Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 196-199

Angioembolization of renal artery pseudoaneurysm in blunt trauma abdomen


Department of Surgery, Shrikrishna Hospital, Karamsad, Gujarat, India

Date of Submission19-Apr-2021
Date of Decision19-Apr-2021
Date of Acceptance03-May-2021
Date of Web Publication13-Jun-2022

Correspondence Address:
Jayesh Patel
Department of Surgery, Shrikrishna Hospital, Karamsad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_25_21

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  Abstract 


Pseudoaneurysm of the renal artery is a presentation of blunt abdominal injury. We present the case of a 40-year-old male with a history of road traffic accident with a complaint of severe abdominal pain and distention of the abdomen. Contrast-enhanced computed tomography (CECT) shows large perinephric hematoma with free fluid in the abdomen. He was treated conservatively for 48 h but having persistence hypotension with increase free fluids in the abdomen, so mesenteric injury and bowel ischemia was suspected and laparotomy performed and found retroperitoneal hematoma and rest are normal. After that he had persistent hematuria with shock. Repeat CECT showed large pseudoaneurysm of the right renal artery with extravasation of contrast with clot in the bladder. In view this condition, renal artery angioembolization was done.

Keywords: Angioembolization, blunt trauma abdomen, renal artery pseudoaneurysm


How to cite this article:
Patel J, Patel A, Limbad V, Kapadiya N. Angioembolization of renal artery pseudoaneurysm in blunt trauma abdomen. Indian J Vasc Endovasc Surg 2022;9:196-9

How to cite this URL:
Patel J, Patel A, Limbad V, Kapadiya N. Angioembolization of renal artery pseudoaneurysm in blunt trauma abdomen. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 1];9:196-9. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/196/347257




  Introduction Top


Renovascular injuries account for 0.05% of all blunt trauma admissions. The cause of vascular injuries may be rapid deceleration, direct anteroposterior crushing, and direct laceration. The left renal artery is 1.3–1.6 times more likely to be injured than the right renal artery.[1],[2],[3] Rapid deceleration injuries may cause intimal tears and subsequent arterial thrombosis at a later stage. In approximately 50% of cases with blunt arterial injury, there is thrombosis. Avulsion of the artery occurs in 12% of cases.[4],[5],[6] In 9%–14% of cases, there may be bilateral renovascular injury.The clinical presentation is variable depending upon severity of injury. Abdominal contrast-enhanced computed tomography (CECT) is highly sensitive in diagnostic renovascular trauma and should be first-line investigation about associated injuries.[7] Endovascular treatment may play an important role in selected case, and it should be considered the first-line therapeutic option in stable condition with intimal teras, acute occlusion, false aneurysm, and arteriovenous fistula reavscularization[8] within 4–6 h of injury is recommended. However, most surgeon will avoid revascularization in patients diagnosed more than 6 h after injury unless the injuries involved both kidneys or injury to solitary kidney, some authors recommend revascularization even up to 20 h after injury. The results after revascularization are generally disappointing.

Here, we present a case of pseudoaneurysm of the right renal artery with hematuria treated with angioembolization.[9],[10],[11]


  Case Report Top


A 40-year-old male with a history of road traffic accident presented with a complaint of abdominal pain and distention of the abdomen for that he was treated conservatively. On presentation, he was vitally stable. There were no comorbidities. On CECT, he had large retroperitoneal hematoma on the right side with free fluid in the abdomen. After 48 h, he had hypotension, hypoxia, and drop in HB started on vasopressor, and on clinical examination, the abdomen was distended and signs of peritonitis present. Ultrasonography of the abdomen and pelvis shows increase in free fluid suspected mesenteric injury and mesenteric ischemia and laparotomy done. Intraoperatively, serosanguineous free fluid about 400–500 ml drained and large retroperitoneal hematoma on the right side and rest normal. Blood transfusion done and he was vitally stable and extubated. On the 5th postinjury day, he had hematuria and again he develop hypotension and drop in hematocrit and increase abdominal girth. Repeat CECT [Figure 1] performed shows active leak from pseudoaneurysm from the right renal artery with large retroperitoneal hematoma with nonopacification of the right kidney with large clot in the bladder.
Figure 1: Ct angiogram

