INTRODUCTION: Renal biopsy-related vascular injuries are frequent but usually unimportant. However, they can lead to dramatic situations of hemodynamic instability and even death. Transcatheter embolization is a minimally invasive technique used to treat some forms of arterial bleeding.
CASE PRESENTATION: A 33-year-old woman with acute renal insufficiency requiring hemodialysis received an ultrasound-guided renal biopsy of the right kidney. She developed a perirenal hematoma (12 cm diameter) with active bleeding from the lower pole. Superselective embolization was performed with a 2.7F catheter and microcoils 0.018 inches in diameter. Her hemodynamic status was stabilized and there was no further decrease in the hematocrit level. The renal parenchyma remained well perfused except for the embolized segment. Imaging during the follow-up period showed no significant damage. The patient was discharged with a residual hematoma.
CONCLUSION: Superselective embolization therapy for renal trauma provides an effective and minimally invasive means to stop active bleeding. Immediate clinical success with minimal renal parenchyma loss can be obtained.
KEYWORDS: Therapeutic embolization; Hemorrhage; Renal Biopsy
CORRESPONDENCE: Francisco Botelho, MD, Servico de Urologia - Hospital S. João, Alameda Prof. Hernani Monteiro; 4200-319 Porto, Portugal ().
CITATION: UroToday Int J. 2009 Oct;2(5). doi:10.3834/uij.1944-5784.2009.10.10
Percutaneous renal biopsy is an invaluable tool in the diagnosis, prognosis, and management of patients with kidney disease. It has been recognized as a safe and effective method of obtaining renal parenchyma . Most of its related complications are minor and associated with bleeding; typically there are no clinical consequences .
The second most frequent complication after hematuria is perirenal hematoma, occurring after 1.5% to 22% of the procedures [2,3,4,5]. Renal surgical exploration is indicated in cases of hemodynamic instability or expanding perirenal hematoma. Relative indications include persistent bleeding and suspected renal pelvis or ureteral injury. Performing surgical exploration as a therapeutic option on these patients in order to end the hemorrhage would probably lead to nephrectomy. For all other patients, supportive care with bed rest, hydration, and antibiotics is the preferred treatment [6,7].
Angiographic intervention has now emerged as a third option for patients that do not present life-threatening bleeding but have persistent hemorrhage, an arteriovenous fistula or pseudoaneurysm. It is also an option for patients that require 2 or more blood transfusions. The first reported use of renal arterial embolization for control of hemorrhage was conducted by Bookstein and Goldstein , in 1973. Interventional radiographic techniques such as angiography and, more recently, superselective embolization are considered effective approaches to the diagnosis and treatment of acute renal injury. These approaches have high technical and clinical success rates in both native and transplanted kidneys [9,10,11,12].
The present authors describe a patient who received a percutaneous superselective segmental renal artery embolization procedure to treat a bleeding kidney. They also briefly review other previously published papers on endovascular treatments for acute renal hemorrhage.
A 33-year-old female patient with a history of preeclampsia presented with acute kidney failure (pCr: 16.8mg/dL), thrombocytopenia (PLQ: 104x109/L), and severe hemolytic anemia (Hg: 5.3g/dL), with presence of squizocytes in the peripheral blood. The coagulation study was unremarkable. The direct Coombs test, immunoglobulins, autoantibodies, complement study, and serology for HIV, HBV, and HCV were all negative.
Daily plasmapheresis was prescribed. There was no clinical or analytical improvement of the thrombotic microangiopathy, so the patient was started on corticotherapy. She had partial improvement of the thrombocytopenia and hemolysis. After normalization of the platelet count, she received a percutaneous ultrasound-guided renal biopsy to determine the cause of kidney failure.
About 3 hours after the biopsy, the patient began presenting with hypotension, tachycardia, and a perirenal hematoma (12cm largest diameter). Active bleeding was also detected in the lower pole of the biopsied kidney by means of a contrasted axial tomography (Figure 1). Blood analysis revealed maintenance of the kidney failure (pCr: 6.9mg/dL) and anemia (Hg: 7.3g/dL). The patient accepted the recommendation of an arteriography with an attempt to occlude the bleeding vessel.
