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Post-biopsy Intrarenal Arteriovenous Fistula
0022-5347/79 /1222-0233$02.00/0 THE JOURNAL OF UROLOGY Copyright © 1979 by The Williams & Wilkins Co.
Vol. 122, August
Printed in U.S.A.
POST-BIOPSY INTRARENAL ARTERIOVENOUS FISTULA JUSTO H. GRAU, PAUL GONICK
AND
AUDREY WILSON
From the Division of Urology and the Department of Radiology, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
ABSTRACT
We present 5 cases of intrarenal arteriovenous fistulas after renal biopsy. Of these cases 3 followed percutaneous needle biopsy and 2 occurred after open renal biopsy. A nephrectomy was necessary in 1 patient to control the severe hypertension secondary to a hydronephrotic kidney and 1 patient required a partial nephrectomy to control marked hematuria. With the widespread use of selective renal arteriography to evaluate patients with renal disease has come the realization that an arteriovenous fistula is a relatively frequent occurrence. Herein we add 5 cases to the approximately 300 cases reported in the medical literature, including 2 fistulas following open renal biopsy.
phritis. An excretory urogram (IVP) before the biopsy was reported as normal. The patient was rehospitalized 1 year later for severe hypertension (140/100). The serum creatinine was 0.6 mg./100 ml. A renal arteriogram showed a small hydronephrotic right kidney with an arteriovenous fistula in the lower pole (fig. 1, A). The left kidney was normal. A right nephrec-
FIG. 1. A, catheter is positioned in 1 of 2 renal arteries supplying right kidney in case 1. Small non-functioning hydronephrotic kidney with completely destroyed cortex is seen. Hydronephrosis resulted from ureteropelvic junction obstruction owing to fibrosis probably secondary to postoperative hemorrhage. Note arteriovenous fistula in lower pole. B, selective left renal arteriogram in case 2 shows large arteriovenous fistula in lower pole with communication between major segmental artery and corresponding draining vein. Simultaneous opacification of artery and vein paralleling each other along medial aspect of lower pole is seen. Note end stage kidney owing to chronic pyelonephritis.
CASE REPORTS
Case 1. A 5-year-old boy was hospitalized on October 1, 1972 because of massive proteinuria discovered at routine examination. He was otherwise asymptomatic and had a blood pressure of 100/70. The creatinine clearance was 85 ml. per minute. An open renal biopsy was done for diagnostic purposes on October 6. The pathological diagnosis was membranous glomeruloneAccepted for publication October 27, 1978.
233
tomy was done and the blood pressure returned to normal. Case 2. A 56-year-old woman was hospitalized on October 25, 1972 for evaluation of anemia, hypertension, proteinuria, diabetes mellitus and azotemia. An IVP performed elsewhere was reported as normal. An open renal biopsy was done on November 1, 1972 with the patient under local anesthesia. No postoperative complications were noted. The pathologic report was chronic pyelonephritis. The patient was rehospitalized on May 7, 1973 because of progressive renal failure. A bilateral selective
Fm. 2. Selective left renal arteriogram in case 3 shows communication between renal artery and renal vein at hilus. Note simultaneous opacification of renal vein. Small kidney with scant cortex and attenuated arborization is seen.