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The patient was shifted to Cath laboratory and right femoral artery puncture was done retrograde, duplex guided and 7 French sheath kept and aortogram taken with 6 French pigtail catheter followed by selective cannulation of right renal artery [Figure 2] ostium with 6 French renal diagnostic catheter and selective angiography done which shows large two pseudoaneurysm sac one was 2.5 cm × 2 cm and another was 1.5 cm × 1 cm of right renal artery few cm after ostium with active leak of contrast then with progreat 2.8 French microcatheter [Figure 3] and four coils IMWCE 35-5-5 kept in renal artery just proximal to pseudoaneurysm sac with progreat wire still there was partially filling of sac so glue [Figure 4] (histoacryal) 1 ml mixed with lipiodol 2 ml and embolization was performed [Figure 5] and immediately progreat catheter was taken out and flush with copious amount of 5% dextrose solution. Following angiogram shows no filling of sac [Figure 6].
Figure 2: Selective renal angiogram

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Figure 3: Coil embolization of renal artery

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Figure 4: Glue embolization

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Figure 5: Cast formation

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Figure 6: Completion Angiogram

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Puncture site was compressed manually.

Follow-up course in the hospital was uneventful, and the patient was discharged on follow-up after 3 months, the patient is asymptomatic and vitally stable.


  Discussion Top


Right renal artery is protected from deceleration injuries because of its course underneath the inferior vena cava.[12],[13] The diagnosis of renovascular injury after penetrating trauma is always made intraoperatively;[14],[15] however, in blunt trauma, the diagnosis is usually made during routine the CT evaluation of the abdomen. The clinical presentation is subtle and nondiagnostic, and the diagnosis is often delayed.[16]

In a National Trauma Data Bank study covering the period 1993–2001, none of the 517 blunt renal artery injuries were managed with endovascular techniques.[17],[18] In a more recent study from 2004 to 2009, only 3.2% were managed with endovascular stenting.

The management of renovascular injuries depends on the mechanism injury, time of diagnosis, ischaemia time, general condition of patient, and presence of contralateral normal kidney. In blunt trauma, the management of renal artery injuries is complicated by the often delayed diagnosis and prolonged ischemia of the kidney. Renal function is severely affected after 3 h of total ischemia and 6 h of partial ischemia although with collateral circulation from the renal capsule or surrounding soft-tissue kidney function may be preserved despite prolonged ischemia.[19]

In stable patients diagnosed with renovascular trauma, within 4–6 h of injuries, the general recommendation is revascularization. However, revascularization is rarely performed even in patients with no other injuries.[20]

The advancement of endovascular techniques has opened new horizons in the management of renovascular injuries with endovascular techniques because of the safety of this approach and potential for renal salvage and life salvage.


  Conclusion Top


Renal artery pseudoaneurysm is a rare vascular condition following blunt abdominal injuries which is often life-threatening. They remain asymptomatic sometimes. Decision-making in such patient poses a challenge for surgeons due to other associated injuries and its location. There is always a risk associated with surgical intervention immediately and on follow-up which has to be carefully weighed upon.

Declaration of patient consent

The authors clarify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that their name and initials will not be published but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lee RS, Porter JR. Traumatic renal artery pseudoaneurysm: Diagnosis and management techniques. J Trauma 2003;55:972-8.  Back to cited text no. 1
    
2.
Swana HS, Cohn SM, Burns GA, Egglin TK. Renal artery pseudoaneurysm after blunt abdominal trauma: Case report and literature review. J Trauma 1996;40:459-61.  Back to cited text no. 2
    
3.
Farrell TM, Sutton JE, Burchard KW. Renal artery pseudoaneurysm: A cause of delayed hematuria in blunt trauma. J Trauma 1996;41:1067-8.  Back to cited text no. 3
    
