Renal Artery and Vein In jury Following Blunt Trauma JAMES T. STURM, M.D., JOHN F. PERRY, JR., M.D., ALEXANDER S. CASS, M.B.B.S.
Blunt injuries of the renal vascular pedicle occur infrequently. The experience with fourteen cases of blunt renal vascular trauma is presented. Most patients were injured in motor vehicle accidents. The diagnosis was made immediately after admission in 6 patients, delayed in 5, and at autopsy in 3. Most patients presented with gross or microscopic hematuria. The diagnosis of renal vascular injury was suggested by IVP in most instances. Surgical management was used in the 6 patients in whom the immediate diagnosis of renal pedicle injury was made; primary vascular repair was carried out in 4 patients and nephrectomy in two. Conservative management was used in 4 of the 5 patients with delayed diagnosis, and nephrectomy was required in the fifth. Three patients received no treatment as two were dead on arrival and one died during laparotomy. Seven patients died (50%Yo). One of the 7 survivors has a functioning kidney following repair of a renal vein laceration. Three patients with devascularized kidneys have been followed long term and have not developed hypertension. An IVP should be mandatory following severe blunt trauma, especially when hematuria is present. Renal arteriography is indicated with distortion of calyces, extravasation or nonfunction seen on IVP and allows a definitive diagnosis of renal vessel injury to be made.
From the Departments of Surgery and Urology, St. Paul-Ramsey Hospital, 640 Jackson Street, Saint Paul, Minnesota 55101 and the University of Minnesota Health Sciences Center, 412 S. E. Union Street, Minneapolis, Minnesota 55455
The presence of gross or microscopic hematuria on admission, or the finding of retroperitoneal or perinephric hematoma at laparotomy were the indications for infusion IVP. When distortion of the calyces, extravasation or non-function was demonstrated on IVP, selective renal arteriography was performed. Arteriography was omitted in favor of renal exploration when these radiographic findings were seen on IVP performed during laparotomy. Exploration of the kidney was accomplished after control of the renal vessels was acquired. Surgical management of these injuries was only carried out since 1968.
A LTHOUGH BLUNT INJURIES of the renal pedicle occur infrequently, loss of renal tissue results unless there Results is restoration of blood flow. Approximately 30 cases have Age and Sex been reported in the literature. The immediate diagnosis The ages of patients ranged from 2 to 74 years. Six and management of these lesions is mandatory if preser- patients were under 20 years of age and 4 patients were in vation of renal tissue is to be achieved. This report re- the 20-40 year group. There were 9 males and 5 females. cords the experience with blunt renal vascular injuries in fourteen patients. Type and Site of Injury Eleven patients were involved in traffic accidents: 8 as Material automobile passengers and three were pedestrians. One Between January, 1959 and June, 1974, 466 patients patient was injured in a skiing accident, one as a result of were treated for renal injuries. Fourteen of these had a child beating and one due to a crush injury by a steam blunt renal vascular trauma. shovel. The most common injury was renal artery thrombosis Submitted for publication May 22, 1975. which occurred in 5 patients. Renal artery laceration This study was supported in part by the Saint Paul-Ramsey Medical Education and Research Foundation. occurred in 4 and renal vein laceration in 4 patients. One 696
RENAL ARTERY AND VEIN INJURY
Vol. 182 * No. 6
697
TABLE 1. Management and Results of Renal Vessel Injury
Sex, Age
Site & Type of Injury
Associated Injuries
Diagnosis
Management
Followup IVP on Side of Injury
M, 35
Rt. vein laceration
Fracture femur, tibia,
None
Repair
Normal 7 mos
None None None
Repair Repair
Repair
Non-function 1 yr Died from assoc. inj. Died from assoc. inj.
None
Nephrectomy
None
Nephrectomy
Died from assoc. inj.