Performed in the same day as the biopsy, a renal arteriography revealed active bleeding from a branch of the lower segmental right renal artery (Figure 2a). An embolization was carried out immediately after the arteriography, using a 2.7F catheter. Two microcoils 0.018 inches in diameter were placed with apparent success (Figure 2b). There were no noticeable procedure-related complications.
The patient regained hemodynamic stability. The hematoma slowly decreased throughout the rest of the hospitalization period. The patient only needed 1 more pack of blood transfusion due to hemolytic loss. The anemia slowly recovered, beginning the day after the procedure when her hemoglobin was 8.1g/dL. However, renal function (pCr: 7.3mg/dL the day after the procedure) never normalized. The kidney remained well perfused, except for the embolized segment which comprised about 10% of the renal parenchyma. Imaging showed no significant damage during the follow-up period (Figure 3). The patient never presented with clot-related obstructive uropathy, so no nephrostomy tube was necessary.
Unfortunately for the patient, her status was complicated due to an infection which started at the central venous catheter. A pleural effusion required temporary thoracic drainage. These complications resolved except for the kidney failure. The patient was later discharged with a hemoglobin of 11.7mg/dL. She is now undergoing a hemodialysis program while waiting for renal transplant. The kidney failure was attributed to non-Shiga toxin-associated hemolytic uremic syndrome. The patient is now performing genetic tests.
Most acute renal injuries are minor and, in those cases, conservative treatment is the best option for maximum renal preservation. However, in the case of a large perinephric hematoma resulting in hemodynamic instability, conservative treatment is not an option. Most authors agree that indications for intervention are: (1) persistent bleeding from a renal segmental artery, with or without parenchymal laceration; (2) an unstable condition with grade 3-4 injury; (3) an arteriovenous fistula or pseudoaneurysm; (4) persistent gross hematuria with rapidly decreasing hematocrit, requiring more than 2 units of blood [10,11,12,13]. If there are main renal artery or vein injuries or renal pelvis avulsion, open operative repair is advised .
A recent review of the literature on embolization therapy for renal trauma showed that overall technical success and overall clinical success ranged from 85%-100% and 61%-100%, respectively . The most commonly reported complication was pyrexia, followed by pain. Other less frequent yet more relevant complications are ectopic coil placement in 4% of cases, renal intimal dissection in 2%, hypertension in 1%, and renal abscess in 0.6% [9,13,14]. Some embolization sequelae, such as hypertension or arteriovenous fistula formation, may present later and be overlooked.
Arterial embolization for treatment of renal trauma requires a trained team and specialized equipment. It is not recommended for grade 5 renal injuries or hemodynamically unstable patients . Unsuccessful cases reported in the literature occur mainly when the latter contraindications are not considered. When compared with successful conservative management, arterial embolization is probably less nephron-sparing, and renal infarction is always a risk due to ectopic coil placement or movement. Authors of one study reported that out of 26 patients receiving initial embolization therapy, 12% later required open surgical repair, 10% required nephrectomy, and 2% required partial nephrectomy . The development of newer superselective coaxial catheters has facilitated the procedure and reduced the infarct extent to 0-15%, resulting in greater nephron preservation . The present patient also had good nephron preservation, despite the fact that her renal function remained deteriorated due to the primary cause of renal insufficiency.
Embolization therapy has been used with success in other cases of urologic context. There are published cases of efficacious interventions for bleeding after urological surgery, as in a pseudoaneurysm after robotic radical prostatectomy , severe bleeding after laparoscopic radical prostatectomy , and pseudoaneurysm of the renal artery following partial nephrectomy [17,18]. Ruptured renal angiomyolipomas , blunt renal trauma , and intractable bladder hematuria  have also been treated with success with different embolization techniques.
When compared with open surgery, embolization of a bleeding artery is an efficient procedure with much lower costs and comorbidity. The authors believe that its use will increase as other possible indications are published.
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