EMBOLIZATION
OF POST-TRAUMATIC
RENAL ARTERIOVENOUS PAUL TUCCI, DILIP
FISTULA
M.D.
DOCTOR,
M.D.
ANTHONY DIAGONALE,
M.D.
From the Department of Urology, Misericordia Hospital Medical Center, Bronx, New York
ABSTRACT - This report is of successful arterial embolization of large intrarenalfistula serious penetrating injury of the kidney, thus sparing the patient possible nephrectomy.
More than 200 renal arteriovenous fistulas have been reported in the medical literature.’ These fist&s, diagnosed radiologically, are described as either congenital or acquired. The congenital fistulas, usually multiple, account for about 25 per cent. Acquired fistulas, usually single, most following renal biopsies, constitute 75 per cent of the total. ’ Traditionally arteriovenous fistulas have been treated by nephrectomy. In recent years with advances in vascular surgery and angiography, conservative procedures have been tried, such as partial nephrectomy,2 excision of individual fistulas, intrarenal ligation of branch arteries,3 balloon catheter obliteration of fistulas, and percutaneous intravascular embolization of the feeding vessels. Very small arteriovenous fistulas have closed spontaneously. The larger fistulas require some treatment. Bookstein and Goldstein4 reported successful management of postrenal biopsy arteriovenous fistulas with embolization. Autologous clots have been used to embolize renal arteriovenous fistulas using percutaneous renal angiographic technique.4 As the clot is placed into the feeding vessel of the fistula, part of it gets into the fistula and part remains in the feeding vessel. The latter, having a normal intact intima allows dissolution of the clot by fibrinolysins. The fistulous tract does not have an intact intima. Therefore, fibrinolysis cannot occur, and the clot remains and seals off the fistula.
192
done after
Embolization of renal arteriovenous fistulas after a serious penetrating injury of the kidney has not been reported. The following is such a case. Case Report A twenty-eight-year-old man was admitted in hemorrhagic shock after a stab wound into the left flank. The wound was in the midaxillary line below the twelfth rib and was bleeding moderately. Gross hematuria was noted. Infusion pyelogram revealed prompt bilateral renal visualization without extravasation; the ureters and bladder were unremarkable. Surgical exploration revealed no intestinal or splenic injuries. A large left retroperitoneal hematoma was noted. A 2-cm. laceration of the midposterior surface of the kidney extending into the collecting system was seen. This was sutured, the area drained, and the abdomen closed. The patient remained stable until two weeks postoperative when he began to pass a large amount of clots in the urine; his hematocrit dropped from 33 to 24 requiring multiple transfusions. A left selective renal arteriogram was done which showed an intrarenal arteriovenous fistula with pseudoaneurysm formation. The patient continued to bleed intermittently for two weeks; his blood pressure from 180/80 mm. Hg stabilized to around I40/100, and a bruit was
UROLOGY
I
FEBRUARY
1979 I
VOLUME
XIII,
NUMBER 2
FIGURE 1. Zntrauenous two weeks pyelogram showing postsurgery poor visualization of left kidney and large clot in bladder. (B) Selective left renal angiogram showing arteriovenous jistula three weeks postoperative. (C) Angiogram showing occlusion of arteriovenous fistula I(D) Left renal tract. angiogr ‘am six months postoccl usion of aGerioz)enous fist&a showing normal arterial architecture.
heard over the left upper quadrant. It was decided to embolize the arteriovenous fistula using the percutaneous renal angiographic technique. Autologous blood (10 cc.) was instilled. Following this procedure, lung scan demonstrated several minute bilateral pulmonary infarcts which resolved since succeeding scans were negative after the third day. The hematuria stopped, the blood pressure remained at 120/80 mm. Hg and hematocrit stabilized at 34. Urine analyses were unremarkable. A repeat intravenous pyelogram
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
was normal except for diminished visualization on the left side. The patient was discharged ten days after embolization. He was followed up periodically. Six months after embolization, left selective renal angiogram was normal. Comment In renal arteriovenous fistulas that develop after renal biopsies, the penetrating wound is
193
relatively minute. In our case the penetrating wound was larger in proportion and degree. It was successfully treated by embolization suggesting that this technique can be used on larger arteriovenous fistulas that might develop after a serious penetrating injury of the kidney. This case also illustrates that pulmonary emboli can occur after embolization of the arteriovenous fistula but as in the other reported cases these emboli are small and clear quickly.’ Primary or secondary exploration in a large number of such cases results in nephrectomy; embolization of fistula is recommended to save renal tissue.
194
Department of Urology Misericordia Hospital Medical Center 600 East 233rd Street Bronx, New York 10466 (DR. TUCCI) References 1. Messing E, and Lanany P: Renal arteriovenous fist&s, Urology 8: 101 (1976). 2. Gosgrove M, Mendez R, and Morrow JW: Traumatic renal A-V fistula. 1. Urol. 110: 627 (1973). 3. IDEM: Branch artery ligation ‘of renal A-V fistula, ibid. 110: 632 (1973). 4. Bookstein JJ, and Goldstein AM: Successful management of post-biopsy arteriovenous fistula with selective arterial embolization, Radiology 109: 535 (1973).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
2
OF POST-TRAUMATIC
RENAL ARTERIOVENOUS PAUL TUCCI, DILIP
FISTULA
M.D.