Conservative
Delayed Nephrectomy Conservative
Non-function 8 yrs Died from assoc. inj. Non-function 5 yrs
Conservative Delayed Nephrectomy Conservative
Non-function 6 yrs
F, 17 M, 23 F, 17
Rt. artery laceration Lt. artery laceration Rt. vein laceration
F, 52
Lt. vein laceration
F, 74
Rt. artery thrombosis
M, 16 M, 2 F, 19 M, 36
Rt. artery thrombosis Rt. artery laceration Rt. artery thrombosis Lt. artery thrombosis
M, 21 M, 48
Lt. artery thrombosis Rt. artery and vein laceration
M, 57
Rt. vein laceration
M, 17
Rt. artery laceration
Delay in
ankle, pelvis Ruptured liver Ruptured colon Ruptured diaphragm, liver, colon, Hemothorax fractured tibia, radius. Head injury Ruptured spleen Subdural hematoma Ruptured diaphragm, spleen, small bowel Abdominal wall avulsion Abdominal bowel infarction Ruptured liver
Ruptured liver, spleen Fracture lumbar vert. Ruptured aorta, bowel, liver, spleen, ureter. Subdural hematoma Ruptured liver, colon, ileac artery. Head injury Ruptured liver, spleen. Head injury
patient suffered laceration of both the renal artery and vein (Table 1). Diagnosis The diagnosis was made immediately after admission in 6 patients, delayed in 5 and at autopsy in 3 (Table 1). With immediate diagnosis hematuria was present in 5 (gross in 3 and microscopic in 2) and not recorded in the sixth patient. An infusion IVP revealed unilateral nonfunction in 3, extravasation in one and poor visualization in two patients. The diagnosis was delayed 12 hours after admission in two patients, 24 hours in two and 3 years in the remaining patient. Hematuria was present in three (gross in one and microscopic in 2) and not known in 2 patients. An infusion IVP revealed non-function in 4 and was not performed in one patient in whom the diagnosis was made at a 12-hour delayed laparotomy for associated visceral in-
juries. The patient with a 3-year delay had recurrent urinary tract infections and had a history of being in an automobile accident 3 years previously, at which time he sustained a lumbar vertebral fracture and had microscopic hermturia which cleared over several days. Aside from several urinary tract infections the patient had had no other difficulties since the accident. Non-function of the left kidney was demonstrated on an IVP done for the workup of his recurrent urinary tract infections. Arteriography showed an abrupt cutoff 5 mm beyond the origin of the left renal artery.
12 12 24 24
hrs hrs hrs hrs
3 yrs D.O.A.
D.0.A. Died in O.R.
The diagnosis was made at autopsy in two patients admitted dead on arrival and in one patient who died on the operating room table after an infusion IVP had shown non-function of the left kidney. Associated Injuries Associated injuries were present in all 14 patients. The patients had an average of 3 major injuries. Twelve had intra-abdominal injuries. The intra-abdominal injuries were: 6 liver lacerations, 6 bowel ruptures, 5 ruptured spleens, and 2 ruptured diaphragms. Associated injuries were responsible for the death of 7 patients. Treatment
Surgical management was used in the 6 patients in whom immediate diagnosis of renal pedicle injury was made. Primary vascular repair was carried out in 4 and nephrectomy in 2 patients. Two patients having primary vascular repair and one patient having a nephrectomy died from the associated injuries in the postoperative period. Conservative management was used in 4 of the 5 patients with the delayed diagnosis of renal pedicle injury. The fifth patient had a nephrectomy at the time of a 12-hour delayed laparotomy for associated visceral injuries and died from these associated injuries in the postoperative period. One of the 4 patients managed conservatively required a nephrectomy for persistent retroperitoneal hemorrhage. Three patients had no treatment as two were dead on
STURM, PERRY AND CASS
698
TABLE 2. Associated Injuries with Renal Pedicle Trauma
Liver laceration Rupture of small or large bowel Severe closed head injury Ruptured spleen Ruptured diaphragm Rupture of the thoracic aorta Extremity fracture Lumbar fracture Abdominal wall avulsion
arrival and one died sociated injuries.
on
the operating table from
6 6 5 5 2 1 5 1 1 as-
Ann.