Fm. 3. Case 4. A, selective left renal arteriogram before biopsy shows findings characteristic of nephrosclerosis. B, subselective injection into renal artery supplying lower pole of left kidney after biopsy shows large arteriovenous fistula with rapid venous filling and multiple arteriovenous communications. C, lower pole artery after intra-arterial injection of 5 11g. epinephrine is markedly vasoconstricted but arteriovenous communications are still patent (A) and early venous drainage persists (B). D, 7 cc autologous clot was injected into epinephrinized lower pole artery. Filling defect represents clot. Early venous filling is no longer seen and arteriovenous communications are not demonstrated. However, clot apparently dissolved because hematuria was not controlled. 234
POST-BIOPSY INTRARENAL ARTERIOVENOUS FISTULA
235
pain over the left flank area immediately after the injection of clot. Films obtained after the embolization showed a filling defect in the vessel (fig. 3, D) with partial interruption of the blood flow through the arteriovenous fistula. The hematuria persisted and 2 units of packed cells were required. Because of the persistent hematuria, flank pain and decrease in the hematocrit surgical exploration was done 2 days after injection of the embolus. A strong thrill was palpable over the lower pole of the kidney. The lower segmental branch of the left renal artery was isolated and a vascular clamp was applied, causing the thrill to disappear. The artery was then ligated and indigo carmine injected distal to the ligature demonstrated the area of the kidney supplied by the artery. A partial nephrectomy of this segment was then done. Convalescence was uneventful and the patient was discharged from the hospital 6 days postoperatively. Case 5. A 56-year-old man was hospitalized for evaluation of hypertension and chronic renal failure. A needle biopsy of the right kidney was done. Hematuria developed 4 hours later and continued for 1 week. On the second day a right renal arteriogram showed a large arteriovenous fistula (fig. 4). The patient needed several blood transfusions to maintain stable signs. In 1 week the bleeding stopped and the patient was discharged from the hospital 4 days later. DISCUSSION
Fm. 4. Right renal arteriogram 2 days after needle biopsy in case 5. Note large arteriovenous fistula in periphery of right kidney and early draining vein.
renal arteriogram showed an unsuspected arteriovenous fistula in the lower pole of the left kidney (fig. 1, B). Case 3. A 60-year-old man was hospitalized on May 25, 1975 for evaluation of hypertension and a urinary tract infection. An IVP showed bilateral small kidneys. The serum creatinine was 2.5 mg./100 ml. and serum urea nitrogen was 52 mg./100 ml. On May 30 a percutaneous needle biopsy of the left kidney was done. No postoperative complications were observed. A bilateral selective arteriogram 5 days later showed an arteriovenous fistula of the left kidney (fig. 2). No additional treatment was given. The pathologic report of the needle biopsy was arterionephrosclerosis and arteriolonephrosclerosis. Case 4. A 36-year-old man was hospitalized on January 1, 1976 for evaluation of accelerated hypertension. A selective arteriogram was reported as normal (fig. 3, A). A percutaneous needle biopsy was then done on the left kidney followed by several days of hematuria. The pathologic report of the needle biopsy was arteriolonephrosclerosis. The patient was readmitted for hematuria and mild left flank pain 2 weeks after discharge from the hospital. Blood pressure was 110/80 and pulse was 82. No bruit was heard over the abdomen or flank. The remainder of the blood studies, including a coagulation profile, was normal. The patient was placed on bed rest and intravenous fluids. The hematuria persisted and a left selective arteriogram showed a large arteriovenous fistula in the lower pole of the left kidney (fig. 3, B). Epinephrine injected into the lower branch of the left renal artery decreased the flow significantly (fig. 3, C). A 7 cc autologous blood clot was then injected through the arterial catheter into the segmental renal artery. The patient experienced acute
The major cause of intrarenal arteriovenous fistulas is thought to be renal biopsy. 1- 5 The first case of a renal arteriovenous fistula after a percutaneous needle biopsy was reported in 1962 by Boijsen and Kohler. 1 In 1 series of patients 18 per cent had been found to have these fistulas after therapy. 6 In experimental studies as many as 44 per cent of rabbits had a fistula immediately after percutaneous needle biopsy. 7 Since most of the biopsies performed on humans are not followed by angiography it is estimated that 95 per cent of the fistulas heal spontaneously within 3 to 30 months. 4 ' 5 The symptomatic arteriovenous fistula usually involves a large segmental vessel and most commonly presents with hematuria, heart failure, hypertension abdominal or lumbar bruit, or a combination of these sympto~s. Rupture of the fistula is a rare complication with a high mortality. Hypertension has been documented previously in normotensive individuals after percutaneous biopsies with the creation of an arteriovenous fistula. Cure of the hypertension has been effected after a nephrectomy or a partial nephrectomy. 3' 4 ' 6 The diagnosis of an arteriovenous fistula should be suspected when there is a history of renal biopsy along with the sudden onset of 1 of the aforementioned symptoms. The IVP often shows cortical distortion. A renal scan will show an area of poor or non-functional parenchyma. Renal arteriograms are diagnostic and will determine the size, location and approximate flow through the fistula. The management of an intrarenal arteriovenous fistula depends upon the size, location and clinical presentation. Many of the biopsy fistulas are asymptomatic and need observation only. Severe hypertension, continuous or severe hematuria, heart failure or a large size is an indication for surgical intervention. 3-6 Procedures used previously include nephrectomy, partial nephrectomy, ligation of the arterial side of the arteriovenous fistula 8 and arterial embolization with a transfemoral percutaneous catheter. 9 Conservation of as much renal tissue as possible is mandatory, since the renal disease process is usually bilateral and frequently progressive. REFERENCES
E. and Kohler, R.: Renal arteriovenous fistula. Acta Radiol., 57: 433, 1962. 2. Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula 1. Boijsen,
and aneurysms. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965.
