Iatrogenic Renal Artery Injury in 90 Cases: Arteriographic Findings and Outcomes after Embolization for Bleeding.

PURPOSE: To evaluate differences in arteriographic findings and outcomes after embolization among patients with a suspected iatrogenic renal arterial injury (IRAI). MATERIALS AND METHODS: Patients at the authors' institution who underwent renal arteriography for suspected IRAIs after partial nephrectomy, biopsy, or percutaneous access over a 20-year period were included. Records, imaging, and outcomes were reviewed. Data analysis was performed using the Fisher exact or Kruskal-Wallis test. RESULTS: Ninety arteriograms were performed on 83 patients after partial nephrectomy (n = 32), biopsy (n = 27), or percutaneous access (n = 24), including for nephrostomy/ureterostomy and stone removal. The median number of days between the index procedure and arteriogram was highest (15 days) after partial nephrectomy and lowest (5 days) after biopsy (P = .0001). Embolization was performed during 76% of arteriograms. If prearteriographic imaging showed positive results for IRAIs, embolization was performed in 67% versus 33% if imaging showed negative results (P = .005). The transfusion rate was higher after biopsy than after partial nephrectomy or percutaneous access (P = .002). Acute kidney injury after arteriogram occurred in 7% of patients; however, all returned to baseline by 1 week. CONCLUSIONS: Despite the different mechanism of IRAIs in partial nephrectomy, biopsy, and percutaneous access, arteriographic findings and outcomes were overall similar among groups. Prearteriographic imaging can help identify IRAIs but cannot supersede the clinical judgment regarding indication for embolization. IRAIs can present acutely or after a long interim, although patients who underwent biopsy presented earlier and more frequently required a blood transfusion. IRAIs can be treated with embolization without permanent deleterious effects on renal function.

Management of Renal Artery-Inferior Vena Cava Fistula Following Nephrectomy for Penetrating Trauma.

Background: Renal artery to inferior vena cava fistula is a rare event postnephrectomy. We report a case of an adult male in whom a renal artery to inferior vena cava fistula was detected on non-invasive studies following nephrectomy for penetrating trauma. Case Report: A fistula between the right renal artery and inferior vena cava was confirmed with diagnostic angiography. The fistula was successfully embolized using microcoils. Discussion: This case highlights the importance of exploring retroperitoneal hematomas secondary to penetrating trauma.

Post-Traumatic Arteriovenous Fistula of Left Renal Vessels: Case Report of a Silent Complication for 23 Years.

Abdominal trauma leads rarely to severe renal injury such as acquired arterioveinous fistula. Here, we present the case of a 46-year-old man with a history of suicide attempt by a gunshot in the abdomen. At that time, explorative laparotomy was unremarkable. He consulted 23 years later for chronic left lumbar pain and was diagnosed with an arterioveinous fistula of left renal vessels with a-10-cm aneurysm of the left renal artery. We performed a left nephrectomy and endovascular clamping was the best option to manage this giant aneurysm in a hostile abdomen.

[Treatment of Renal Artery Perforation with Covered Stent after Percutaneous Biopsy of Pancreatic Head]. / Behandlung einer Nierenarterienperforation mit gecovertem Stent nach perkutaner Pankreaskopfbiopsie.

HISTORY AND CLINICAL FINDING: In a 67-year-old female patient with upper abdominal pain, computed tomography showed a partly calcified swelling of the pancreatic head and wall thickening of the duodenum. EXAMINATIONS: Inpatient physical examination findings were normal. Laboratory showed increased pancreatic enzymes (amylase 210 U/l [Standard range: 28-100 U/l], lipase 2115 U/l [Standard range: 23-300 U/l]) and inflammation values (CRP 11.7 mg/l [Standard range: < 5.0 mg/l]), otherwise largely normal laboratory parameters. In the esophago-gastro-duodenoscopy, biopsy of swollen, partly stenosing mucous membrane areas in the duodenum was performed. DIAGNOSIS: Histology revealed partial erosive duodenitis, no evidence of a malignant tumor. If chronic calcifying pancreatitis was suspected, a sonographically guided percutaneous biopsy of the pancreatic head was performed to exclude a tumor. TREATMENT AND COURSE: Post-biopsy, the patient developed abdominal pain and temporary circulatory instability with nausea/vomiting and a drop in Hb to 7.5 g/dl [Standard range: 12.3-15.3 g/dl]. The sonographic suspicion of a retroperitoneal hematoma was confirmed by computed tomography. The cause was a haemorrhage from a renal artery perforation on the right side, which could be stopped by immediate angiographic intervention with a covered stent. CONCLUSION: After percutaneous biopsy, vascular perforation must always be considered. Computed tomography provides a reliable and quick diagnosis. Minimally invasive percutaneous insertion of a covered stent is the therapy of choice in the case of a renal artery accessible to stents.