4.
Miller DC, Forauer A, Faerber GJ. Successful angioembolization of renal artery pseudoaneurysms after blunt abdominal trauma. Urology 2002;59:444.  Back to cited text no. 4
    
5.
Rouppe DL. Renal artery aneurysm. Nova Acta Phys Med Acad Nat Curios 1770;4:76.  Back to cited text no. 5
    
6.
Rashid M, Abbas SZ, Haque F, Rizvi SA, Ali WM. Intrarenal posttraumatic pseudoaneurysm-USG colour Doppler diagnosis: A case report with review of literature. Emerg Radiol 2007;14:257-60.  Back to cited text no. 6
    
7.
Han KR, Goldstein DW, Pantuck AJ, Burno DK, Marmar JL, Lobby N. Angiographic management of pseudoaneurysm and arteriocalyceal fistula following blunt trauma: Case report and review of the literature. Can J Urol 1998;5:654-7.  Back to cited text no. 7
    
8.
Lee DG, Lee SJ. Delayed hemorrhage from a pseudoaneurysm after blunt renal trauma. Int J Urol 2005;12:909-11.  Back to cited text no. 8
    
9.
Heyns CF, de Klerk DP, de Kock ML. Stab wounds associated with hematuria – A review of 67 cases. J Urol 1983;130:228-31.  Back to cited text no. 9
    
10.
Kawashima A, Sandler CM, Corl FM, West OC, Tamm EP, Fishman EK, et al. Imaging of renal trauma: A comprehensive review. Radiographics 2001;21:557-74.  Back to cited text no. 10
    
11.
Morgan R, Belli AM. Current treatment methods for postcatheterization pseudoaneurysms. J Vasc Interv Radiol 2003;14:697-710.  Back to cited text no. 11
    
12.
Saad NE, Saad WE, Davies MG, Waldman DL, Fultz PJ, Rubens DJ. Pseudoaneurysms and the role of minimally invasive techniques in their management. Radiographics 2005;25 Suppl 1:S173-89.  Back to cited text no. 12
    
13.
Uflacker R, Paolini RM, Lima S. Management of traumatic hematuria by selective renal artery embolization. J Urol 1984;132:662-7.  Back to cited text no. 13
    
14.
Hagiwara A, Sakaki S, Goto H, Takenega K, Fukushima H, Matuda H, et al. The role of interventional radiology in the management of blunt renal injury: A practical protocol. J Trauma 2001;51:526-31.  Back to cited text no. 14
    
15.
Cinat M, Yoon P, Wilson SE. Management of renal artery aneurysms. Semin Vasc Surg 1996;9:236-44.  Back to cited text no. 15
    
16.
Parildar M, Oran I, Memis A. Embolization of visceral pseudoaneurysms with platinum coils and N-butyl cyanoacrylate. Abdom Imaging 2003;28:36-40.  Back to cited text no. 16
    
17.
Chuang VP, Reuter SR, Walter J, Foley WD, Bookstein JJ. Control of renal hemorrhage by selective arterial embolization. Am J Roentgenol Radium Ther Nucl Med 1975;125:300-6.  Back to cited text no. 17
    
18.
Lieberman SF, Keller FS, Pearse HD, Fuchs EF, Rösch J, Barry JM. Percutaneous vaso-occlusion for nonmalignant renal lesions. J Urol 1983;129:805-9.  Back to cited text no. 18
    
19.
Testart J, Watelet J, Poels D. Pseudoaneurysm resulting from avulsion of the right renal artery: Endoaneurysmal bypass. Eur J Vasc Surg 1991;5:475-8.  Back to cited text no. 19
    
20.
Aburano T, Taniguchi M, Hisada K, Miyazaki Y, Fujioka M, Ito H, et al. Renal artery pseudoaneurysm demonstrated on radionuclide scintiscan. Clin Nucl Med 1994;19:25-7.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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