Digital radiograph (DR) guided bedside IVC filter placements in patients with intracranial pressure monitors

PurposeThe purpose of this study is to report a single center experience with portable digital radiographically (DR) guided bedside IVC filters placed in intensive care unit (ICU) patients with high ICP and elevated head of bed (HOB).Materials and methodsA retrospective chart review was conducted on all bedside IVC filters placed from January 1, 2010 to September 16, 2020. Patients with high ICP and elevated head of bed requirements were included. Charts were reviewed for filter type, common femoral vein (CFV) access, filter location, pre procedure imaging, pre and post filter ICPs, glascow coma scale, number of radiographs taken, and filter removal. ICPs were obtained 1 ​h prior to procedure and 2 ​h post procedure and analyzed with a paired T test.Filters were placed by reviewing prior CT scan for IVC size, caval variants, renal and iliac veins and vertebral body landmarks. Then, CFV access was obtained and a Bentson wire was advanced 30–40 ​cm. A radiograph was used to confirm adequate position of the of the wire. The filter sheath was advanced and serial radiographs were used to position the filter sheath at the final predetermined position below the renal veins and above the iliac bifurcation. The filter was deployed, and a radiograph was obtained to confirm filter positioning.ResultsA total of 9 DR guided bedside IVC filters were placed (4 Denali, 3 Option Elite, 2 Celect). Indications included prophylactic placement (n ​= ​8) and acute DVT (n ​= ​1). The average patient age was 35.8 years (range: 18–56 years) CT abdomen and pelvis was used to assess for the level of renal veins in all patients (n ​= ​9). No caval variants were encountered on pre-procedural planning. The average pre, intraprocedural, and post procedure intracranial pressure was 16 ​mmHg, 13 ​mmHg, and 16 ​mmHg, respectively. Confirmation of placement after final placement was available in 7 patients (4 DR, 2 CT and one fluoroscopic examination). Two non-procedural related deaths occurred.Technical success, defined as successful placement of IVC filter at the predetermined level, was achieved in 100% of patients (n ​= ​9). The right CFV was used in most patients (n ​= ​7). The left CFV was used for access in two patients due to right CFV thrombus (n ​= ​1) and existing right femoral venous central line (n ​= ​1). The average number of radiographs taken was 5.8 (range 4–9). In all cases, filters were placed below the level of the lowest renal vein (n ​= ​9). A comparison of pre, during and post intervention ICP pressures is shown in table, 2. No differences between pre and post filter ICP was noted (p ​= ​0.77). Three filters were later removed. One minor complication was reported, which was filter tilt (23%) in an Option filter.ConclusionBedside IVC filters can be safely placed in patients with head trauma and high ICP who are unable to lay supine using portable DR guidance with a high rate of technical success and minimal complications.     

Inferior Vena Cava Filters: Aligning Practice With Evidence to Improve Patient Outcomes

BackgroundDespite indications for the removal of temporary inferior vena cava (IVC) filters, many filters are unintentionally left in place, predisposing patients to adverse outcomes.ObjectiveThis quality improvement study set out to determine the impact of an IVC filter retrieval protocol on filter retrieval rates and patients lost to follow-up for patients who had undergone placement of a temporary IVC filter.MethodsFollowing a quasi-experimental design, data of all consecutive patients who underwent insertion of a temporary IVC filter for a period of 24-month preprotocol and 12-month postprotocol were compared.ResultsFilter retrieval rates of eligible filters increased from 64.2% to 100%; patients lost to follow-up decreased from 35.9% to 0% (p < .01, both outcomes).ConclusionAdoption of a comprehensive IVC filter protocol by the service that implants these devices can improve filter retrieval rates and decrease patients being lost to follow-up.     

Endovascular therapy for floating thrombus in the inferior vena cava

ObjectiveWe aimed to summarize the clinical characteristics of floating thrombus in the inferior vena cava (IVC).MethodsFrom January 2014 to June 2019, four patients with floating thrombus in the IVC were admitted to our hospital and underwent intracavitary therapy. Diagnosis, therapy, and clinical characteristics of floating thrombus were summarized.ResultsThree patients presented with pulmonary embolism. Three of the patients had a floating thrombus discovered by inferior venacavography and one was found by contrast-enhanced computed tomography. Two patients had deep venous thrombosis in the lower extremities. One patient had a double IVC, one had left iliac vein compression syndrome, and one had right renal phlebothrombosis. The four patients underwent implantation of a temporary IVC filter and were treated with anti-coagulation, debulking, and thrombolysis. All four patients achieved satisfactory results.ConclusionsFloating thrombus in the IVC is often caused by spread of branch vein thrombosis, and is more likely to lead to pulmonary embolism. Anti-coagulant therapy and debulking under the protection of filters can achieve satisfactory clinical results.     