DOCTOR,
M.D.
ANTHONY DIAGONALE,
M.D.
From the Department of Urology, Misericordia Hospital Medical Center, Bronx, New York
ABSTRACT - This report is of successful arterial embolization of large intrarenalfistula serious penetrating injury of the kidney, thus sparing the patient possible nephrectomy.
More than 200 renal arteriovenous fistulas have been reported in the medical literature.’ These fist&s, diagnosed radiologically, are described as either congenital or acquired. The congenital fistulas, usually multiple, account for about 25 per cent. Acquired fistulas, usually single, most following renal biopsies, constitute 75 per cent of the total. ’ Traditionally arteriovenous fistulas have been treated by nephrectomy. In recent years with advances in vascular surgery and angiography, conservative procedures have been tried, such as partial nephrectomy,2 excision of individual fistulas, intrarenal ligation of branch arteries,3 balloon catheter obliteration of fistulas, and percutaneous intravascular embolization of the feeding vessels. Very small arteriovenous fistulas have closed spontaneously. The larger fistulas require some treatment. Bookstein and Goldstein4 reported successful management of postrenal biopsy arteriovenous fistulas with embolization. Autologous clots have been used to embolize renal arteriovenous fistulas using percutaneous renal angiographic technique.4 As the clot is placed into the feeding vessel of the fistula, part of it gets into the fistula and part remains in the feeding vessel. The latter, having a normal intact intima allows dissolution of the clot by fibrinolysins. The fistulous tract does not have an intact intima. Therefore, fibrinolysis cannot occur, and the clot remains and seals off the fistula.
192
done after
Embolization of renal arteriovenous fistulas after a serious penetrating injury of the kidney has not been reported. The following is such a case. Case Report A twenty-eight-year-old man was admitted in hemorrhagic shock after a stab wound into the left flank. The wound was in the midaxillary line below the twelfth rib and was bleeding moderately. Gross hematuria was noted. Infusion pyelogram revealed prompt bilateral renal visualization without extravasation; the ureters and bladder were unremarkable. Surgical exploration revealed no intestinal or splenic injuries. A large left retroperitoneal hematoma was noted. A 2-cm. laceration of the midposterior surface of the kidney extending into the collecting system was seen. This was sutured, the area drained, and the abdomen closed. The patient remained stable until two weeks postoperative when he began to pass a large amount of clots in the urine; his hematocrit dropped from 33 to 24 requiring multiple transfusions. A left selective renal arteriogram was done which showed an intrarenal arteriovenous fistula with pseudoaneurysm formation. The patient continued to bleed intermittently for two weeks; his blood pressure from 180/80 mm. Hg stabilized to around I40/100, and a bruit was
UROLOGY
I
FEBRUARY
1979 I
VOLUME
XIII,
NUMBER 2
FIGURE 1. Zntrauenous two weeks pyelogram showing postsurgery poor visualization of left kidney and large clot in bladder. (B) Selective left renal angiogram showing arteriovenous jistula three weeks postoperative. (C) Angiogram showing occlusion of arteriovenous fistula I(D) Left renal tract. angiogr ‘am six months postoccl usion of aGerioz)enous fist&a showing normal arterial architecture.
heard over the left upper quadrant. It was decided to embolize the arteriovenous fistula using the percutaneous renal angiographic technique. Autologous blood (10 cc.) was instilled. Following this procedure, lung scan demonstrated several minute bilateral pulmonary infarcts which resolved since succeeding scans were negative after the third day. The hematuria stopped, the blood pressure remained at 120/80 mm. Hg and hematocrit stabilized at 34. Urine analyses were unremarkable. A repeat intravenous pyelogram
UROLOGY
/ FEBRUARY
1979 / VOLUME
XIII,
NUMBER 2
was normal except for diminished visualization on the left side. The patient was discharged ten days after embolization. He was followed up periodically. Six months after embolization, left selective renal angiogram was normal. Comment In renal arteriovenous fistulas that develop after renal biopsies, the penetrating wound is
193
relatively minute. In our case the penetrating wound was larger in proportion and degree. It was successfully treated by embolization suggesting that this technique can be used on larger arteriovenous fistulas that might develop after a serious penetrating injury of the kidney. This case also illustrates that pulmonary emboli can occur after embolization of the arteriovenous fistula but as in the other reported cases these emboli are small and clear quickly.’ Primary or secondary exploration in a large number of such cases results in nephrectomy; embolization of fistula is recommended to save renal tissue.
194
Department of Urology Misericordia Hospital Medical Center 600 East 233rd Street Bronx, New York 10466 (DR. TUCCI) References 1. Messing E, and Lanany P: Renal arteriovenous fist&s, Urology 8: 101 (1976). 2. Gosgrove M, Mendez R, and Morrow JW: Traumatic renal A-V fistula. 1. Urol. 110: 627 (1973). 3. IDEM: Branch artery ligation ‘of renal A-V fistula, ibid. 110: 632 (1973). 4. Bookstein JJ, and Goldstein AM: Successful management of post-biopsy arteriovenous fistula with selective arterial embolization, Radiology 109: 535 (1973).
UROLOGY
/
FEBRUARY
1979
/
VOLUME
XIII,
NUMBER
2
