Postpyelolithotomy Renal Artery Pseudoaneurysm Management with Percutaneous Thrombin Injection: A Case Report

Renal artery pseudoaneurysm leading to life-threatening hematuria can occur after a surgical procedure such as pyelolithotomy, albeit rarely. With recent advances in transarterial embolization techniques, this minimally invasive procedure has become the treatment of choice, replacing surgery. We present a case of massive hematuria due to renal artery pseudoaneurysm developing after pyelolithotomy that was managed with percutaneus thrombin injection directly into the pseudoaneurysm.     

Renal injury in sport

Hematuria is the most common presenting sign of renal injury. Its presence in athletes may indicate a benign entity such as exercise-induced hematuria or a more serious injury in the presence of trauma. Exercise-induced hematuria can originate in the kidney, bladder, urethra, or prostate. The type of activity, as well as activity duration and intensity, contributes to its development. A wide differential diagnosis must be considered if hematuria persists longer than 24 to 72 hours. Trauma to the kidney can occur from a direct blow or deceleration; contact and collision sports are most commonly involved. Fortunately, most sports-related renal trauma is mild, and can be managed expectantly. A sporting injury rarely results in nephrectomy. Determining return to play for the athlete with a single kidney remains a controversial issue that requires patient education and an individualized approach.     

Traumatic occlusion of renal artery: CT and angiography

Four cases of traumatic renal artery occlusion are reported. A direct blow to the abdomen was considered to have caused renal artery occlusion in two cases. They were severely injured and had macroscopic hematuria. Aortography revealed an abrupt cut-off type of obstruction of the renal artery. In the other two, a rapid decelerating-type of injury resulted in damage to the intima of the renal artery. They showed almost no outward signs of injury and no macroscopic hematuria. Aortography disclosed a tapered occlusion of the renal artery. CT showed the rim sign between the seventh day and sixth week before the compromised kidney became apparent. It had disappeared by the time follow-up CT revealed contraction. One patient developed hypertension, which subsided after nephrectomy. CT findings of the patient suggested the possibility of predicting hypertension as a sequelae of acute renal artery occlusion.     

Segmental renal infarction after blunt abdominal trauma: Clinical significance and appropriate management

Segmental infarction after blunt trauma is an uncommon type of injury occurring as a result of occlusion of a segmental renal artery. We retrospectively reviewed 32 cases of segmental renal infarction after nonpenetrating injury in order to assess the clinical significance and the most appropriate management. Thirty-five segmental infarcts were demonstrated by contrast medium-enhanced computed tomography (CT), 19 in the left and 16 in the right kidney. Twenty-five of the 35 infarcts (71%) occurred as an isolated renal injury. A distinct upper pole predilection for segmental infarct was observed. Angiography showed an occluded branch vessel without contrast medium extravasation in four cases. None of the 30 surviving patients experienced delayed renal hemorrhage or deterioration of renal function. Only 2 of 24 evaluable patients developed mild diastolic hypertension during follow-up. Our data indicate that segmental renal infarction in the blunt trauma patient, as demonstrated by contrast medium-enhanced CT, should be managed nonoperatively and requires no further evaluation with angiography.     

Pseudoaneurysm and renal arteriovenous fistula after nephrectomy: two cases treated by transcatheter coil embolization

Pseudoaneurysms and arteriovenous fistulas of renal arteries are rare clinical lesions. Invasive renal procedures may lead to pseudoaneurysm or arteriovenous fistulas (AVFs). We report two pseudoaneurysms and arteriovenous fistula cases that were treated by transcatheter embolization with metallic coils. The first case is left main renal artery pseudoaneurysm after nephrectomy in a patient with a solid renal tumor. The second case is right main renal artery AVF with giant pseudoaneurysm after both gunshot injury and nephrectomy. On the basis of color Doppler sonography and computed tomography (CT) findings, cases were diagnosed as pseudoaneurysm after nefrectomy. Contrast-enhanced CT scans showed a hyperdense area within the hematoma consistent with pseudoaneurysm. Endovascular treatment with coil embolization succeeds to total occlusion in renal artery pseudoaneurysm. Delayed hemorrhage related to postnephrectomy may be life-threatening conditions because of diagnostic difficulties. AVF and pseudoaneurysm can be treated safely and successfully by transcatheter arterial embolization.     

