- Email: [email protected]
Successful angioembolization of renal artery pseudoaneurysms after blunt abdominal trauma
CASE REPORT
SUCCESSFUL ANGIOEMBOLIZATION OF RENAL ARTERY PSEUDOANEURYSMS AFTER BLUNT ABDOMINAL TRAUMA DAVID C. MILLER, ANDREW FORAUER,
AND
GARY J. FAERBER
ABSTRACT We report a case of minimally invasive management of renal artery pseudoaneurysms after blunt abdominal trauma. A 44-year-old man developed gross hematuria after a motor vehicle collision. The initial radiographic evaluation revealed only a parenchymal laceration of the right kidney, and the patient was treated conservatively. Persistent gross hematuria necessitated repeat renal angiography that revealed numerous small pseudoaneurysms. Angioembolization was successfully performed with minimal compromise of the renal parenchyma. Transcatheter embolization is safe and effective for controlling hemorrhage from traumatic renal artery pseudoaneurysms and should be the initial treatment of choice in hemodynamically stable patients. UROLOGY 59: 444xiii–444xv, 2002. © 2002, Elsevier Science Inc.
R
enal artery pseudoaneurysm is a rare complication of blunt abdominal trauma. We report a case of traumatic pseudoaneurysm successfully managed with minimally invasive angiographic techniques. CASE REPORT A 44-year-old man was the restrained, back-seat passenger in a motor vehicle collision. Foley catheter placement at an outside facility revealed gross hematuria. On arrival at our institution, the patient was hemodynamically stable but reported rightsided chest and abdominal pain. On physical examination, he had right costovertebral angle tenderness and grossly bloody urine. His hematocrit was 37%. Chest x-ray revealed a minimally displaced fracture of the lateral aspect of the right 10th rib. Computed tomography demonstrated a traumatic laceration of the right kidney with associated perinephric fluid (Fig. 1A). Renal arteriography revealed wedge-shaped parenchymal defects with no active extravasation (Fig. 1B). The patient was admitted to the intensive care unit for serial hematocrit monitoring and strict bedrest. He was transfused 2 U on hospital day 2
From the Departments of Urology and Radiology, University of Michigan School of Medicine, Ann Arbor, Michigan Address for correspondence: Gary J. Faerber, M.D., Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109 Submitted: July 20, 2001, accepted (with revisions): November 6, 2001 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
and remained hemodynamically stable. On posttrauma day 8, his hematocrit dropped to 31%, from a peak of 38% after the transfusion. Given his falling hematocrit and persistent gross hematuria, a repeat renal angiogram was obtained that revealed a normal left kidney but numerous small pseudoaneurysms arising from a proximal branch of the anterior division of the right renal artery (Fig. 2A). Selective embolization was performed, with postembolization images identifying no residual extravasation (Fig. 2B). The resulting nephrogram defect represented less than 20% of the renal parenchyma. The patient’s urine rapidly cleared, and his hematocrit and creatinine remained stable. He was discharged home on post-trauma day 12. The patient was seen at the clinic 6 weeks later and was normotensive (134/82 mm Hg) and asymptomatic. A follow-up diuretic renal scan at 3 months demonstrated 48% of total renal function on the right and no evidence of obstruction. COMMENT Pseudoaneurysm development after blunt abdominal trauma is less common than with penetrating trauma and is believed to result from rapid deceleration-induced, full or partial-thickness injury to arteries supplying the renal parenchyma.1,2 Initially, the hemorrhage may be contained by surrounding tissues such as the vascular adventitia, renal parenchyma, or Gerota’s fascia.1 With progression, however, gross hematuria results from 0090-4295/02/$22.00 PII S0090-4295(01)01595-3 444xiii
FIGURE 1. (A) Computed tomography scan demonstrating traumatic laceration of the right kidney with perinephric fluid. (B) Concomitant right renal arteriogram identified no contrast extravasation.
FIGURE 2. (A) Follow-up angiography 8 days later demonstrating the interval development of numerous small pseudoaneurysms (arrow). (B) Postembolization images identified no residual extravasation at site of prior pseudoaneurysms (arrow).