236
GRAU, GONICK AND WILSON
3. O'Conor, V. J., Jr. and Bergan, J. J.: Surgical repair in solitary kidney of a large intrarenal arteriovenous fistula resulting from needle biopsy. J. Urol., 109: 934, 1973. 4. Vicente, Ocando y Colaboradores: Revista Venezolana de Urologia, 26: 125, 1974. 5. Maldonado, J. E. and Sheps, S. G.: Renal arteriovenous fistula. Postgrad. Med., 46: 263, 1966. 6. Tynes, W. V., Devine, C. J., Jr., Devine, P. C. and Poutasse, E. F.: Surgical treatment of renal arteriovenous fistula. J. Urol., 103:
692, 1970. 7. Ekelund, L.: Arteriovenous fistulae secondary to renal biopsy. An experimental study in the rabbit. Acta Radial. [Diag.] (Stockh.), 10: 218, 1970. 8. Cosgrove, M. D., Mendez, R. and Morrow, J. W.: Traumatic renal arteriovenous fistula: report of 12 cases. J. Urol., 110: 627, 1973. 9. Nelson, B. D., Brosman, S. A. and Goodwin, W. E.: Renal arteriovenous fistulas. J. Urol., 109: 779, 1973.
Vol. 122, August
Printed in U.S.A.
POST-BIOPSY INTRARENAL ARTERIOVENOUS FISTULA JUSTO H. GRAU, PAUL GONICK
AND
AUDREY WILSON
From the Division of Urology and the Department of Radiology, Hahnemann Medical College and Hospital, Philadelphia, Pennsylvania
ABSTRACT
We present 5 cases of intrarenal arteriovenous fistulas after renal biopsy. Of these cases 3 followed percutaneous needle biopsy and 2 occurred after open renal biopsy. A nephrectomy was necessary in 1 patient to control the severe hypertension secondary to a hydronephrotic kidney and 1 patient required a partial nephrectomy to control marked hematuria. With the widespread use of selective renal arteriography to evaluate patients with renal disease has come the realization that an arteriovenous fistula is a relatively frequent occurrence. Herein we add 5 cases to the approximately 300 cases reported in the medical literature, including 2 fistulas following open renal biopsy.
phritis. An excretory urogram (IVP) before the biopsy was reported as normal. The patient was rehospitalized 1 year later for severe hypertension (140/100). The serum creatinine was 0.6 mg./100 ml. A renal arteriogram showed a small hydronephrotic right kidney with an arteriovenous fistula in the lower pole (fig. 1, A). The left kidney was normal. A right nephrec-
FIG. 1. A, catheter is positioned in 1 of 2 renal arteries supplying right kidney in case 1. Small non-functioning hydronephrotic kidney with completely destroyed cortex is seen. Hydronephrosis resulted from ureteropelvic junction obstruction owing to fibrosis probably secondary to postoperative hemorrhage. Note arteriovenous fistula in lower pole. B, selective left renal arteriogram in case 2 shows large arteriovenous fistula in lower pole with communication between major segmental artery and corresponding draining vein. Simultaneous opacification of artery and vein paralleling each other along medial aspect of lower pole is seen. Note end stage kidney owing to chronic pyelonephritis.