Percutaneous Cyanoacrylate Glue Injection into the Renal Pseudoaneurysm to Control Intractable Hematuria After Percutaneous Nephrolithotomy

We report a case of a 43-year-old man who developed intractable hematuria after percutaneous nephrolithotomy. Angiography detected a pseudoaneurysm arising from the lower polar artery; however, embolization could not be performed because of unfavorable vascular anatomy. A percutaneous thrombin injection under ultrasound guidance initially controlled the bleeding, but hematuria subsequently recurred as a result of recanalization of the aneurysm. The case was successfully managed with ultrasound- and fluoroscopic-guided direct injection of cyanoacrylate glue into the pseudoaneurysm.     

Prostate brachytherapy seed embolization to the right renal artery

PurposeWe report three cases of seed embolization to the right renal artery after iodine-125 (I-125) transperineal interstitial permanent prostate brachytherapy.Methods and materialsCase 1: A 65-year-old man presented with right flank and back pain less than 4 months after prostatic seed implantation. CT evaluation for renal stone showed a seed embedded in the lower aspect of the right kidney. Case 2: A 73-year-old man complained of painless hematuria 3 years after prostatic seed brachytherapy. CT and subsequent abdominal angiography showed a seed embolization to a lower branch of the right renal artery. Case 3: An 84-year-old man presented with gross hematuria 7 months after prostatic seed implantation. Excretory urogram and subsequent CT demonstrated the right lower renal seed migration.ResultsProstatic seed embolization to the right renal artery may cause pain and hematuria. This pattern of seed migration may be easily overlooked by imagers because it mimics renal lithiasis on cross-sectional imaging. Knowledge of prior history of permanent interstitial prostate brachytherapy and careful radiologic interpretation may help to achieve the correct diagnosis of rare renal seed migration.ConclusionsWe present an additional atypical site of brachytherapy seed relocation in the right renal artery in 3 patients. This type of migration is probably secondary to pulmonary arteriovenous malformation or right-to-left cardiac shunts. Awareness of the propensity of seeds to dislodge and vigilance in imaging interpretation of prostatic brachytherapy recipients are necessary for the correct diagnosis of seed embolization.     

Grawitz's tumor with arterial hypertension in children. Apropos of a case

A boy of two years has an hematuria which was first related with an hypertensive acute glomerulonephritis. However because of recurrency of the hematuria radiological investigations were performed and a solid tumor of the right kidney was discovered. The arterial hypertension regressed after the right nephrectomy. Pathology demonstrated a tumor of Grawitz which is rare in children and which is seldom associated with an arterial hypertension. We found only five similar cases in the literature. Arterial hypertension can be related either with a compression of the renal artery of with an inadequate secretion of renin by the tumor.     

Massive hemoperitoneum due to ruptured inferior phrenic artery pseudoaneurysm after blunt trauma

There had been no previous reports of ruptured pseudoaneurysm of inferior phrenic artery shortly after blunt abdominal trauma. Traumatic arterial pseudoaneurysms are either iatrogenic or the result of penetrating injuries and one of the sequelae of trauma. Post-traumatic pseudoaneurysm develops at varying time intervals after the initial insult. To our knowledge, this is the first report of massive hemoperitoneum caused by ruptured inferior phrenic artery pseudoaneurysm after blunt trauma. Pseudoaneurysm of inferior phrenic artery in patient with diaphragm injury is potentially a life-threatening condition and requires urgent management. Diagnosis of ruptured inferior phrenic artery pseudoaneurysm is based on clinical assessment combined with radiological investigations. We report a case of ruptured left inferior phrenic artery pseudoaneurysm as one aspect of massive hemoperitoneum caused by blunt abdominal trauma.     

Pseudoaneurysm of the Internal Carotid Artery: Treatment with a Covered Stent

Dissection of the cervical segment of the internal carotid artery may occur spontaneously or after trauma. We report the management of a 53-year-old right-handed man with progressive dizziness and neck pain 6 weeks after a motor vehicle collision. The clinical and neurologic examinations were normal. The CT scan led to the diagnosis of a pseudoaneurysm of the right internal carotid artery near the skull base. We successfully treated this post-traumatic lesion with a covered stent. The patient underwent the endovascular procedure under general anesthesia and transcranial Doppler monitoring. No neurologic event was observed. Obliteration of the pseudoaneurysm with preservation of the carotid artery was achieved. The patient was discharged from the hospital 72 hr later with no complications. Clinical and imaging follow-up at 6 months was unremarkable.     