可取出式下腔静脉滤器的实验研究

目的探讨一种可取出式下腔静脉滤器的可回收性和安全性。方法22只猪分为A(n=13)、B(n=9)两组,A组用圈套器经股静脉取出滤器,B组以及A组无法圈套取出滤器的剖腹取出滤器。通过下腔静脉造影、不同时间段回收滤器、下腔静脉大体观察和显微镜检查评价滤器的可回收性能和下腔静脉内膜改变。结果所有滤器均置入成功,观察期内没有出现滤器移位。7、10、12天可安全回收滤器,2周后滤器无法取出。滤器置入后7天内膜开始包绕滤器,10、12天内膜增生为轻度增生;14、16、20天为中度增生;30~103天为显著增生。结论这款可取出式下腔静脉滤器置入和回收简便,动物实验的最大安全可回收时间为10天。     

Successful endovascular treatment with long-term antibiotic therapy for infectious pseudoaneurysm due to Klebsiella pneumoniae: A case report

BACKGROUNDInfectious common femoral artery pseudoaneurysm caused by Klebsiella pulmonary infection is a relatively infrequent entity but is potentially life and limb threatening. The management of infectious pseudoaneurysm remains controversial.CASE SUMMARYWe reported a 79-year-old man with previous Klebsiella pneumoniae pulmonary infection and multiple comorbidities who presented with a progressive pulsate mass at the right groin and with right lower limb pain. Computed tomography angiography showed a 6 cm × 6 cm × 9 cm pseudoaneurysm of the right common femoral artery accompanied by occlusion of the right superficial femoral artery and deep femoral artery. He underwent endovascular treatment (EVT) with stent–graft, and etiology of infectious pseudoaneurysm was confirmed. Then, 3-mo antibiotic therapy was given. One-year follow-up showed the stent–graft was patent and complete removal of surrounding hematoma.CONCLUSIONThe femoral artery pseudoaneurysm can be caused by Klebsiella pneumoniae deriving from the pulmonary infection. Moreover, this unusual case highlights the use of EVT and prolonged antibiotic therapy for infectious pseudoaneurysm.     

CT IVC venogram: normalized quantitative criteria for patency and thrombosis

Purpose

Establish normal attenuation ratios for vein to artery on CT IVC venogram and determine a vascular attenuation ratio diagnostic of thrombus.

Methods

This retrospective, HIPAA-compliant study included 56 CT IVC venograms. Images were reviewed for the presence of femoral vein or IVC thrombus. Attenuation ratios for each vein and its corresponding artery were calculated by two observers and averaged in four venous stations (right and left femoral veins, and IVC at the confluence of the iliac veins and at the left renal vein). The reference standard for the absence of thrombus was clinical follow-up and for the presence of thrombus it was thrombectomy or catheter venogram. Receiver operating characteristic (ROC) analysis was performed using ratios from one venous station and threshold for thrombus was determined using the Youden’s index.

Results

36 of 56 CTs demonstrated no thrombus. 20 CTs demonstrated thrombus, confirmed in eight patients. For CTs with no thrombus, median ratios among the venous stations ranged from 0.89 (IQR 0.83–0.93) to 0.91 (IQR 0.86–0.94). ROC analysis of ratios from a single representative station (left femoral vein, n = 4 confirmed clots) demonstrated an area under the curve (AUC) of 0.994 (p = 0.001) and a threshold of 0.67 for diagnosing thrombus [sensitivity 100% (95% CI 39.76–100%), specificity 97.5% (86.84–99.94%)].

Conclusion

The normal attenuation ratio of vein to artery in the absence of venous thrombus on a 3-min delay CT IVC venogram is approximately 0.91. A ratio less than 0.67 is highly suggestive of thrombus.

     

Using inferior vena cava filters to prevent pulmonary embolism

OBJECTIVE

To review the evidence for using inferior vena cava (IVC) filters to prevent pulmonary embolism (PE) in high-risk patients.

QUALITY OF EVIDENCE

Ovid MEDLINE was searched from 1966 to 2006 for all English-language papers on IVC filters. Evidence was graded according to the 3-level classification system. Most evidence found was level II.