Surg. * December 1975
function. The mortality rate in our series is higher than previous reports.1-4 This appears to be due to the greater number of associated injuries in our series of patients. Some degree of success revascularizing kidneys has been achieved with surgical repair 10-19 hours after blunt trauma with injury to the renal pedicle.5"' When the diagnosis of renal pedicle injury is made later than 24 hours following injury no surgical treatment is indicated unless hemorrhage, infection or hypertension ensue. We have followed 4 such patients for one to 8 years and none has developed hypertension. Careful followup is necessary because hypertension has been reported in some
patients. 13
Followup Review of the literature on blunt renal vascular inSeven patients (50%) survived and were discharged juries'-4'6-'4 identifies the salvage of only one kidney1' from the hospital; 2 following primary vascular repair, 2 among 29 pedicle injuries (3.4%). Guerriero5 reports 4 following nephrectomy (one immediate and one late) and survivors of blunt renal vascular injuries, but only com3 managed conservatively. ments on followup of one patient who had hypertension One primary repair of a renal artery failed as shown by and decreased renal function following revascularization non-function on a followup IVP. The patient has been of an arterial injury. Ross'0 reported a patient whose observed for one year and has developed no symptoms or renal function returned following heminephrectomy for signs. The other primary repair of a renal vein has been thrombosis of an upper pole artery. successful for 7 months with normal function on postReferences operative IVP. The three patients with devascularized kidneys man- 1. Baichwal, K. S. and Waugh, D.: Traumatic Renal Artery Thrombosis, J. Urol., 99:14, 1968. aged conservatively have been followed for 5, 6 and 8 2. Birkenstock, W. E., Rabkin, R. and Stables, D. P.: Bilateral years so far with no return of function as shown by IVP. Traumatic Renal Artery Occlusion with Survival After Late Reconstitution of Arterial Flow, Br. J. Surg., 59:915, 1972. Hypertension has not developed but one patient had 3 3. Caponegro, P. J. and Leadbetter, G. W. Jr.: Traumatic Renal lower urinary tract infections. Artery Thrombosis, J. Urol., 109:769, 1973.
Discussion
The kidney salvage rate is low with blunt renal pedicle injuries. This results from A) the late diagnosis of renal pedicle injury and B) high mortality rate due to the frequent multiple, severe associated injuries. The late diagnosis of renal pedicle injury results from the conservative management of renal injury. Following trauma the finding of hematuria or a retroperitoneal hematoma at laparotomy for associated injuries makes an infusion IVP mandatory. Renal arteriography makes the definitive diagnosis of renal pedicle injury and is indicated if the IVP demonstrates distortion of calyces, extravasation or non/function of a kidney. Multiple severe injuries were associated with renal pedicle injuries and resulted in a 50% mortality rate. Twelve of the 14 patients had associated abdominal injuries requiring immediate laparotomy. In these cases renal arteriography should be omitted in favor or renal exploration when the IVP on the operating room table shows distortion of calyces, extravasation or non-
4. Grablowsky, 0. M., Wiechert. R. F., Goff, J. B. and Schlegel, J. U.: Renal Artery Thrombosis Following Blunt Trauma: Report of Four Cases, Surgery, 67:895, 1970. 5. Guerriero, W. G., Carlton, C. E. Jr., Scott, R. Jr. and Beal, A. C. Jr.: Renal Pedicle Injuries, J. Trauma, 11:53, 1971. 6. Jevtich, M. J.: Injuries to Renal Vessels by Blunt Trauma in Children, J. Urol., 102:493, 1969. 7. Kolihova, E., Obenbergerova, D. and Apetaurova, B.: Total Severance of Renal Pedicle Caused by Blunt Trauma in Children, Ped. Radiol., 1:59, 1973. 8. Leandoer, J. L., Tremann, J. A., Oishi, R. H. and Marchioro, T. L.: Bilateral Renal Artery Thrombosis Following Blunt Trauma: Report of Two Cases, J. Trauma, 12:166, 1972. 9. Ready, B., Wright, C. and Baltzan, R. B.: Bilateral Traumatic Renal Artery Thrombosis, Canad. Med. Ass. J., 109:885, 1973. 10. Ross, R. Jr., Ackerman, E. and Pierce, J. M. Jr.: Traumatic Subintimal Hemorrhage of the Renal Artery, J. Urol., 104:11, 1970. 11. Skinner, D. G.: Traumatic Renal Artery Thrombosis: A Successful Thrombectomy and Revascularization, Ann. Surg., 177:264, 1973. 12. Stables, D. P. and Thatcher, G. N.: Traumatic Renal Vein Thrombosis Associated with Renal Artery Occlusion, Br. J. Surg., 46:64, 1973. 13. Sullivan, M. J., Smalley, R. and Banowsky, L. H.: Renal Artery Occlusion Secondary to Blunt Abdominal Trauma, J. Trauma, 12:509, 1972. 14. Wilkinson, A. E.: Thrombosis of the Renal Artery Due to Trauma; Suid-Afrikaanse Tydskrif. Chir., 11:39, 1973.
