HERSCHMAN,* MELVIN J. KLEIN
AND
ARNOLD G. BLUMBERG
From the Departments of Radiology and Medicine, Long Island Jewish Medical Center, New Hyde Park, New York
Major complications of percutaneous renal biopsy are rare, occurring in less than 1 per cent of such examinations. 1- 4 We had 1 patient in whom an intrarenal arteriovenous fistula was noted 4 weeks after percutaneous renal biopsy for evaluation of hypertension and proteinuria. Subsequent angiography 2 years later revealed spontaneous healing of the fistula.
Abdominal aortography revealed an arteriovenous fistula in the lower pole of the left kidney (fig. 1). No abdominal bruit was audible. The high blood pressure was medically controlled for 2 years and the patient was then hospitalized for re-evaluation of the left kidney. Aortography and selective left renal arteriography failed to demonstrate the previously identified arteriovenous fistula (fig. 2).
CASE REPORT
S.T., a 29-year-old white woman, was hypertensive with a blood pressure of 180/130. There was no history of renal disease. Urinalysis revealed proteinuria and red cells, white cells and granular and red cell casts were present. Blood urea nitrogen was 15 mg. per 100 cc. Excretory urography with early sequence films was normal. Urinary vanillyl mandelic acid excretion was normal and lupus erythematosus preparations were negative. A left percutaneous renal biopsy was performed with a Vim-Silverman needle. Subsequently the patient complained of severe left flank pain and had transient gross hematuria. Microscopic examination of the biopsy specimen revealed medullary renal tissue with no glomeruli. It was presumed that no cortical tissue had been removed by the biopsy needle. The patient was treated with antihypertensive medications and 4 weeks later was readmitted to the hospital with a blood pressure of 150/95.
DISCUSSI0:'>1
Arteriovenous fistula resulting from renal biopsy was first reported by Boijsen and Kohler 5 and since has been reported by several authors. 6- 12 Of 9 such cases reported by Bennett and Wiener 6 spontaneous disappearance of the fistula was documented in 3 instances and a fourth case demonstrated decrease in size of the lesion. Healing time ranged from 3.5 to 20 months. No change in the clinical course of the hypertension was noted in these patients. The hypertensive patient described by Nilsson and Ross had bilateral renal arteriovenous fistulas 5 Boijsen, E. and Kohler, R.: Renal arteriovenous fistulae. Acta Radiol., 57: 433, 1962. 6 Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula and aneurysm. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965. 7 Blake, S., Heffernan, S. and McCann, P.: Renal arteriovenous fistula after percutaneous renal biopsy. Brit. Med. J., 1: 1458, 1963. 8 Maldonado, J. E. and Sheps, S. G.: Renal arteriovenous fistula. Postgrad. Med., 40: 263, 1966. 9 Fernstrom, I. and Lindblom, K.: Selective renal biopsy using roentgen television control. J. Urol., 88: 709, 1962. 10 Nilsson, C. G. and Ross, R. J.: Bilateral renal arteriovenous fistulas and decreased blood pressure following renal biopsies. J. U rol., 97: 176, 1967. 11 Riley, J.M.: Renal arteriovenous fistula: a complication of percutaneous renal biopsy. J. Urol., 93: 333, 1965. 12 Kaufman, J. J., Gordon, A. and Maxwell, M. H.: Intrarenal arteriovenous fistula following needle biopsy of the kidney. Calif. Med., 103: 350, 1965.
Accepted for publication February 7, 1970. * Current address: Lakeville Medical Center, 2035 Lakeville Road, New Hyde Park, New York 11040.
1 Kark, R. M., Muehrcke, R. C., Pollak, V. E., Pirani, C. L. and Kiefer, J. H.: An analysis of five hundred percutaneous renal biopsies. Arch. Intern. Med., 101: 439, 1958. 2 Slotkin, E. A. and Madsen, P. 0.: Complications of renal biopsy: incidence in 5000 reported cases. J. Urol., 87: 13, 1962. 3 Lee, D. A., Roger, R., Agre, K. M. and Rubini, M.: Late complications of percutaneous renal biopsy. J. Urol., 97: 793, 1967. 4 Muth, R. G.: The safety of percutaneous renal biopsy: an analysis of 500 consecutive cases. J. Urol., 94: 1, 1965.
4
DISAPPEARANCE OF IATROGENIC RENAL ARTERIOVENOUS FISTULA
following percutaneous renal biopsies. The patient became normotcnsive but 3 weeks later hypertension recurred. Repeat angiography failed to demonstrate the previously seen fistulas.
The pathophysiological relationship between intrarenal arteriovenous fistula and hypertension is complex. Although resection of the lesion can result in cure of hypertension,5 patency of the
FIG. 1. A, initial aortogram. B, close-up left kidney, early arterial phase, C, close-up left kidney in later arterial phase demonstrates early filling of large venous structures from lower pole and faint opacification of inferior vena cava.
Fw. 2. A, aortogram and B, selective left renal arteriogram 2 years after initial study. No evidence of arteriovenons fistula demonstrated.
6
HERSCHMAN, KLEIN AND BLUMBERG
fistula was associated with transient remission of hypertension in the case reported by Nilsson and Ross 10 and in case 4 of Boijsen and Kohler. 5 Several mechanisms have been postulated to account for lowered blood pressures during fistula patency but none have been proved. 5 • 10 No change in our patient's hypertension occurred which could be attributed to patency or healing of the renal arteriovenous fistula. Our case and the cases cited suggest that watchful waiting, rather than immediate operation, may suffice when this complication of per-
cutaneous renal biopsy occurs. Repeat angiography after an interval of 4 to 6 months should be performed to ascertain whether any evidence of healing has occurred. SUMMARY
A case of spontaneous disappearance of a postbiopsy intrarenal arteriovenous fistula is described and 5 similar case reports are reviewed. It is suggested that surgical treatment be delayed pending interval repeat angiography when a fistula of this type occurs.