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Correction of Deteriorating Renal Function by Superselective Embolization of an Arcuate Renal Artery Pseudoaneurysm
0022-53L}7/94/1526~-208 7$03.0D/O
l52,
THE JmJRNAL OF UROLOGY
Copyright© 1994 by
AtVIERICAl'.J DROI,OGICfu; AssOC}:ATION, INC.
Case Reports CORRECTION OF DETERIORATING RENAL FUNCTION BY SUPERSELECTIVE EMBOLIZATION OF A,~ ARCUATE RENAL ARTERY PSEUDOANEURYSM B. T. BUI, V. L. OLIVA, F. PELOQUIN, C. HA._B,EL, V. NICOLET
AND
L. CARIGNAN
From the Departments of Radiology and Urology, Hopital Notre-Dame, Universite de Montreal, Quebec, Canada
ABSTRACT
We performed superselective embolization of an iatrogenic pseudo aneurysm of the right kidney that was causing hematuria and deterioration of renal function in a patient with chronic renal failure. An arcuate artery was embolized with absorbable gelatin sponge and a straight embolization wire without significant loss of renal vascularization, thus restoring baseline renal function. To our knowledge the clinical and technical aspects of our case are unique. The technique is described. KEY WORDS:
embolization, therapeutic; kidney; angiography; iatrogenic disease; arteries
Renal pseudoaneurysms are common, and the etiology is usually posttraumatic or iatrogenic. When symptomatic, they commonly present with h.ematuria. We report a case of iatrogenic pseudoaneurysm of the kidney in a patient with chronic renal failure who presented with gross hematuria and deterioration of renal function. The lesion was effectively treated with su.perselective embolization. CASE REPORT
A 65-year-old man presented with gross hematuria 4 days after surgical wedge biopsy of the right kidney for chronic renal failure. The serum creatinine was 2.5 mg./dl. (normal 0. 7 to 1.4). Histological examination of the specimen revealed moderate nephrosclerosis and immunofluorescence studies were negative for vasculitis. Initially the patient was disAccepted for publication March 25, 1994.
charged home after spontaneous cessation of hematuria 10 but he was pu,v.",hvu 1 week later for recurrent hematuria. The patient denied The serum creatinine had increased to 3.5 mg./dl. Ultrasound was normal and a selective angiogram of the right kidney showed a 1 cm. pseudoaneurysm originating from an arcuate artery of the lower pole in the biopsy area (part A of figure). Because of renal failure it was elected to attempt superselective embolization of the feeding branch to preserve renal parenchyma. A 5F 2.5Ch catheter was placed in the proximal portion of the right renal artery. A 2.5F catheter -was then advanced coaxially through the 5F catheter. The 0.038-inch inner diameter permitted injection of small boluses of contrast material through the 5F catheter during manipulation of the 2.5F catheter, which was advanced into the arcuate artery feeding the pseudoaneurysm B of figure). Small particles of absorbable gelatin sponge were injected through the
A, selective renal angiogram reveals peripheral pseudoaneurysm of lower pole and diffuse arteriolar nephrosclerosis. B, magnified angiogram through 2.5F catheter shows arcuate artery supplying pseudoaneurysm. C, final angiogram demonstrates occlusion of pseudoaneurysm after embolization with straight wire (arrows). 2087
2088
CORRECTION OF DETERIORATING RENAL FUNCTION
2.5F catheter until occlusion of the pseudoaneurysm. A 7 mm. 0.018-inch straight embolization wire was then delivered through the same catheter into the arcuate artery for permanent occlusion. Final selective renal arteriography showed complete occlusion of the pseudoaneurysm with preservation of the remaining vascular supply to the right kidney (part C of figure). Hematuria ceased immediately after the procedure and no sign of the post-embolization syndrome was observed. The serum creatinine returned to initial baseline value of 2.5 mg./dl. and the patient is well at 6-month followup. DISCUSSION
The increasing role of percutaneous interventional procedures has been recognized in the management of renal vascular injuries. A success rate in excess of 80% can be achieved with transcatheter embolization of traumatic vascular lesions to the kidney with a low complication rate. 1 ~ 4 Deterioration of renal function is a seldom reported manifestation of renal vascular injury, especially in native kidneys, which is why the clinical presentation of our patient is unusual. We favor clot retention with partial obstruction of the collecting system as the best hypothesis for renal functional deterioration in our case. Although ultrasound was normal, acute obstruction seldom leads to hydronephrosis in early stages. Since most patients who undergo renal biopsy already suffer chronic renal failure, acute deterioration can be expected if bleeding occurs, which emphasizes the importance of preserving flow to the renal parenchyma during an embolization procedure. DeSouza et al reported improvement or stabilization of renal function after superselective embolization of vascular injuries in renal allografts without mentioning baseline renal function. 5 Loss of renal tissue has been shown to decrease with selective embolization when compared to nontarget vascular occlusions. 6 • 7 However, in most reported cases selective embolization is performed in the segmental arterial branches. The use of micro-catheters now permits cannulation of 1 mm. or smaller vessels. 4 In our case we were able to identify, catheterize and embolize the arcuate artery supplying the flow to the pseudoaneurysm, which to our knowledge has not been reported previously. A few technical points need to be emphasized. Injection of contrast material through the 5F guiding catheter during
fluoroscopy was helpful in coaxially selecting the appropriate branch with the 2.5F catheter. Roadmapping was unreliable due to respiratory motion, as it is common in abdominal organs. Straight embolization wires are well suited for occlusion of 1 mm. or smaller vessels. Although gelatin sponge is efficient in achieving immediate vessel occlusion, it is an absorbable hemostatic material and a wire was used in our case to avoid any possibility of recanalization. Accurate placement of the straight wire is possible due to platinum radiopacity. It is also useful to know that these wires can be delivered by injection of saline with a syringe after being loaded into the catheter instead of using a coil pusher, which reduces catheter motion, especially when the route is tortuous. Refinements in imaging modalities and catheter technology allow increasingly accurate endovascular procedures, as is well illustrated by our case. Superselective occlusion of the pseudoaneurysm allowed preservation of renal parenchyma and restoration of baseline renal function.