Traumatic injury of the internal mammary artery: embolization versus surgical and nonoperative management

The purpose of the study was to compare the outcomes, complications, and effectiveness of embolization versus surgical and nonoperative management in patients with injury to the internal mammary artery. Eighteen cases of angiographically proven internal mammary artery injury were identified by a retrospective review. Patient age range was 17–71 years (mean 34 years). Causes of vascular injury were equally divided (9 each) between penetrating and blunt trauma. Type of trauma, associated injury, plain film findings, treatment complications (immediate and delayed), and overall outcomes were assessed. Results of embolization versus surgical and nonoperative management were compared. Angiographic findings included occlusion, active hemorrhage, and pseudoaneurysm of the internal mammary artery. Of the 18 patients studied, 12 underwent embolization; 2 underwent surgical ligation, and 4 were managed by nonoperative observation. No patient died as a direct result of vascular injury; one died of renal failure unrelated to chest trauma and one other died of myocardial contusion. One patient who underwent embolization had delayed bleeding and two patients with conservative management developed a delayed hemothorax. This small series demonstrates that embolotherapy offers an effective, efficient, and safe alternative to conventional surgical management of internal mammary artery injuries. Electronic Publication     

Renal artery pseudoaneurysm following partial nephrectomy treated with stent-graft

Haemorrhagic complications due to pseudoaneurysms of branch arteries can be treated by selective embolisation. Injuries to the main renal artery cannot be treated in this way without sacrificing the kidney. We report the successful percutaneous treatment of a main renal artery pseudoaneurysm with a stent-graft in a patient with a solitary kidney.     

Endovascular treatment of a post-traumatic pseudoaneurysm arising from a ruptured posterior tibial artery with Menox. A case report

Posterior tibial artery pseudoaneurysms are rare and can occur in the setting of trauma. Endovascular treatment of post-traumatic pseudoaneurysms has become a viable less-invasive method particularly in young patients in whom the presence of collaterals guarantees distal vascularization. We report an unusual case of a 16-year- old patient who sustained blunt trauma to his right lower extremity due to a bicycle injury and developed a delayed symptomatic pseudoaneurysm of the posterior tibial artery in the absence of tibia fracture. Superselective endovascular treatment with Ethylene Vinyl Alcohol Copolymer based liquid embolic system (Menox) was successfully performed, achieving exclusion of the pseudoaneurysm with preservation of the remaining vascularization of the lower limb.     

Successful transcatheter arterial embolization for pseudoaneurysm of the deep femoral artery in a patient with presumptive ACTA2-related vasculopathy

ACTA2-related vasculopathy is an autosomal dominant genetic disorder characterized by aortic aneurysms and dissection, and limb artery lesions are rare. We report a case of transcatheter arterial embolization for a pseudoaneurysm of a deep femoral artery in a patient with presumptive ACTA2-related vasculopathy. A 58-year-old woman was presumed to have an ACTA2 mutation based on her history of aortic diseases and family history of ACTA2 mutations. During follow-up, contrast-enhanced computed tomography for aortic diseases revealed occlusion and vessel wall abnormalities of the bilateral deep femoral arteries. Two weeks later, she complained of acute right inguinal pain without any triggering factors, and contrast-enhanced computed tomography revealed a pseudoaneurysm of the right deep femoral artery. Vascular fragility due to ACTA2 mutation was believed to be the cause of the pseudoaneurysm. Transcatheter arterial embolization was successfully performed and no rebleeding occurred during 1.5 years after the transcatheter arterial embolization.     

Traumatic mesenteric bleeding managed solely with transcatheter embolization

We report a rare case of mesenteric bleeding following blunt abdominal trauma successfully treated solely with transcatheter arterial embolization (TAE) of the right colic marginal artery. A 56-year-old woman presented with mesenteric bleeding after being involved in a car accident. Computed tomography (CT) showed a large mesenteric hematoma and hemoperitoneum with no associated major injuries to other organs. There was a pseudoaneurysm with extravasation inside the hematoma. TAE was attempted to control bleeding during the preparation for surgical laparotomy. A superior mesenteric angiogram revealed a right colic marginal artery pseudoaneurysm. After successful TAE with microcoils, the affected colon perfusion was preserved via collateral circulation from the ileocolic artery. No ischemic gastrointestinal complications have occurred, and laparotomy has not been necessary during the 6 months after TAE. In isolated mesenteric injury cases, TAE may be a reasonable alternative to emergency laparotomy.     

