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Blunt trauma to renal artery
BLUNT TRAUMA TO RENAL ARTERY
S. R. BRYNIAK, A. MORALES,
M.D. F.R.C.S.
(C)
From the Department of Urology, Kingston, Ontario, Canada
Queen’s
University,
ABSTRACT -A case of intimal laceration of the renal artery by blunt trauma is presented. Although complete and prolonged functional loss was documented, total recovery was eventually observed. Postulates regarding pathogenesis are provided. The usefulness of arteriography fm therapeutic and prognostic reasons is emphasized.
The concept that injury to the renal pedicle demands rapid diagnosis and treatment is of unquestionable importance. It is evident, however, that in some cases the severity of the injury or the condition of the patient dictates a more conservative attitude. A situation in which such approach is warranted is illustrated in this report.
renal artery and its branches were normal. Several small intimal defects were observed in the middle third of the left renal artery; its branches were of smaller caliber than their right counterparts. There was also some stretching and separation of the interlobar branches. An expectant attitude was decided on in regard to the renal trauma. The patient improved over the next week, and ten days later intravenous pyelogram was repeated. The right kidney was normal; on the left side no function was detected up to five hours after injection of the contrast medium. The patient’s condition continued to improve and prior to discharge three weeks later intravenous pyelogram again documented the findings of the previous study (Fig. 1C). Eight weeks after the initial injury intravenous pyelogram showed both kidneys functioning promptly (Fig. 1D). No deformity was observed in the left kidney. The patient has been followed up for more than two years. Blood pressure and renal function have remained normal. Periodic examinations of the urine have not shown abnormalities.
Case Report An eighteen-year-old man was admitted unconscious after a motor vehicle accident. Physical examination revealed many superficial lacerations of the right side of chest and abdomen. A large hematoma was present overlying the right zygoma. The patient was in obvious respiratory distress. Blood pressure was 100/60 mm. Hg and pulse 125 per minute. Chest x-ray film showed a right pneumothorax. A chest tube was inserted and a large amount of blood obtained. Tracheal intubation was carried out and, again, a large amount of blood also came through the endotracheal tube. Grossly bloody urine was obtained from a catheter inserted into the bladder. A portable intravenous pyelogram showed prompt excretion by the right kidney, with a normal collecting system. On the left side, however, no evidence of functioning renal parenchyma was observed (Fig. 1A). Twelve hours later, after stabilization of vital signs, a renal arteriogram was carried out (Fig. 1B). The right
UROLOGY
i
OCTOBER
1976
/
VOLU’ME VIII,
NUMBER
Comment Blunt trauma to the renal pedicle is more common in young individuals with mobile kidneys.’ Evans and Moggs2 and Grablowsky et al3 noted that when renal thrombosis occurs as a complication it is usually unilateral and
4
379
FIGURE
1.
Znitial
intra-
venous p yelogram showing good function in right kidney but no excretion from left kidney. (B) Renal arteriogram revealing irregularity of main left renal artery, with separation of its branches clearly demonstrated. (C) Intravenous p yelogram three weeks after injury; no function is observed In ,?ej3 kidney. (D)Two months after accident intravenous pyelogram shows functioning both kidneys promptly; no anatomic abnormalities are observed in left kidney.
involves the left kidney. The postulate of hypermobility of this kidney with its relatively long pedicle has been proposedS4 Consequently, it is not unlikely that such acceleration-deceleration of the left kidney produces the shearing force transmitted to the renal pedicle which tears the intima or subintimal tissue. In the majority of cases in the literature these patients had sustamed severe trauma with multiple associated Prompt recognition of main renal injuries. artery thrombosis and immediate surgical intervention is mandatory.’