REFERENCES
1. Heyns, C. F. and van Vollenhoven, P.: Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J. Urol., 147: 1231, 1992. 2. Kantor, A., Sclafani, S. J. A., Scalea, T., Duncan, A. 0., Atweh, N. and Glanz, S.: The role of interventional radiology in the management of genitourinary trauma. Urol. Clin. N. Amer., 16: 255, 1989. 3. Uflacker, R., Paolini, R. M. and Lima, S.: Management of traumatic hematuria by selective renal artery embolization. J. Urol., 132: 662, 1984. 4. Teitelbaum, G. P., Reed, R. A., Larsen, D., Lee, R. K., Pentecost, M. J., Finck, E. J. and Katz, M. D.: Microcatheter embolization of non-neurologic traumatic vascular lesions. J. Vase. Intervent. Rad., 4: 149, 1993. 5. deSouza, N. M., Reidy, J. F. and Koffman, C. G.: Arteriovenous fistulas complicating biopsy of renal allografts: treatment of bleeding with superselective embolization. AJR, 156: 507, 1991. 6. Eastham, J. A., Wilson, T. G., Larsen, D. W. and Ahlering, T. E.: Angiographic embolization ofrenal stab wounds. J. Urol., 148: 268, 1992. 7. Fisher, R. G., Ben-Menachem, Y. and Whigham, C.: Stab wounds of renal artery branches: angiographic diagnosis and treatment by embolization. AJR, 152: 1231, 1989.
l52,
THE JmJRNAL OF UROLOGY
Copyright© 1994 by
AtVIERICAl'.J DROI,OGICfu; AssOC}:ATION, INC.
Case Reports CORRECTION OF DETERIORATING RENAL FUNCTION BY SUPERSELECTIVE EMBOLIZATION OF A,~ ARCUATE RENAL ARTERY PSEUDOANEURYSM B. T. BUI, V. L. OLIVA, F. PELOQUIN, C. HA._B,EL, V. NICOLET
AND
L. CARIGNAN
From the Departments of Radiology and Urology, Hopital Notre-Dame, Universite de Montreal, Quebec, Canada
ABSTRACT
We performed superselective embolization of an iatrogenic pseudo aneurysm of the right kidney that was causing hematuria and deterioration of renal function in a patient with chronic renal failure. An arcuate artery was embolized with absorbable gelatin sponge and a straight embolization wire without significant loss of renal vascularization, thus restoring baseline renal function. To our knowledge the clinical and technical aspects of our case are unique. The technique is described. KEY WORDS:
embolization, therapeutic; kidney; angiography; iatrogenic disease; arteries
Renal pseudoaneurysms are common, and the etiology is usually posttraumatic or iatrogenic. When symptomatic, they commonly present with h.ematuria. We report a case of iatrogenic pseudoaneurysm of the kidney in a patient with chronic renal failure who presented with gross hematuria and deterioration of renal function. The lesion was effectively treated with su.perselective embolization. CASE REPORT
A 65-year-old man presented with gross hematuria 4 days after surgical wedge biopsy of the right kidney for chronic renal failure. The serum creatinine was 2.5 mg./dl. (normal 0. 7 to 1.4). Histological examination of the specimen revealed moderate nephrosclerosis and immunofluorescence studies were negative for vasculitis. Initially the patient was disAccepted for publication March 25, 1994.