Early Transplant Arteriopathy in Kidney Transplantation.

BACKGROUND: Early dysfunction of renal allografts may be associated with vascular injury, which raises the specter of active rejection processes that require medical intervention. In our practice, we have encountered patients who present with delayed graft function and demonstrate a unique pattern of endothelial cell injury that raises concern for rejection in their biopsy. Therefore, we sought to systematically determine the biopsy characteristics and outcome of these patients. METHODS: During a 17-year period at the University of Washington in Seattle, United States, we identified 24 cases of a distinct arterial vasculopathy presenting in the first year posttransplantation. This early transplant arteriopathy (ETA) is characterized by endothelial cell swelling and intimal edema but without the intimal arteritis that defines vascular rejection. RESULTS: Approximately 1% of transplant biopsies during the study period showed ETA, almost all of which were in deceased donor organs (96%), and most presented with delayed graft function (54%) or increased serum creatinine (38%) soon after transplantation (median 13 days; range, 5-139). In this study, 77% of patients were managed expectantly, with only 2 patients (7.6%) subsequently developing acute vascular rejection. Except for 1 patient who died, all patients had functioning allografts at 1 year follow-up. CONCLUSION: Recognizing ETA and distinguishing it from vascular rejection is important to prevent over-treatment because most patients appear to recover allograft function rapidly with expectant management.

Epidemiology and management of isolated blunt renal artery injuries.

BACKGROUND: Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade. METHODS: Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI. RESULTS: During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting. CONCLUSION: Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.

Spontaneous rupture of a renal artery pseudoaneurysm in a hemodialysis patient: A case report.

RATIONALE: Renal artery pseudoaneurysm is a rare vascular lesion usually caused by trauma or percutaneous urological procedures. Spontaneous rupture of pseudoaneurysms without predisposing events, especially in hemodialysis patients, has rarely been reported. PATIENT CONCERNS: A 25-year-old man receiving maintenance hemodialysis visited the emergency room because of sudden severe right flank pain. He had no history of trauma or urological procedures except for a left renal biopsy to diagnose Alport syndrome 10 years prior. DIAGNOSIS: Contrast-enhanced computed tomography revealed a right perirenal hematoma with pseudoaneurysms. INTERVENTIONS: On renal angiography, multiple pseudoaneurysms were observed in the right renal artery branches and embolization was performed. OUTCOMES: Post-angiography showed no pseudoaneurysms. His abdominal pain improved, and he was discharged 2 weeks after embolization. LESSONS: When maintenance dialysis patients complain of severe abdominal pain, spontaneous rupture of a renal pseudoaneurysm should be considered as a differential diagnosis, even if the patient has no history of trauma or previous urological procedures.

Horseshoe Kidney Blunt Trauma With Double Laceration: Endovascular Management.

A 78-year-old male patient was admitted to our hospital after abdominal trauma. Contrast-enhanced computed tomography (CT) scan demonstrated a horseshoe kidney with a perinephric hematoma and evidence of arterial hemorrhage. An anomalous renal arterial anatomy was noted as well, with a renal artery originating from the left common iliac artery. He was successfully treated via an endovascular approach. Varying forms of vascularization may complicate angiographic treatment of patients with abdominal trauma in a setting of kidney anomalies. Obtaining and evaluating contrast-enhanced CT angiography can identify anomalous vessels and can be invaluable when deciding on the most appropriate interventional approach.