380
In our case the prolonged lack of function in the left kidney remains unclear. Explanations readily offered include: (1) intimal fracture and subintimal dissection followed by hematoma formation and resultant obstruction;’ and (2) vasospasm secondary to trauma.6 The arteriogram excluded an obstruction commensurate with the degree of functional loss. Although there is no conclusive evidence for it, renal vein thrombosis has to be considered. The arterial stretching and separation and the severe functional derangement followed by a complete
UROLOGY
/ OCTOBER1976
I VOLWMEVIII,
NUMBER4
recovery substantiate this explanation. Vascular spasm of moderate degree, documented by the arteriographic findings, would not explain prolonged functional impairment unless the postulate of complicating acute tubular necrosis is advanced. In fact, absence of a nephrogram and failure of visualization of the tertiary arterial segments are consistent arteriographic findings of acute tubular necrosis. Several points are emphasized by this case. (1) The location and severity of external injuries bears little relationship to the internal ones. (2) Arteriography is of utmost importance in renal trauma to establish therapeutic priorities and define prognosis. (3) Injuries to the renal pedicle should be qualified. Intimal lacerations without further injury to the vessel or kidney are compatible with total functional recovery and an expectant attitude is warranted. (4) Delayed return of function may vary from a few days to several weeks.
UROLOGY
/
OCTOBER 1976 /
VOLUME VIII, NUMBER 4
Queen’s University Kingston,
Ontario,
Canada K7L 3N6 (DR. BRYNIAK)
References 1. Ross, R., ACKERMAN, E., and PIERCE, J. M.: Traumatic subintimal hemorrhage of the renal artery, J. Urol. 194: 11 (1970). 2. EVANS, A., and MOGGS, R. A.: Renal artery thrombosis due to closed trauma, ibid. 105: 330 (1971). 3. GRABLOWSKY, 0. M., WEICHERT, R. F., III, GOFF J. B., and SCHLECEL, J. G.: Renal artery thrombosis following blunt trauma, Surgery 67: 895 (1970). 4. COLLINS, H. A., and JACOBS, J. K.: Acute arterial injuries due to blunt trauma, J. Bone Joint Surg. 43-A: 195 (1961). 5. SKINNER, D. G.: Traumatic renal artery thrombosis: a successful thrombectomy and revascularization, Ann. Surg. 177: 264 (1973). 6. HOLLAND, M. T., HURWITZ, L. M., and NICE, C. M., JR.: Traumatic lesions of the urinary tract, Radiol. Clin. North Am. 4: 433, (1966).
381
S. R. BRYNIAK, A. MORALES,
M.D. F.R.C.S.
(C)
From the Department of Urology, Kingston, Ontario, Canada
Queen’s
University,
ABSTRACT -A case of intimal laceration of the renal artery by blunt trauma is presented. Although complete and prolonged functional loss was documented, total recovery was eventually observed. Postulates regarding pathogenesis are provided. The usefulness of arteriography fm therapeutic and prognostic reasons is emphasized.
The concept that injury to the renal pedicle demands rapid diagnosis and treatment is of unquestionable importance. It is evident, however, that in some cases the severity of the injury or the condition of the patient dictates a more conservative attitude. A situation in which such approach is warranted is illustrated in this report.
renal artery and its branches were normal. Several small intimal defects were observed in the middle third of the left renal artery; its branches were of smaller caliber than their right counterparts. There was also some stretching and separation of the interlobar branches. An expectant attitude was decided on in regard to the renal trauma. The patient improved over the next week, and ten days later intravenous pyelogram was repeated. The right kidney was normal; on the left side no function was detected up to five hours after injection of the contrast medium. The patient’s condition continued to improve and prior to discharge three weeks later intravenous pyelogram again documented the findings of the previous study (Fig. 1C). Eight weeks after the initial injury intravenous pyelogram showed both kidneys functioning promptly (Fig. 1D). No deformity was observed in the left kidney. The patient has been followed up for more than two years. Blood pressure and renal function have remained normal. Periodic examinations of the urine have not shown abnormalities.