MAIN MESSAGE

Inferior vena cava filters are used to prevent PE in patients with contraindications to, complications of, or failure of anticoagulation therapy and patients with extensive free-floating thrombi or residual thrombi following massive PE. Current evidence indicates that IVC filters are largely effective; breakthrough PE occurs in only 0% to 6.2% of cases. Contraindications to implantation of IVC filters include lack of venous access, caval occlusion, uncorrectable coagulopathy, and sepsis. Complications include misplacement or embolization of the filter, vascular injury or thrombosis, pneumothorax, and air emboli. Recurrent PE, IVC thrombosis, filter migration, filter fracture, or penetration of the caval wall sometimes occur with long-term use.

CONCLUSION

When used appropriately, IVC filters are a safe and effective method of preventing PE. Using retrievable filters might reduce long-term complications.     

Hemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis: A case report and review of literature

BACKGROUNDHemosuccus pancreaticus is a very rare but severe form of upper gastrointestinal hemorrhage. The most common etiology is peripancreatic pseudoaneurysm secondary to chronic pancreatitis. Due to the rarity of gastroduodenal artery pseudoaneurysms, most of the current literature consists of case reports. Limited knowledge about the disease causes diagnostic difficulty.CASE SUMMARYA 39-year-old man with a previous history of chronic pancreatitis was hospitalized due to hematemesis and melena for 2 wk, with a new episode lasting 1 d. Two weeks prior, the patient had visited a local hospital for repeated hematemesis and melena. Esophagogastroduodenoscopy indicated hemorrhage in the descending duodenum. The patient was discharged after the bleeding stopped, but hematemesis and hematochezia recurred. Bedside esophago-gastroduodenoscopy showed no obvious bleeding lesion. On admission to our hospital, he had hematemesis, hematochezia, left middle and upper abdominal pain, severe anemia, and elevated blood amylase. After admission, intermittent hematochezia was observed. Abdominal contrast-enhanced computed tomography revealed a pseudoaneurysm in the pancreas head. Angiography confirmed the diagnosis of gastroduodenal artery pseudoaneurysm. The pseudoaneurysm was successfully embolized with a coil and cyanoacrylate. No bleeding was observed after the operation. After discharge from the hospital, a telephone follow-up showed no further bleeding signs.CONCLUSIONHemosuccus pancreaticus caused by gastroduodenal artery pseudoaneurysm associated with chronic pancreatitis is very rare. This diagnosis should be considered when upper gastrointestinal bleeding and abdominal pain are intermittent. Abdominal enhanced computed tomography and angiography are important for diagnosis and treatment.     

Comparative outcomes of Inferior Vena Cava filters placed at bedside using digital radiography versus conventional fluoroscopy

PurposeTo retrospectively assess the outcomes of Inferior Vena Cava (IVC) filters placed in critically ill patients in the ICU at bedside using digital radiograph (DR) guidance with previous cross-sectional imaging for planning, compared to IVC filters placed by conventional fluoroscopy (CF).Method and materialsThe cohort consisted of 129 IVC filter placements; 48 placed at bedside and 81 placed conventionally from July 2015 to September 2016. Patient demographics, indication, radiation exposures, access site, procedural duration, dwell time, and complications were identified by the EMR. IVC Filter positioning with measurements of tip to renal vein distance and lateral filter tilt were performed when cavograms or post placement CTs were available for review. Statistical analysis was performed using Stata IC 11.2.ResultsTechnical success of the procedure was 100% in both groups. Procedural duration was longer at the bedside lasting 14.5 +/- 10.2 versus 6.7 +/- 6.0 ​min (p<0.0001). The bedside DR group had a median radiation exposure of 25 ​mGy (15–35) and the CF group had mean radiation exposure of 256.94 ​mGy +/- 158.6. There was no significant difference in distance of IVC tip to renal vein (p=0.31), mispositioning (p=0.59), degree of filter tilt (p=0.33), or rate of complications (p=0.65) between the two groups.ConclusionIVCF placement at the bedside using DR is comparable to CF with no statistical difference in outcomes based on IVCF positioning, degree of lateral tilt or removal issues. It decreased radiation dose, but with overall increased procedural time.     