CASE REPORTS
Case 1. A 5-year-old boy was hospitalized on October 1, 1972 because of massive proteinuria discovered at routine examination. He was otherwise asymptomatic and had a blood pressure of 100/70. The creatinine clearance was 85 ml. per minute. An open renal biopsy was done for diagnostic purposes on October 6. The pathological diagnosis was membranous glomeruloneAccepted for publication October 27, 1978.
233
tomy was done and the blood pressure returned to normal. Case 2. A 56-year-old woman was hospitalized on October 25, 1972 for evaluation of anemia, hypertension, proteinuria, diabetes mellitus and azotemia. An IVP performed elsewhere was reported as normal. An open renal biopsy was done on November 1, 1972 with the patient under local anesthesia. No postoperative complications were noted. The pathologic report was chronic pyelonephritis. The patient was rehospitalized on May 7, 1973 because of progressive renal failure. A bilateral selective
Fm. 2. Selective left renal arteriogram in case 3 shows communication between renal artery and renal vein at hilus. Note simultaneous opacification of renal vein. Small kidney with scant cortex and attenuated arborization is seen.
Fm. 3. Case 4. A, selective left renal arteriogram before biopsy shows findings characteristic of nephrosclerosis. B, subselective injection into renal artery supplying lower pole of left kidney after biopsy shows large arteriovenous fistula with rapid venous filling and multiple arteriovenous communications. C, lower pole artery after intra-arterial injection of 5 11g. epinephrine is markedly vasoconstricted but arteriovenous communications are still patent (A) and early venous drainage persists (B). D, 7 cc autologous clot was injected into epinephrinized lower pole artery. Filling defect represents clot. Early venous filling is no longer seen and arteriovenous communications are not demonstrated. However, clot apparently dissolved because hematuria was not controlled. 234
POST-BIOPSY INTRARENAL ARTERIOVENOUS FISTULA
235
pain over the left flank area immediately after the injection of clot. Films obtained after the embolization showed a filling defect in the vessel (fig. 3, D) with partial interruption of the blood flow through the arteriovenous fistula. The hematuria persisted and 2 units of packed cells were required. Because of the persistent hematuria, flank pain and decrease in the hematocrit surgical exploration was done 2 days after injection of the embolus. A strong thrill was palpable over the lower pole of the kidney. The lower segmental branch of the left renal artery was isolated and a vascular clamp was applied, causing the thrill to disappear. The artery was then ligated and indigo carmine injected distal to the ligature demonstrated the area of the kidney supplied by the artery. A partial nephrectomy of this segment was then done. Convalescence was uneventful and the patient was discharged from the hospital 6 days postoperatively. Case 5. A 56-year-old man was hospitalized for evaluation of hypertension and chronic renal failure. A needle biopsy of the right kidney was done. Hematuria developed 4 hours later and continued for 1 week. On the second day a right renal arteriogram showed a large arteriovenous fistula (fig. 4). The patient needed several blood transfusions to maintain stable signs. In 1 week the bleeding stopped and the patient was discharged from the hospital 4 days later. DISCUSSION
Fm. 4. Right renal arteriogram 2 days after needle biopsy in case 5. Note large arteriovenous fistula in periphery of right kidney and early draining vein.