charged home after spontaneous cessation of hematuria 10 but he was pu,v.",hvu 1 week later for recurrent hematuria. The patient denied The serum creatinine had increased to 3.5 mg./dl. Ultrasound was normal and a selective angiogram of the right kidney showed a 1 cm. pseudoaneurysm originating from an arcuate artery of the lower pole in the biopsy area (part A of figure). Because of renal failure it was elected to attempt superselective embolization of the feeding branch to preserve renal parenchyma. A 5F 2.5Ch catheter was placed in the proximal portion of the right renal artery. A 2.5F catheter -was then advanced coaxially through the 5F catheter. The 0.038-inch inner diameter permitted injection of small boluses of contrast material through the 5F catheter during manipulation of the 2.5F catheter, which was advanced into the arcuate artery feeding the pseudoaneurysm B of figure). Small particles of absorbable gelatin sponge were injected through the
A, selective renal angiogram reveals peripheral pseudoaneurysm of lower pole and diffuse arteriolar nephrosclerosis. B, magnified angiogram through 2.5F catheter shows arcuate artery supplying pseudoaneurysm. C, final angiogram demonstrates occlusion of pseudoaneurysm after embolization with straight wire (arrows). 2087
2088
CORRECTION OF DETERIORATING RENAL FUNCTION
2.5F catheter until occlusion of the pseudoaneurysm. A 7 mm. 0.018-inch straight embolization wire was then delivered through the same catheter into the arcuate artery for permanent occlusion. Final selective renal arteriography showed complete occlusion of the pseudoaneurysm with preservation of the remaining vascular supply to the right kidney (part C of figure). Hematuria ceased immediately after the procedure and no sign of the post-embolization syndrome was observed. The serum creatinine returned to initial baseline value of 2.5 mg./dl. and the patient is well at 6-month followup. DISCUSSION
The increasing role of percutaneous interventional procedures has been recognized in the management of renal vascular injuries. A success rate in excess of 80% can be achieved with transcatheter embolization of traumatic vascular lesions to the kidney with a low complication rate. 1 ~ 4 Deterioration of renal function is a seldom reported manifestation of renal vascular injury, especially in native kidneys, which is why the clinical presentation of our patient is unusual. We favor clot retention with partial obstruction of the collecting system as the best hypothesis for renal functional deterioration in our case. Although ultrasound was normal, acute obstruction seldom leads to hydronephrosis in early stages. Since most patients who undergo renal biopsy already suffer chronic renal failure, acute deterioration can be expected if bleeding occurs, which emphasizes the importance of preserving flow to the renal parenchyma during an embolization procedure. DeSouza et al reported improvement or stabilization of renal function after superselective embolization of vascular injuries in renal allografts without mentioning baseline renal function. 5 Loss of renal tissue has been shown to decrease with selective embolization when compared to nontarget vascular occlusions. 6 • 7 However, in most reported cases selective embolization is performed in the segmental arterial branches. The use of micro-catheters now permits cannulation of 1 mm. or smaller vessels. 4 In our case we were able to identify, catheterize and embolize the arcuate artery supplying the flow to the pseudoaneurysm, which to our knowledge has not been reported previously. A few technical points need to be emphasized. Injection of contrast material through the 5F guiding catheter during
fluoroscopy was helpful in coaxially selecting the appropriate branch with the 2.5F catheter. Roadmapping was unreliable due to respiratory motion, as it is common in abdominal organs. Straight embolization wires are well suited for occlusion of 1 mm. or smaller vessels. Although gelatin sponge is efficient in achieving immediate vessel occlusion, it is an absorbable hemostatic material and a wire was used in our case to avoid any possibility of recanalization. Accurate placement of the straight wire is possible due to platinum radiopacity. It is also useful to know that these wires can be delivered by injection of saline with a syringe after being loaded into the catheter instead of using a coil pusher, which reduces catheter motion, especially when the route is tortuous. Refinements in imaging modalities and catheter technology allow increasingly accurate endovascular procedures, as is well illustrated by our case. Superselective occlusion of the pseudoaneurysm allowed preservation of renal parenchyma and restoration of baseline renal function.
REFERENCES
1. Heyns, C. F. and van Vollenhoven, P.: Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J. Urol., 147: 1231, 1992. 2. Kantor, A., Sclafani, S. J. A., Scalea, T., Duncan, A. 0., Atweh, N. and Glanz, S.: The role of interventional radiology in the management of genitourinary trauma. Urol. Clin. N. Amer., 16: 255, 1989. 3. Uflacker, R., Paolini, R. M. and Lima, S.: Management of traumatic hematuria by selective renal artery embolization. J. Urol., 132: 662, 1984. 4. Teitelbaum, G. P., Reed, R. A., Larsen, D., Lee, R. K., Pentecost, M. J., Finck, E. J. and Katz, M. D.: Microcatheter embolization of non-neurologic traumatic vascular lesions. J. Vase. Intervent. Rad., 4: 149, 1993. 5. deSouza, N. M., Reidy, J. F. and Koffman, C. G.: Arteriovenous fistulas complicating biopsy of renal allografts: treatment of bleeding with superselective embolization. AJR, 156: 507, 1991. 6. Eastham, J. A., Wilson, T. G., Larsen, D. W. and Ahlering, T. E.: Angiographic embolization ofrenal stab wounds. J. Urol., 148: 268, 1992. 7. Fisher, R. G., Ben-Menachem, Y. and Whigham, C.: Stab wounds of renal artery branches: angiographic diagnosis and treatment by embolization. AJR, 152: 1231, 1989.