Blunt injuries of the renal vascular pedicle occur infrequently. The experience with fourteen cases of blunt renal vascular trauma is presented. Most patients were injured in motor vehicle accidents. The diagnosis was made immediately after admission in 6 patients, delayed in 5, and at autopsy in 3. Most patients presented with gross or microscopic hematuria. The diagnosis of renal vascular injury was suggested by IVP in most instances. Surgical management was used in the 6 patients in whom the immediate diagnosis of renal pedicle injury was made; primary vascular repair was carried out in 4 patients and nephrectomy in two. Conservative management was used in 4 of the 5 patients with delayed diagnosis, and nephrectomy was required in the fifth. Three patients received no treatment as two were dead on arrival and one died during laparotomy. Seven patients died (50%Yo). One of the 7 survivors has a functioning kidney following repair of a renal vein laceration. Three patients with devascularized kidneys have been followed long term and have not developed hypertension. An IVP should be mandatory following severe blunt trauma, especially when hematuria is present. Renal arteriography is indicated with distortion of calyces, extravasation or nonfunction seen on IVP and allows a definitive diagnosis of renal vessel injury to be made.
From the Departments of Surgery and Urology, St. Paul-Ramsey Hospital, 640 Jackson Street, Saint Paul, Minnesota 55101 and the University of Minnesota Health Sciences Center, 412 S. E. Union Street, Minneapolis, Minnesota 55455
The presence of gross or microscopic hematuria on admission, or the finding of retroperitoneal or perinephric hematoma at laparotomy were the indications for infusion IVP. When distortion of the calyces, extravasation or non-function was demonstrated on IVP, selective renal arteriography was performed. Arteriography was omitted in favor of renal exploration when these radiographic findings were seen on IVP performed during laparotomy. Exploration of the kidney was accomplished after control of the renal vessels was acquired. Surgical management of these injuries was only carried out since 1968.
A LTHOUGH BLUNT INJURIES of the renal pedicle occur infrequently, loss of renal tissue results unless there Results is restoration of blood flow. Approximately 30 cases have Age and Sex been reported in the literature. The immediate diagnosis The ages of patients ranged from 2 to 74 years. Six and management of these lesions is mandatory if preser- patients were under 20 years of age and 4 patients were in vation of renal tissue is to be achieved. This report re- the 20-40 year group. There were 9 males and 5 females. cords the experience with blunt renal vascular injuries in fourteen patients. Type and Site of Injury Eleven patients were involved in traffic accidents: 8 as Material automobile passengers and three were pedestrians. One Between January, 1959 and June, 1974, 466 patients patient was injured in a skiing accident, one as a result of were treated for renal injuries. Fourteen of these had a child beating and one due to a crush injury by a steam blunt renal vascular trauma. shovel. The most common injury was renal artery thrombosis Submitted for publication May 22, 1975. which occurred in 5 patients. Renal artery laceration This study was supported in part by the Saint Paul-Ramsey Medical Education and Research Foundation. occurred in 4 and renal vein laceration in 4 patients. One 696
RENAL ARTERY AND VEIN INJURY
Vol. 182 * No. 6
697
TABLE 1. Management and Results of Renal Vessel Injury
Sex, Age
Site & Type of Injury
Associated Injuries
Diagnosis
Management
Followup IVP on Side of Injury
M, 35
Rt. vein laceration
Fracture femur, tibia,
None
Repair
Normal 7 mos
None None None
Repair Repair
Repair
Non-function 1 yr Died from assoc. inj. Died from assoc. inj.
None
Nephrectomy
None
Nephrectomy
Died from assoc. inj.