Surgery for hepatocellular carcinoma with tumor thrombosis in inferior vena cava: A case report

BACKGROUNDHepatocellular carcinoma (HCC) accompanied by a tumor thrombus is very common. However, the treatment strategy is controversial and varies by the location of the thrombus.CASE SUMMARYWe report herein a case of HCC with a tumor thrombus in the suprahepatic inferior vena cava (IVC), which was successfully treated by hepatectomy combined with thrombectomy following sorafenib chemotherapy. A 47-year-old woman with chronic hepatitis was diagnosed with HCC. Computed tomography and magnetic resonance imaging showed that the tumor lesion was located in the right half of the liver, and a tumor thrombus was detected in the suprahepatic IVC near the right atrium. After multi-departmental discussion and patient informed consent, right major hepatectomy and total removal of the tumor thrombus were successfully performed under cardiopulmonary bypass. There were no serious complications after surgery. Following sorafenib treatment, no recurrence has been detected so far (11 mo later).CONCLUSIONSurgical treatment followed by adjuvant sorafenib therapy might be an acceptable choice for HCC patients with tumor thrombosis in the IVC.     

Endometrial stromal sarcoma extending to the pulmonary artery: A rare case report

BACKGROUNDEndometrial stromal sarcoma (ESS) is a rare malignant mesenchymal tumor. Early in the disease, the findings on magnetic resonance imaging are similar to those of leiomyoma. When the lesion involves both vascular and cardiac tissue, it might be misdiagnosed as intravenous leiomyomatosis, which is not common in the clinic. CASE SUMMARYWe present the case of a 34-year-old female patient with tumor embolus, which extended from the right iliac vein and ovarian vein to the inferior vena cava (IVC), and then to the right atrium and right ventricle, and finally protruded into the pulmonary artery. The patient had undergone a hystero-myomectomy 7 years previously. Based on the findings of the imaging examinations, the diagnosis of intravenous leiomyomatosis was considered preoperatively. The patient then underwent complete resection of the endovascular and intracardiac tumor embolus. The postoperative pathology results confirmed metastatic ESS with endovascular and intracardiac involvement. The patient was discharged from hospital in good condition, and there was no sign of recurrence 5 mo after the operation.CONCLUSIONExtending from the iliac vein and ovarian vein to the IVC, this metastatic ESS invaded both vascular and cardiac tissues. For patients with ESS involving vascular and cardiac tissues, pathological examinations are essential for the differential diagnosis, such as intravenous leiomyomatosis. In addition, due to the high recurrence rate of ESS, long-term and close follow-up evaluation is necessary.     

猪腹主动脉下端及髂总动脉不同程度狭窄引起股总动脉血流动力学变化的比较

目的 探讨腹主动脉下端、髂总动脉不同程度狭窄引起股总动脉血流动力学变化的差异.方法 幼年家猪6只,利用血管夹夹闭腹主动脉下端、左侧髂总动脉侧壁依次造成1/3、1/2、3/4管腔狭窄,记录对应股总动脉血流频谱波形,测算PSV、Vmin、S/D、D/S.分析所有实验数据并进行统计学处理,观察血流参数与狭窄程度的相关性,并比较腹主动脉下端、髂总动脉相同程度狭窄引起股总动脉血流动力学变化的差异.结果 超过1/2管腔狭窄时反向波消失,出现持续正向波.PSV与狭窄程度呈线性负相关,D/S在管腔狭窄超过1/3后与狭窄程度呈线性正相关.左侧髂总动脉狭窄时,右侧股总动脉血流参数无显著性变化.髂总动脉狭窄较同等程度腹主动脉狭窄引起股总动脉血流动力学改变显著.结论 根据一侧股总动脉血流频谱波形的改变可以推断其上游存在狭窄性病变和反应狭窄下游有效循环血容量的情况,离心脏越远处的分支动脉管腔狭窄引起其下游血流动力学改变越显著.     