Management of Complex Traumatic Renal Artery-Inferior Vena Cava Fistula: A Case Report and Review of the Literature.

BACKGROUND: Renal artery-inferior vena cava (IVC) fistula is usually caused by penetrating injury to the back. However, it is a very rarely reported entity with only 20 cases reported in the literature. They may present acutely with hemodynamic instability or chronically as congestive heart failure. A thorough examination and adequate imaging are required to avoid missing such injuries. CASE PRESENTATION: A 28-year-old gentleman presented after sustaining stab injury to the back. The stab had penetrated the renal artery and IVC, leading to arteriovenous fistula. He was managed surgically, as he went into hemorrhagic shock, with a successful outcome. The case is also unique as an accessory renal artery was also involved in the fistula. CONCLUSION: Early identification and management of renal artery-IVC fistula is important to ensure a successful outcome. Such fistulas can be managed by either endovascular approach or surgical approach. The decision of approach depends on the level of expertise available and hemodynamic status of the patient.

Profile of renal artery embolization (RAE) for renal trauma: A comparison of data from two major trauma center

ABSTRACT Objective To evaluate usage of renal artery embolization (RAE) for renal injuries and discuss the indications for this treatment. Materials and Methods A retrospective study was performed evaluating the electronic medical records of all patients with renal trauma admitted to two major comprehensive hospitals in Shantou city from January 2006 to December 2015. Results There were 264 and 304 renal traumatic patients admitted to hospital A and B, respectively. LGRT was the reason for presentation in the majority of patients (522, 91.9%). A total of 534 (94.0%) patients were treated conservatively. RAE was performed in 9 patients from 2012 to 2015 at hospital A, including in 6 patients (6/9, 66.7%) with LGRT, and 3 patients (3/9, 33.3%) with HGRT. No patient underwent interventional therapy (RAE) at hospital B during the same period. No significant differences in the operative rate of hospital A were observed between the two time periods (2006-2011 and 2012-2015). The operative rate for LGRT between the two hospitals from 2006 to 2011 and 2012 to 2015 was not significantly different. Hospital A showed a significant decrease in the rate of conservative treatment for patients with LGRT. In the univariate and multivariate analyses, the AAST renal grade both were significantly associated with undergoing RAE. Conclusions LGRT was present in the majority of patients, and most cases of renal trauma could be treated with conservative treatment. RAE was well utilized for the treatment of renal trauma. However, some patients with LGRT were treated with unnecessary interventional therapy.

Initial Experience With the Microvascular Plug in Selective Renal Artery Embolization.

PURPOSE: To evaluate the safety and efficacy of the microvascular plug (MVP) for selective renal artery embolization. METHODS: Retrospective review was performed on a cohort of 6 patients undergoing renal artery embolization using the MVP between July 2015 and August 2018. Patients' demographics, indication for embolization, technical details of the embolization procedure, and clinical events were gathered from the patients' electronic medical records. RESULTS: The patients underwent selective renal artery embolization with a MVP for iatrogenic vascular injuries (n = 3), traumatic vascular injuries (n = 2), and for elective embolization of an angiomyolipoma (n = 1), in native kidneys (n = 4) or in renal allografts (n = 2). Immediate occlusion of the feeding artery was achieved with 1 MVP device in 4 patients. In 1 patient, a second MVP was needed, and in another patient, additional 0.018-inch microcoils were used to completely occlude the injured artery. Technical success was achieved in all patients. The volume of the resulting renal infarction was estimated less than 5% of the renal volume. No other procedure-related complications occurred. CONCLUSION: The MVP is a safe and effective device allowing superselective renal artery embolization. Therefore, we recommend the MVP as a valuable embolic in superselective renal artery embolization. Additionally, a single device is sufficient in most cases, potentially reducing the cost, duration, and radiation exposure of the procedure.

An Original Bailout Solution for Renal Artery Dissection after Fenestrated/Branched EVAR.