renal arteriogram showed an unsuspected arteriovenous fistula in the lower pole of the left kidney (fig. 1, B). Case 3. A 60-year-old man was hospitalized on May 25, 1975 for evaluation of hypertension and a urinary tract infection. An IVP showed bilateral small kidneys. The serum creatinine was 2.5 mg./100 ml. and serum urea nitrogen was 52 mg./100 ml. On May 30 a percutaneous needle biopsy of the left kidney was done. No postoperative complications were observed. A bilateral selective arteriogram 5 days later showed an arteriovenous fistula of the left kidney (fig. 2). No additional treatment was given. The pathologic report of the needle biopsy was arterionephrosclerosis and arteriolonephrosclerosis. Case 4. A 36-year-old man was hospitalized on January 1, 1976 for evaluation of accelerated hypertension. A selective arteriogram was reported as normal (fig. 3, A). A percutaneous needle biopsy was then done on the left kidney followed by several days of hematuria. The pathologic report of the needle biopsy was arteriolonephrosclerosis. The patient was readmitted for hematuria and mild left flank pain 2 weeks after discharge from the hospital. Blood pressure was 110/80 and pulse was 82. No bruit was heard over the abdomen or flank. The remainder of the blood studies, including a coagulation profile, was normal. The patient was placed on bed rest and intravenous fluids. The hematuria persisted and a left selective arteriogram showed a large arteriovenous fistula in the lower pole of the left kidney (fig. 3, B). Epinephrine injected into the lower branch of the left renal artery decreased the flow significantly (fig. 3, C). A 7 cc autologous blood clot was then injected through the arterial catheter into the segmental renal artery. The patient experienced acute
The major cause of intrarenal arteriovenous fistulas is thought to be renal biopsy. 1- 5 The first case of a renal arteriovenous fistula after a percutaneous needle biopsy was reported in 1962 by Boijsen and Kohler. 1 In 1 series of patients 18 per cent had been found to have these fistulas after therapy. 6 In experimental studies as many as 44 per cent of rabbits had a fistula immediately after percutaneous needle biopsy. 7 Since most of the biopsies performed on humans are not followed by angiography it is estimated that 95 per cent of the fistulas heal spontaneously within 3 to 30 months. 4 ' 5 The symptomatic arteriovenous fistula usually involves a large segmental vessel and most commonly presents with hematuria, heart failure, hypertension abdominal or lumbar bruit, or a combination of these sympto~s. Rupture of the fistula is a rare complication with a high mortality. Hypertension has been documented previously in normotensive individuals after percutaneous biopsies with the creation of an arteriovenous fistula. Cure of the hypertension has been effected after a nephrectomy or a partial nephrectomy. 3' 4 ' 6 The diagnosis of an arteriovenous fistula should be suspected when there is a history of renal biopsy along with the sudden onset of 1 of the aforementioned symptoms. The IVP often shows cortical distortion. A renal scan will show an area of poor or non-functional parenchyma. Renal arteriograms are diagnostic and will determine the size, location and approximate flow through the fistula. The management of an intrarenal arteriovenous fistula depends upon the size, location and clinical presentation. Many of the biopsy fistulas are asymptomatic and need observation only. Severe hypertension, continuous or severe hematuria, heart failure or a large size is an indication for surgical intervention. 3-6 Procedures used previously include nephrectomy, partial nephrectomy, ligation of the arterial side of the arteriovenous fistula 8 and arterial embolization with a transfemoral percutaneous catheter. 9 Conservation of as much renal tissue as possible is mandatory, since the renal disease process is usually bilateral and frequently progressive. REFERENCES
E. and Kohler, R.: Renal arteriovenous fistula. Acta Radiol., 57: 433, 1962. 2. Bennett, A. R. and Wiener, S. N.: Intrarenal arteriovenous fistula 1. Boijsen,
and aneurysms. A complication of percutaneous renal biopsy. Amer. J. Roentgen., 95: 372, 1965.
236
GRAU, GONICK AND WILSON
3. O'Conor, V. J., Jr. and Bergan, J. J.: Surgical repair in solitary kidney of a large intrarenal arteriovenous fistula resulting from needle biopsy. J. Urol., 109: 934, 1973. 4. Vicente, Ocando y Colaboradores: Revista Venezolana de Urologia, 26: 125, 1974. 5. Maldonado, J. E. and Sheps, S. G.: Renal arteriovenous fistula. Postgrad. Med., 46: 263, 1966. 6. Tynes, W. V., Devine, C. J., Jr., Devine, P. C. and Poutasse, E. F.: Surgical treatment of renal arteriovenous fistula. J. Urol., 103:
692, 1970. 7. Ekelund, L.: Arteriovenous fistulae secondary to renal biopsy. An experimental study in the rabbit. Acta Radial. [Diag.] (Stockh.), 10: 218, 1970. 8. Cosgrove, M. D., Mendez, R. and Morrow, J. W.: Traumatic renal arteriovenous fistula: report of 12 cases. J. Urol., 110: 627, 1973. 9. Nelson, B. D., Brosman, S. A. and Goodwin, W. E.: Renal arteriovenous fistulas. J. Urol., 109: 779, 1973.