Posttraumatic pseudoaneurysm of the posterior cerebral artery

We present the case of a traumatic posterior cerebral artery pseudoaneurysm of a 29-year-old man due to a penetrating stab wound to the brain. The patient was brought to the emergency room in coma. The neurological examination revealed a Glasgow Coma Scale Score of 8 and left hemiplegy. The initial CT scan showed right temporal lobe haemorrhage with penetration in the lateral ventricle and subarachnoid haemorrhage. The cerebral angiography performed after three weeks, revealed a high PCA pseudoaneurysm. After surgery, a pseudoaneurysm was demonstrated in the histological study.     

Transcatheter embolization of biopsy-related vascular injuries in renal allografts. Long-term technical,clinical and biochemical results

Purpose:
Biopsy-related vascular injuries in renal transplants are rare, but they can lead to dramatic clinical symptoms prompting immediate treatment. Transcatheter embolization is a known minimally invasive technique to treat some form of arterial bleeding. This study evaluated the efficacy of this technique in iatrogenic biopsy-related vascular lesions in renal allografts. Material and Methods:
Between 1993 and 2001, 13 patients were treated by percutaneous transcatheter intervention. Indications for embolization were hypovolemic shock due to perinephric hematoma ( n  = 5), persistent macroscopic hematuria ( n  = 7) and an asymptomatic large intrarenal pseudoaneurysm in 1 patient. Selective angiography revealed an arteriovenous fistula ( n  = 7), a pseudoaneurysm ( n  = 6), and perinephric contrast extravasation ( n  = 4). Results:
In all patients, successful embolization of the feeding artery could be performed; in 11 patients it was performed in one session, in 2 patients an additional session was needed. In 1 patient thrombosis of a segmental artery occurred immediately after embolization, but was successfully treated by short-term in situ thrombolysis. Clinical symptoms disappeared in all patients. Serum creatinine levels (determined 30 and 60 days after embolization, compared to the level before embolization) decreased significantly in 10 patients; a progressive deterioration of the renal function was observed in 3 patients. Conclusions:
Transcatheter embolization is a safe and effective endovascular technique to treat biopsy-related vascular injuries in renal transplants. In the vast majority of cases an immediate clinical success and significant benefit in renal function can be obtained and the longevity of the allograft after successful embolization mainly depends on the natural (medical) outcome.     

动脉栓塞治疗男性先天性盆腔动静脉畸形一例

报道1例长期原因不明肉眼血尿多囊肾患者。影像检查显示两侧盆区动静脉畸形(CPAVM)。经超选择栓塞髂内动脉8支分支血尿治愈,随访6个月,血尿无复发。文献复习表明CPAVM发病甚少,形态多样。介入治疗是有效的微创方法。     

Imaging of renal trauma

Trauma is a major cause of death and disability and renal injuries occur in up to 10% of patients with significant blunt abdominal trauma. Patients with penetrating trauma and hematuria, blunt trauma with shock and hematuria, or gross hematuria warrant imaging of the urinary tract specifically and CT is the preferred modality. If there is significant perinephric fluid, especially medially, or deep laceration, delayed images should be obtained to evaluate for urinary extravasation. Most renal injuries are minor, including contusions, subcapsular and perinephric hematoma, and superficial lacerations. More significant injuries include deep lacerations, shattered kidney, active hemorrhage, infarctions, and vascular pedicle and UPJ injuries. These injuries are more likely to need surgery or have delayed complications but may still often be managed conservatively. The presence of urinary extravasation and large devitalized areas of renal parenchyma, especially with associated injuries of intraperitoneal organs, is particularly prone to complication and usually requires surgery. Active hemorrhage should be recognized because it often indicates a need for urgent surgery or embolization to prevent exsanguination.     

Pseudoaneurysm of the renal interlobar artery in Behçet's disease

Beh?et's disease is a rare clinical event characterized by recurrent oral and genital ulcers, and iridocyclitis. Vascular involvement is a rare but serious form of the disease. We present a case of renal interlobar artery pseudoaneurysm occurring in a 20-year-old male patient with a 5-year history of Beh?et's disease, who had been admitted because of right flank pain. Findings obtained on abdominal ultrasonography, abdominal computed tomography, and renal angiography confirmed a right renal pseudoaneurysm and subcapsular hematoma.