BACKGROUND: Renal artery (RA) dissection may occur during endovascular treatment of thoracoabdominal aneurysms. The aim of this paper is to report the use of kissing coronary stents in the renal bifurcation as a bailout solution for dissection after fenestraded/branched endovascular aortic repair (F/B-EVAR). METHODS/RESULTS: A 73-year-old male with an asymptomatic Crawford type 4 thoracoabdominal aneurysm and a concomitant right common iliac artery aneurysm was proposed for endovascular repair, consisting of thoracic endovascular aortic repair plus custom-made device F/B-EVAR, followed by staged bifurcated EVAR plus right-sided IBD. In the control angiogram of the first procedure, a distal occlusion of the left renal artery was observed and attributed to iatrogenic dissection. The 6F sheath was reintroduced and the two main branches of the RA were catheterized with 0.014 wires. Then, two coronary drug-eluting stents were used for a kissing stenting technique with good angiographic and clinical results. As planned, one week later the patient underwent an uneventful second stage procedure. Follow-up CTA at 1 year showed normal patency of the renal stents as well as aneurysm shrinking and no signs of endoleak. CONCLUSIONS: In the reported case, the use of coronary stents was a safe and long-lasting solution to rescue an iatrogenic renal artery dissection during F/B-EVAR.

The consequences of major visceral vascular injuries on outcome in patients with pancreatic injuries: a case-matched analysis.

BACKGROUND: Major pancreatic injuries are complex to treat, especially when combined with vascular and other critical organ injuries. This case-matched analysis assessed the influence of associated visceral vascular injuries on outcome in pancreatic injuries. METHOD: A registered prospective database of 461 consecutive patients with pancreatic injuries was used to identify 68 patients with a Pancreatic Injury combined with a major visceral Vascular Injury (PIVI group) and were matched one-to-one by an independent blinded reviewer using a validated individual matching method to 68 similar Pancreatic Injury patients without a vascular injury (PI group). The two groups were compared using univariate and multivariate logistic regression analysis and outcome including complication rates, length of hospital stay and 90-day mortality rate was measured. RESULTS: The two groups were well matched according to surgical intervention. Mortality in the PIVI group was 41% (n = 28) compared to 13% (n = 9) in the PI alone group (p = 0.000, OR 4.5, CI 1.00-10.5). On univariate analysis the PIVI group was significantly more likely to (i) be shocked on admission, (ii) have a RTS < 7.8, (iii) require damage control laparotomy, (iv) require a blood transfusion, both in frequency and volume, (v) develop a major postoperative complication and (vi) die. On multivariate analysis, the need for damage control laparotomy was a significant variable (p = 0.015, OR 7.95, CI 1.50-42.0) for mortality. Mortality of AAST grade 1 and 2 pancreatic injuries combined with a vascular injury was 18.5% (5/27) compared to an increased mortality of 56.1% (23/41) of AAST grade 3, 4 and 5 pancreatic injuries with vascular injuries (p = 0.0026). CONCLUSION: This study confirms that pancreatic injuries associated with major visceral vascular injuries have a significantly higher complication and mortality rate than pancreatic injuries without vascular injuries and that the addition of a vascular injury with an increasing AAST grade of pancreatic injury exponentially compounds the mortality rate.

Blunt renal vascular trauma resulting in arterial avulsion injury with a nephron-sparing outcome.

Blunt renal vascular traumatic injury is uncommon, and most injuries can be managed conservatively in a patient who is clinically stable. Pseudoaneurysm or active bleeding at presentation is rare and in an unstable patient, endovascular techniques offer a low morbidity option for rapid treatment. We present an unusual case of avulsion of a second order renal artery from the main renal artery, with active bleeding at presentation treated by excluding the bleed with a stent graft. This was complicated by delayed pseudoaneurysm formation, treated with a larger stent graft. This resulted in preservation of renal parenchyma and renal function in a young patient.

Arteriovenous Fistula-A Rare Complication of IVC Filter Retrieval.