communication of the pseudoaneurysm with the collecting system. An understanding of this natural history is critical to the nonoperative management of blunt renal trauma. Typically, gross hematuria from blunt parenchymal injury resolves within several hours3 and can be effectively managed with strict bedrest and transfusion support until the urine clears and vital signs remain stable. However, persistent bleeding or delayed gross hematuria should raise the suspicion of segmental vascular injury, including pseudoaneurysm formation, and prompt further investigation. Therefore, although the initial angiogram may be negative, follow-up imaging often demonstrates that, with time and resuscitation, previously undetected vascular injuries can blossom into multifocal pseudoaneurysms with active extravasation and gross hematuria.1 Historically, persistent hematuria from blunt re444xiv
nal trauma mandated operative exploration, and extirpative surgery in the form of nephrectomy was frequently required for definitive management.1 Recently, however, advances in radiologic techniques and technology have provided clinicians with minimally invasive alternatives for the diagnosis and management of traumatic renovascular lesions, including pseudoaneurysms.4 Several imaging modalities, including sonography and computed tomography, can be used when pseudoaneurysm is suspected.1,2 The reference standard, however, is contrast angiography, which not only confirms the presence of pseudoaneurysms but also provides anatomic localization and assessment of the renal parenchyma.1,4 Moreover, with angiography, concomitant therapeutic intervention is available in the form of transcatheter embolization.1,4 Currently, 3F microcatheters are UROLOGY 59 (3), 2002
available that allow superselective catheterization and embolization of interlobular arteries within the renal parenchyma. The evolution of embolization techniques during the past two decades has obviated the need for surgical exploration in the vast majority of patients with gross hematuria of renal origin after blunt or penetrating abdominal trauma. As illustrated by this case report, transcatheter embolization is safe and effective for controlling hemorrhage from renal artery pseudoaneurysms and has become the initial treatment of choice in hemodynamically stable patients. In addition, the outcome of this case suggests that this nephron-sparing approach may also be effective in reducing the late complications of blunt renal trauma, including hypertension (0% to
UROLOGY 59 (3), 2002
33% of patients) and renal insufficiency. Confirmation of such a benefit, however, requires longterm follow-up of a large number of patients.2,4 REFERENCES 1. Jebara VA, El Rassi I, Achouh PE, et al: Renal artery pseudoaneurysm after blunt abdominal trauma. J Vasc Surg 27: 362–365, 1998. 2. Swana HS, Cohn SM, Burns GA, et al: Renal artery pseudoaneurysm after blunt abdominal trauma: case report and literature review. J Trauma 40: 459 – 461, 1996. 3. Peterson NE: Genitourinary trauma, in Mattox KL, Feliciano DV, and Moore EE (Eds): Trauma. New York, McGraw Hill, 2000, pp 839 – 879. 4. Fisher RG, Ben-Menachem Y, and Whigham C: Stab wounds of the renal artery branches: angiographic diagnosis and treatment by embolization. AJR Am J Roentgenol 152: 1231–1235, 1989.
444xv
SUCCESSFUL ANGIOEMBOLIZATION OF RENAL ARTERY PSEUDOANEURYSMS AFTER BLUNT ABDOMINAL TRAUMA DAVID C. MILLER, ANDREW FORAUER,
AND
GARY J. FAERBER
ABSTRACT We report a case of minimally invasive management of renal artery pseudoaneurysms after blunt abdominal trauma. A 44-year-old man developed gross hematuria after a motor vehicle collision. The initial radiographic evaluation revealed only a parenchymal laceration of the right kidney, and the patient was treated conservatively. Persistent gross hematuria necessitated repeat renal angiography that revealed numerous small pseudoaneurysms. Angioembolization was successfully performed with minimal compromise of the renal parenchyma. Transcatheter embolization is safe and effective for controlling hemorrhage from traumatic renal artery pseudoaneurysms and should be the initial treatment of choice in hemodynamically stable patients. UROLOGY 59: 444xiii–444xv, 2002. © 2002, Elsevier Science Inc.