应用段动脉阻力指数早期评价小儿肾积水手术后疗效

目的 探讨应用段动脉阻力指数(RI)、肾实质厚度(RPT)早期评价小儿肾积水手术疗效的临床可行性。方法 对32例接受手术治疗的单侧肾积水患儿于术前、术后2个月进行静脉尿路造影(IVU)检查,确定肾积水程度,术后恢复情况;手术前及手术后9天、2个月、6个月、1年分别进行彩超检查,测量患侧肾脏RPT、段动脉RI,并进行比较分析。结果 32例患儿中,其中14例为中度肾积水(中度肾积水组),18例为重度肾积水(重度肾积水组),术后2个月复查IVU均提示梗阻解除;患侧RPT均明显低于健侧(P均<0.01),且重度肾积水组明显低于中度肾积水组(P<0.01);中、重度肾积水组患侧肾段动脉RI均高于健侧(P均<0.01),重度肾积水组高于中度重度肾积水组(P<0.05);术后9天患侧RPT无明显变化(P均>0.05),中、重度组间差异有统计学意义(P<0.01);术后9天患侧肾段动脉RI均较术前减低(P均<0.05),中、重度肾积水组间患侧肾术后段动脉RI差异无统计学意义(P均>0.05)。结论 段动脉RI术后9天较术前减低,间接提示小儿肾积水患侧肾脏梗阻解除,可作为一种早期评价小儿肾积水手术后疗效的方法。     

超声引导经皮穿刺下腔静脉滤器置入术的初步研究

目的 探讨超声引导经皮穿刺下腔静脉滤器置入(IVCFI)术的可行性、安全性和临床实用价值。方法 在彩色多普勒血流显像(CDFI)引导下，对连续收治的31例下肢深静脉血栓患者行经皮穿刺IVCFI术。结果 31例患者术前CDFI检查下腔静脉、肾静脉及其最低人121显示清晰，下腔静脉平均内径19．7mm，无变异和血栓，符合所选滤器置入要求。在CDFI引导下，置入Vena Teeh永久型滤器31只，其中经右股静脉置入20只，左股静脉置入11只。术后CDFI和X线腹部平片均证实滤器置入位置正确，张开完全，无并发症，技术成功率为100％。随访结果，栓子俘获率29％，滤器无变形和移位，局部无血栓形成，也无滤器置入后肺血栓栓塞临床病例发生。结论 超声引导是经皮穿刺IVCFI术安全、可靠的方法，同时也是简便易行、无污染、费用低廉的实用方法。     

Delayed pseudoaneurysm formation of the carotid artery following the oral cavity injury in a child: A case report

BACKGROUNDAn impalement injury of the oral cavity is a common traumatic injury in children. In most cases, it is not accompanied by sequelae, but if foreign body residues are not found due to a minor injury, they may result in inflammatory responses and delayed vascular injuries in the surrounding tissues. Without early diagnosis and appropriate initial management, residual foreign bodies can cause serious complications and even mortality in some cases. CASE SUMMARYA 9-year-old boy suffered an intra-oral injury by a wooden chopstick, and the patient was discharged from the hospital after receiving conservative treatment for the injury. However, the patient was readmitted to the hospital due to intra-oral bleeding, and since neck hematoma and right internal carotid artery pseudoaneurysm formation were detected on computed tomography, emergency surgery was performed. A remnant fragment of a wooden chopstick was found during the operation, and a delayed rupture of the internal carotid artery caused by the foreign body was also found.CONCLUSIONThe failure of early detection and diagnosis of a residual foreign body may result in delayed vascular rupture.     

Intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis: A case report

ObjectiveWe describe a case of intracranial and extracranial multiple arterial dissecting aneurysms in rheumatoid arthritis (RA).Case PresentationA 29-year-old man with a medical history of RA since 18 years of age was admitted to our hospital for vomiting, dysarthria, and conscious disturbance. At 23, he underwent ligation of the left internal carotid artery (ICA) with superficial temporal artery to middle cerebral artery anastomosis because of acute infarct of the left hemisphere caused by arterial dissection of the left ICA. During the current admission, computed tomography (CT) revealed subarachnoid hemorrhage, and digital subtraction angiography (DSA) demonstrated dissecting aneurysms of the left intracranial vertebral artery (VA) and right extracranial VA. We diagnosed him with a ruptured dissecting aneurysm of the left intracranial VA and performed endovascular parent artery occlusion on the left VA. For the right unruptured VA aneurysm, we performed coil embolization simultaneously. At 2 weeks after the endovascular treatment, follow-up DSA revealed that multiple de novo dissecting aneurysms developed on the origin of the left VA and left and right internal thoracic arteries. Those aneurysms were treated with coil embolization. Other remaining aneurysms on the left thyrocervical trunk, right transverse cervical artery, and both common iliac arteries were treated by conservative therapy. While continuing medical treatment for RA, the patient recovered and was discharged to a rehabilitation hospital.ConclusionConsidering that RA-induced vasculitis can be a potential risk of vascular complications including multiple arterial dissections, physicians should carefully perform endovascular interventional procedures for patients with long-term RA.     