Inferior vena cava (IVC) filters are important devices for patients who are at high risk for developing thrombi and pulmonary embolism but have conditions that preclude the use of pharmacologic anticoagulants. IVC filter retrieval has become an important quality initiative backed by Food and Drug Administration guidelines for prompt removal after the filter is no longer indicated. Filter retrieval is a common procedure that usually has very few complications. However, when the filter is tilted or embedded in the caval wall, advanced techniques of retrieval may be necessary. These techniques have a higher rate of success but also a higher risk of complications such as injury to the IVC. Here, we describe a case of IVC filter retrieval resulting in formation of an arteriovenous fistula between the right renal artery and IVC and subsequent successful repair of this fistula using a vascular plug.

Superselective renal artery embolization for bleeding complications after percutaneous renal biopsy: a single-center experience.

OBJECTIVE: This study aimed to determine if superselective renal artery embolization is a safe and effective method of treating bleeding complications after percutaneous renal biopsy. METHODS: From January 2006 to December 2017, 43 patients (22 men and 21 women, mean age: 44.5 ± 14.0 years) underwent angiography for post-biopsy bleeding complications following percutaneous biopsy. Patients underwent angiography and superselective artery embolization. We recorded serum creatinine and hemoglobin values to assess the effect of embolization. RESULTS: Successful embolization was achieved in all patients. There was a pseudoaneurysm in 10 cases, arteriovenous fistula in eight, contrast media extravasation in 16, arteriovenous fistula combined with contrast media extravasation in five, and pseudoaneurysm combined with arteriovenous fistula in four. The embolic substance was a microcoil only or combined with a gelatin sponge. The mean creatinine value was not different at 1 day and 1 week after embolization compared with before embolization. Mean hemoglobin values were significantly higher at 1 day and 1 week after embolization than before embolization. CONCLUSIONS: Superselective renal artery embolization is a safe and effective treatment for post-biopsy bleeding complications after percutaneous renal biopsy. Lumbar or iliolumbar artery angiography is necessary if renal arteriography shows no signs of hemorrhage.

Tension haemothorax from a bleeding branch of the renal artery following isolated penetrating thoracic trauma: a rare presentation.

A 27-year-old man presented to a major trauma centre with two posterolateral thoracic stab injuries over the right scapula and thoracoabdominal junction. He was tachycardic and hypotensive with a chest X-ray revealing a large right-sided tension haemothorax, requiring insertion of two intercostal chest drains. A subsequent CT scan demonstrated a grade 4 right kidney laceration with active back bleeding from a renal artery branch, through a right diaphragmatic defect, into the pleural cavity. Embolisation of the feeding renal vessel controlled the bleeding and avoided the need for a nephrectomy. The patient required subsequent video-assisted thoracoscopic evacuation of the haemothorax and diaphragmatic repair, confirming that there was no associated lung or major vessel injury. A ureteric stent was ultimately inserted to manage a persistent urinary leak. This case highlights a rare cause for a common traumatic presentation and the need for a multidisciplinary approach in effective management of complex, multiorgan trauma.

Inter-rater reliability in the radiological classification of renal injuries.

INTRODUCTION: Although many radiologists invoke the surgical classification of renal injury proposed by the American Association for Surgery in Trauma (AAST), there has been only limited work on the role of the AAST system as an imaging stratification. The aim was to determine the inter-rater reliability (IRR) amongst radiologists and urologists using the AAST system. METHODS: A 1-year retrospective study of consecutive patients with computed tomography (CT) evidence of renal trauma managed at a Level 1 trauma center. Three radiologists and three urologists independently stratified the presentation CT findings according to the AAST renal trauma classification. Agreement between independent raters and mutually exclusive groups was determined utilizing weighted kappa coefficients. RESULTS: One hundred and one patients were included. Individual inter-observer agreements ranged from 54/101 (53.4%) to 62/101 (61.4%), with corresponding weighted kappa values from 0.61 to 0.69, constituting substantial agreement. Urologists achieved intra-disciplinary agreement in 49 cases (48.5%) and radiologists in 36 cases (35.6%). Six-reader agreement was achieved in 24 cases (23.7%). The AAST grade I injuries had the highest level of agreement, overall. CONCLUSION: The finding of substantial IRR amongst radiologists and urologists utilizing the AAST system supports continued use of the broad parameters of the AAST system, with some modification in specific categories with lower agreement.