Case Report An eighteen-year-old man was admitted unconscious after a motor vehicle accident. Physical examination revealed many superficial lacerations of the right side of chest and abdomen. A large hematoma was present overlying the right zygoma. The patient was in obvious respiratory distress. Blood pressure was 100/60 mm. Hg and pulse 125 per minute. Chest x-ray film showed a right pneumothorax. A chest tube was inserted and a large amount of blood obtained. Tracheal intubation was carried out and, again, a large amount of blood also came through the endotracheal tube. Grossly bloody urine was obtained from a catheter inserted into the bladder. A portable intravenous pyelogram showed prompt excretion by the right kidney, with a normal collecting system. On the left side, however, no evidence of functioning renal parenchyma was observed (Fig. 1A). Twelve hours later, after stabilization of vital signs, a renal arteriogram was carried out (Fig. 1B). The right
UROLOGY
i
OCTOBER
1976
/
VOLU’ME VIII,
NUMBER
Comment Blunt trauma to the renal pedicle is more common in young individuals with mobile kidneys.’ Evans and Moggs2 and Grablowsky et al3 noted that when renal thrombosis occurs as a complication it is usually unilateral and
4
379
FIGURE
1.
Znitial
intra-
venous p yelogram showing good function in right kidney but no excretion from left kidney. (B) Renal arteriogram revealing irregularity of main left renal artery, with separation of its branches clearly demonstrated. (C) Intravenous p yelogram three weeks after injury; no function is observed In ,?ej3 kidney. (D)Two months after accident intravenous pyelogram shows functioning both kidneys promptly; no anatomic abnormalities are observed in left kidney.
involves the left kidney. The postulate of hypermobility of this kidney with its relatively long pedicle has been proposedS4 Consequently, it is not unlikely that such acceleration-deceleration of the left kidney produces the shearing force transmitted to the renal pedicle which tears the intima or subintimal tissue. In the majority of cases in the literature these patients had sustamed severe trauma with multiple associated Prompt recognition of main renal injuries. artery thrombosis and immediate surgical intervention is mandatory.’
380
In our case the prolonged lack of function in the left kidney remains unclear. Explanations readily offered include: (1) intimal fracture and subintimal dissection followed by hematoma formation and resultant obstruction;’ and (2) vasospasm secondary to trauma.6 The arteriogram excluded an obstruction commensurate with the degree of functional loss. Although there is no conclusive evidence for it, renal vein thrombosis has to be considered. The arterial stretching and separation and the severe functional derangement followed by a complete
UROLOGY
/ OCTOBER1976
I VOLWMEVIII,
NUMBER4
recovery substantiate this explanation. Vascular spasm of moderate degree, documented by the arteriographic findings, would not explain prolonged functional impairment unless the postulate of complicating acute tubular necrosis is advanced. In fact, absence of a nephrogram and failure of visualization of the tertiary arterial segments are consistent arteriographic findings of acute tubular necrosis. Several points are emphasized by this case. (1) The location and severity of external injuries bears little relationship to the internal ones. (2) Arteriography is of utmost importance in renal trauma to establish therapeutic priorities and define prognosis. (3) Injuries to the renal pedicle should be qualified. Intimal lacerations without further injury to the vessel or kidney are compatible with total functional recovery and an expectant attitude is warranted. (4) Delayed return of function may vary from a few days to several weeks.
UROLOGY
/
OCTOBER 1976 /
VOLUME VIII, NUMBER 4
Queen’s University Kingston,
Ontario,
Canada K7L 3N6 (DR. BRYNIAK)
References 1. Ross, R., ACKERMAN, E., and PIERCE, J. M.: Traumatic subintimal hemorrhage of the renal artery, J. Urol. 194: 11 (1970). 2. EVANS, A., and MOGGS, R. A.: Renal artery thrombosis due to closed trauma, ibid. 105: 330 (1971). 3. GRABLOWSKY, 0. M., WEICHERT, R. F., III, GOFF J. B., and SCHLECEL, J. G.: Renal artery thrombosis following blunt trauma, Surgery 67: 895 (1970). 4. COLLINS, H. A., and JACOBS, J. K.: Acute arterial injuries due to blunt trauma, J. Bone Joint Surg. 43-A: 195 (1961). 5. SKINNER, D. G.: Traumatic renal artery thrombosis: a successful thrombectomy and revascularization, Ann. Surg. 177: 264 (1973). 6. HOLLAND, M. T., HURWITZ, L. M., and NICE, C. M., JR.: Traumatic lesions of the urinary tract, Radiol. Clin. North Am. 4: 433, (1966).
381