Right Hepatic Artery Pseudoaneurysm Complicating Acute Pancreatitis: A Case Report

Objective

To report a rare case of right hepatic artery pseudoaneurysm complicating acute pancreatitis based upon imaging findings obtained before and after the development of pseudoaneurysm.

Clinical Presentation and Intervention

A 32-year-old male with a history of acute pancreatitis 1 year prior was readmitted for acute pancreatitis. Computed tomography (CT) and angiography after admission revealed pseudoaneurysm of the right hepatic artery. Transcatheter arterial embolization with coils was used to successfully treat the pseudoaneurysm. A CT and angiography 1 year earlier did not reveal any pseudoaneurysm.

Conclusion

This patient with a rare right hepatic artery pseudoaneurysm complicating acute pancreatitis was successfully treated with coil embolization.Key Words: Pseudoaneurysm, Right hepatic artery, Acute pancreatitis, Angiography     

可回收式滤器在静脉血栓-栓塞病变介入治疗中的应用

目的 评价两种可回收式滤器在静脉血栓-栓塞病变介入治疗中的有效性及安全性.方法 100例急性和亚急性肢体深静脉血栓形成(DVT)患者(其中肺栓塞62例)接受经导管局部溶栓的同时,置入可回收式滤器(OptEase 72例,Tulip 28例).对局部溶栓效果较好者考虑进行滤器回收.结果 两种滤器均成功置入下腔静脉(98例)和上腔静脉(2例),无滤器移位.除1例滤器回收失败外,24枚滤器置入后7～50天(平均18.0天)经颈静脉(Tulip滤器15例)或经股静脉(OptEase滤器9例)回收成功.患者住院期间均未发生肺栓塞加重.10例穿刺部位出现较大血肿,2例发生脑出血,4例出现肉眼血尿.结论 可回收式滤器可安全用于DVT的介入治疗,防止致命性肺栓塞的发生;回收简便、安全.     

Emergency Point-of-Care Ultrasound Diagnosis of a Femoral Artery Pseudoaneurysm

BackgroundIatrogenic femoral artery pseudoaneurysm formation after intervention of the femoral artery may present weeks after intervention. We report a case of a patient with delayed pseudoaneurysm diagnosis that was ultimately diagnosed with bedside ultrasound. Importantly, our case demonstrates a patient who had a left-sided atherectomy and angioplasty with microcatheter access of the right femoral artery.Case ReportA 68-year-old man with multiple comorbidities presented to the Emergency Department (ED) with right inguinal pain, swelling, and overlying skin changes 17 days after an interventional radiology-guided left-sided femoral artery atherectomy and angioplasty. His first postoperative ED visit at an outside hospital led to the diagnosis of a hematoma vs. abscess, with attempted bedside drainage. On presentation to our ED, a bedside ultrasound confirmed arterial pseudoaneurysm formation of the right femoral artery.Why Should an Emergency Physician Be Aware of This?In patients presenting with the constellation of symptoms after arterial site intervention of either side, iatrogenic pseudoaneurysm should be in the differential. Although the patient had atherectomy and angioplasty of the left femoral artery, it is important to highlight that both femoral arteries were accessed during intervention, and thus, both sites are at risk for pseudoaneurysm formation. Emergency sonography can be a useful tool to diagnose, expedite treatment, and avoid potentially harmful invasive procedures in patients presenting with pain and swelling after arterial site intervention.     

Bleeding of two lumbar arteries caused by one puncture following percutaneous nephrolithotomy: A case report

BACKGROUNDLumbar artery bleeding is an uncommon complication of percutaneous nephrolithotomy (PCNL). This report presents a rare complication where two lumbar arteries were injured by a single puncture following PCNL. Only scarce reports of this complication have been reported.CASE SUMMARYA 24-year-old man presented with a 2.2 cm right renal calculus, which was managed by PCNL. During nephrostomy tube removal on the 6^th postoperative day, intense bleeding was observed in the fistula and the catheter. Renal angiography was undertaken immediately; however, an initial selective renal angiogram revealed no evidence of renal vascular injury. One of these injuries involved a pseudoaneurysm from a peripheral branch in the first right lumbar artery, while the other involved an arteriovenous fistula from a peripheral branch in the second right lumbar artery. Subsequently, coil embolization was performed successfully.CONCLUSIONThis case is being reported to inform clinicians that lumbar artery damage is one of the causes of severe bleeding after PCNL and could involve damage of more than one artery.