R
enal artery pseudoaneurysm is a rare complication of blunt abdominal trauma. We report a case of traumatic pseudoaneurysm successfully managed with minimally invasive angiographic techniques. CASE REPORT A 44-year-old man was the restrained, back-seat passenger in a motor vehicle collision. Foley catheter placement at an outside facility revealed gross hematuria. On arrival at our institution, the patient was hemodynamically stable but reported rightsided chest and abdominal pain. On physical examination, he had right costovertebral angle tenderness and grossly bloody urine. His hematocrit was 37%. Chest x-ray revealed a minimally displaced fracture of the lateral aspect of the right 10th rib. Computed tomography demonstrated a traumatic laceration of the right kidney with associated perinephric fluid (Fig. 1A). Renal arteriography revealed wedge-shaped parenchymal defects with no active extravasation (Fig. 1B). The patient was admitted to the intensive care unit for serial hematocrit monitoring and strict bedrest. He was transfused 2 U on hospital day 2
From the Departments of Urology and Radiology, University of Michigan School of Medicine, Ann Arbor, Michigan Address for correspondence: Gary J. Faerber, M.D., Section of Urology, Department of Surgery, University of Michigan Medical Center, Ann Arbor, MI 48109 Submitted: July 20, 2001, accepted (with revisions): November 6, 2001 © 2002, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
and remained hemodynamically stable. On posttrauma day 8, his hematocrit dropped to 31%, from a peak of 38% after the transfusion. Given his falling hematocrit and persistent gross hematuria, a repeat renal angiogram was obtained that revealed a normal left kidney but numerous small pseudoaneurysms arising from a proximal branch of the anterior division of the right renal artery (Fig. 2A). Selective embolization was performed, with postembolization images identifying no residual extravasation (Fig. 2B). The resulting nephrogram defect represented less than 20% of the renal parenchyma. The patient’s urine rapidly cleared, and his hematocrit and creatinine remained stable. He was discharged home on post-trauma day 12. The patient was seen at the clinic 6 weeks later and was normotensive (134/82 mm Hg) and asymptomatic. A follow-up diuretic renal scan at 3 months demonstrated 48% of total renal function on the right and no evidence of obstruction. COMMENT Pseudoaneurysm development after blunt abdominal trauma is less common than with penetrating trauma and is believed to result from rapid deceleration-induced, full or partial-thickness injury to arteries supplying the renal parenchyma.1,2 Initially, the hemorrhage may be contained by surrounding tissues such as the vascular adventitia, renal parenchyma, or Gerota’s fascia.1 With progression, however, gross hematuria results from 0090-4295/02/$22.00 PII S0090-4295(01)01595-3 444xiii
FIGURE 1. (A) Computed tomography scan demonstrating traumatic laceration of the right kidney with perinephric fluid. (B) Concomitant right renal arteriogram identified no contrast extravasation.
FIGURE 2. (A) Follow-up angiography 8 days later demonstrating the interval development of numerous small pseudoaneurysms (arrow). (B) Postembolization images identified no residual extravasation at site of prior pseudoaneurysms (arrow).
communication of the pseudoaneurysm with the collecting system. An understanding of this natural history is critical to the nonoperative management of blunt renal trauma. Typically, gross hematuria from blunt parenchymal injury resolves within several hours3 and can be effectively managed with strict bedrest and transfusion support until the urine clears and vital signs remain stable. However, persistent bleeding or delayed gross hematuria should raise the suspicion of segmental vascular injury, including pseudoaneurysm formation, and prompt further investigation. Therefore, although the initial angiogram may be negative, follow-up imaging often demonstrates that, with time and resuscitation, previously undetected vascular injuries can blossom into multifocal pseudoaneurysms with active extravasation and gross hematuria.1 Historically, persistent hematuria from blunt re444xiv
nal trauma mandated operative exploration, and extirpative surgery in the form of nephrectomy was frequently required for definitive management.1 Recently, however, advances in radiologic techniques and technology have provided clinicians with minimally invasive alternatives for the diagnosis and management of traumatic renovascular lesions, including pseudoaneurysms.4 Several imaging modalities, including sonography and computed tomography, can be used when pseudoaneurysm is suspected.1,2 The reference standard, however, is contrast angiography, which not only confirms the presence of pseudoaneurysms but also provides anatomic localization and assessment of the renal parenchyma.1,4 Moreover, with angiography, concomitant therapeutic intervention is available in the form of transcatheter embolization.1,4 Currently, 3F microcatheters are UROLOGY 59 (3), 2002
available that allow superselective catheterization and embolization of interlobular arteries within the renal parenchyma. The evolution of embolization techniques during the past two decades has obviated the need for surgical exploration in the vast majority of patients with gross hematuria of renal origin after blunt or penetrating abdominal trauma. As illustrated by this case report, transcatheter embolization is safe and effective for controlling hemorrhage from renal artery pseudoaneurysms and has become the initial treatment of choice in hemodynamically stable patients. In addition, the outcome of this case suggests that this nephron-sparing approach may also be effective in reducing the late complications of blunt renal trauma, including hypertension (0% to
UROLOGY 59 (3), 2002
33% of patients) and renal insufficiency. Confirmation of such a benefit, however, requires longterm follow-up of a large number of patients.2,4 REFERENCES 1. Jebara VA, El Rassi I, Achouh PE, et al: Renal artery pseudoaneurysm after blunt abdominal trauma. J Vasc Surg 27: 362–365, 1998. 2. Swana HS, Cohn SM, Burns GA, et al: Renal artery pseudoaneurysm after blunt abdominal trauma: case report and literature review. J Trauma 40: 459 – 461, 1996. 3. Peterson NE: Genitourinary trauma, in Mattox KL, Feliciano DV, and Moore EE (Eds): Trauma. New York, McGraw Hill, 2000, pp 839 – 879. 4. Fisher RG, Ben-Menachem Y, and Whigham C: Stab wounds of the renal artery branches: angiographic diagnosis and treatment by embolization. AJR Am J Roentgenol 152: 1231–1235, 1989.
444xv