Conservative
Delayed Nephrectomy Conservative
Non-function 8 yrs Died from assoc. inj. Non-function 5 yrs
Conservative Delayed Nephrectomy Conservative
Non-function 6 yrs
F, 17 M, 23 F, 17
Rt. artery laceration Lt. artery laceration Rt. vein laceration
F, 52
Lt. vein laceration
F, 74
Rt. artery thrombosis
M, 16 M, 2 F, 19 M, 36
Rt. artery thrombosis Rt. artery laceration Rt. artery thrombosis Lt. artery thrombosis
M, 21 M, 48
Lt. artery thrombosis Rt. artery and vein laceration
M, 57
Rt. vein laceration
M, 17
Rt. artery laceration
Delay in
ankle, pelvis Ruptured liver Ruptured colon Ruptured diaphragm, liver, colon, Hemothorax fractured tibia, radius. Head injury Ruptured spleen Subdural hematoma Ruptured diaphragm, spleen, small bowel Abdominal wall avulsion Abdominal bowel infarction Ruptured liver
Ruptured liver, spleen Fracture lumbar vert. Ruptured aorta, bowel, liver, spleen, ureter. Subdural hematoma Ruptured liver, colon, ileac artery. Head injury Ruptured liver, spleen. Head injury
patient suffered laceration of both the renal artery and vein (Table 1). Diagnosis The diagnosis was made immediately after admission in 6 patients, delayed in 5 and at autopsy in 3 (Table 1). With immediate diagnosis hematuria was present in 5 (gross in 3 and microscopic in 2) and not recorded in the sixth patient. An infusion IVP revealed unilateral nonfunction in 3, extravasation in one and poor visualization in two patients. The diagnosis was delayed 12 hours after admission in two patients, 24 hours in two and 3 years in the remaining patient. Hematuria was present in three (gross in one and microscopic in 2) and not known in 2 patients. An infusion IVP revealed non-function in 4 and was not performed in one patient in whom the diagnosis was made at a 12-hour delayed laparotomy for associated visceral in-
juries. The patient with a 3-year delay had recurrent urinary tract infections and had a history of being in an automobile accident 3 years previously, at which time he sustained a lumbar vertebral fracture and had microscopic hermturia which cleared over several days. Aside from several urinary tract infections the patient had had no other difficulties since the accident. Non-function of the left kidney was demonstrated on an IVP done for the workup of his recurrent urinary tract infections. Arteriography showed an abrupt cutoff 5 mm beyond the origin of the left renal artery.
12 12 24 24
hrs hrs hrs hrs
3 yrs D.O.A.
D.0.A. Died in O.R.
The diagnosis was made at autopsy in two patients admitted dead on arrival and in one patient who died on the operating room table after an infusion IVP had shown non-function of the left kidney. Associated Injuries Associated injuries were present in all 14 patients. The patients had an average of 3 major injuries. Twelve had intra-abdominal injuries. The intra-abdominal injuries were: 6 liver lacerations, 6 bowel ruptures, 5 ruptured spleens, and 2 ruptured diaphragms. Associated injuries were responsible for the death of 7 patients. Treatment
Surgical management was used in the 6 patients in whom immediate diagnosis of renal pedicle injury was made. Primary vascular repair was carried out in 4 and nephrectomy in 2 patients. Two patients having primary vascular repair and one patient having a nephrectomy died from the associated injuries in the postoperative period. Conservative management was used in 4 of the 5 patients with the delayed diagnosis of renal pedicle injury. The fifth patient had a nephrectomy at the time of a 12-hour delayed laparotomy for associated visceral injuries and died from these associated injuries in the postoperative period. One of the 4 patients managed conservatively required a nephrectomy for persistent retroperitoneal hemorrhage. Three patients had no treatment as two were dead on
STURM, PERRY AND CASS
698
TABLE 2. Associated Injuries with Renal Pedicle Trauma
Liver laceration Rupture of small or large bowel Severe closed head injury Ruptured spleen Ruptured diaphragm Rupture of the thoracic aorta Extremity fracture Lumbar fracture Abdominal wall avulsion
arrival and one died sociated injuries.
on
the operating table from
6 6 5 5 2 1 5 1 1 as-
Ann.
Surg. * December 1975
function. The mortality rate in our series is higher than previous reports.1-4 This appears to be due to the greater number of associated injuries in our series of patients. Some degree of success revascularizing kidneys has been achieved with surgical repair 10-19 hours after blunt trauma with injury to the renal pedicle.5"' When the diagnosis of renal pedicle injury is made later than 24 hours following injury no surgical treatment is indicated unless hemorrhage, infection or hypertension ensue. We have followed 4 such patients for one to 8 years and none has developed hypertension. Careful followup is necessary because hypertension has been reported in some
patients. 13
Followup Review of the literature on blunt renal vascular inSeven patients (50%) survived and were discharged juries'-4'6-'4 identifies the salvage of only one kidney1' from the hospital; 2 following primary vascular repair, 2 among 29 pedicle injuries (3.4%). Guerriero5 reports 4 following nephrectomy (one immediate and one late) and survivors of blunt renal vascular injuries, but only com3 managed conservatively. ments on followup of one patient who had hypertension One primary repair of a renal artery failed as shown by and decreased renal function following revascularization non-function on a followup IVP. The patient has been of an arterial injury. Ross'0 reported a patient whose observed for one year and has developed no symptoms or renal function returned following heminephrectomy for signs. The other primary repair of a renal vein has been thrombosis of an upper pole artery. successful for 7 months with normal function on postReferences operative IVP. The three patients with devascularized kidneys man- 1. Baichwal, K. S. and Waugh, D.: Traumatic Renal Artery Thrombosis, J. Urol., 99:14, 1968. aged conservatively have been followed for 5, 6 and 8 2. Birkenstock, W. E., Rabkin, R. and Stables, D. P.: Bilateral years so far with no return of function as shown by IVP. Traumatic Renal Artery Occlusion with Survival After Late Reconstitution of Arterial Flow, Br. J. Surg., 59:915, 1972. Hypertension has not developed but one patient had 3 3. Caponegro, P. J. and Leadbetter, G. W. Jr.: Traumatic Renal lower urinary tract infections. Artery Thrombosis, J. Urol., 109:769, 1973.
Discussion
The kidney salvage rate is low with blunt renal pedicle injuries. This results from A) the late diagnosis of renal pedicle injury and B) high mortality rate due to the frequent multiple, severe associated injuries. The late diagnosis of renal pedicle injury results from the conservative management of renal injury. Following trauma the finding of hematuria or a retroperitoneal hematoma at laparotomy for associated injuries makes an infusion IVP mandatory. Renal arteriography makes the definitive diagnosis of renal pedicle injury and is indicated if the IVP demonstrates distortion of calyces, extravasation or non/function of a kidney. Multiple severe injuries were associated with renal pedicle injuries and resulted in a 50% mortality rate. Twelve of the 14 patients had associated abdominal injuries requiring immediate laparotomy. In these cases renal arteriography should be omitted in favor or renal exploration when the IVP on the operating room table shows distortion of calyces, extravasation or non-
4. Grablowsky, 0. M., Wiechert. R. F., Goff, J. B. and Schlegel, J. U.: Renal Artery Thrombosis Following Blunt Trauma: Report of Four Cases, Surgery, 67:895, 1970. 5. Guerriero, W. G., Carlton, C. E. Jr., Scott, R. Jr. and Beal, A. C. Jr.: Renal Pedicle Injuries, J. Trauma, 11:53, 1971. 6. Jevtich, M. J.: Injuries to Renal Vessels by Blunt Trauma in Children, J. Urol., 102:493, 1969. 7. Kolihova, E., Obenbergerova, D. and Apetaurova, B.: Total Severance of Renal Pedicle Caused by Blunt Trauma in Children, Ped. Radiol., 1:59, 1973. 8. Leandoer, J. L., Tremann, J. A., Oishi, R. H. and Marchioro, T. L.: Bilateral Renal Artery Thrombosis Following Blunt Trauma: Report of Two Cases, J. Trauma, 12:166, 1972. 9. Ready, B., Wright, C. and Baltzan, R. B.: Bilateral Traumatic Renal Artery Thrombosis, Canad. Med. Ass. J., 109:885, 1973. 10. Ross, R. Jr., Ackerman, E. and Pierce, J. M. Jr.: Traumatic Subintimal Hemorrhage of the Renal Artery, J. Urol., 104:11, 1970. 11. Skinner, D. G.: Traumatic Renal Artery Thrombosis: A Successful Thrombectomy and Revascularization, Ann. Surg., 177:264, 1973. 12. Stables, D. P. and Thatcher, G. N.: Traumatic Renal Vein Thrombosis Associated with Renal Artery Occlusion, Br. J. Surg., 46:64, 1973. 13. Sullivan, M. J., Smalley, R. and Banowsky, L. H.: Renal Artery Occlusion Secondary to Blunt Abdominal Trauma, J. Trauma, 12:509, 1972. 14. Wilkinson, A. E.: Thrombosis of the Renal Artery Due to Trauma; Suid-Afrikaanse Tydskrif. Chir., 11:39, 1973.
