British Journal of Radiology (2004) 77, 878-880
© 2004 British Institute of Radiology
doi: 10.1259/bjr/15202270
Lumbar artery bleeding as a complication of percutaneous nephrostomy in a patient with coagulopathy
P N Chan, FRCR
K T Wong, FRCR
S F Lee, FRCR
and
S C H Yu, FRCR
Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, NT, Hong Kong
 |
Abstract
|
|---|
A case of severe lumbar artery bleeding as a complication of percutaneous nephrostomy (PCN) is presented. A 70-year-old man with coagulation disorder (factor VIII deficiency) underwent left PCN because of left hydronephrosis and abnormal renal function. The procedure was complicated by a major haemorrhage from the left first lumbar artery into the left posterior pararenal space. This case illustrates bleeding from the lumbar artery in a patient with coagulation disorder resulting in a fatal outcome. CT can provide the diagnosis, while angiography with embolisation is an effective means to control the bleeding. These examinations should be performed as soon as possible.
|
Introduction
|
|---|
We present a case of lumbar artery injury as a complication of percutaneous nephrostomy (PCN) in a patient with coagulation disorder. Management of a patient with coagulopathy undergoing an interventional procedure is discussed.
|
Case report
|
|---|
We report the case of a 70-year-old man with a past medical history of diabetes and hypertension. He also had carcinoma of the rectum with bladder invasion. Anterior resection and partial cystectomy were performed in August 2001. He was admitted to our hospital because of epigastric pain. His blood pressure and pulse were stable. No fever was recorded on admission. Oesophageal-gastroduodenoscopy revealed antral gastritis and multiple duodenal erosions. His renal function was abnormal, with a creatinine level of 230 µmol l–1 (normal range 57–126 µmol l–1) and a urea level of 20.6 mmol l–1 (normal range 3.4–8.9 mmol l–1). Haematology investigation revealed factor VIII deficiency. His clotting profile was abnormal. On admission, his activated partial thromboplastin time (APTT) was 103 s (normal range 26.2–40.1 s), prothrombin time (PT) was 15.3 s and international normalized ratio (INR) was 1.6 (normal range 0.9–1.1). His platelet count was 154 x 109 l–1, which is within the normal range (140–380 x 109 l–1). Intravenous urography showed a dilated left collecting system with poor contrast medium excretion. CT of the abdomen confirmed left hydroureteronephrosis, probably related to previous surgery comprising ureter re-implantation into an augmented urinary bladder.
Elective PCN was requested to relieve the left urinary tract obstruction. Since the patient had an abnormal clotting profile, 6 units of fresh frozen plasma (FFP) were infused before PCN. Immediately after the infusion, the INR was 1.16 and the APTT was 63.6 s. PCN was then performed.
The procedure was performed under local anaesthesia. The left loin was infiltrated with 5 ml of 2% lignocaine using a 21 G needle. At the same injection site, a small incision was made to the left loin. Under ultrasound guidance, the lower pole calyx of the left kidney was punctured using an 18 G Trocar needle. Under fluoroscopic guidance, a 7 Fr multi-purpose drainage catheter was inserted after serial track dilatation. Turbid whitish urine was drained. The whole procedure was unproblematic and the general condition of the patient was stable.
However, approximately 12 h following the procedure, the patient suffered a hypotensive attack (blood pressure 90/60). An urgent full blood count showed that the patient's haemoglobin level had dropped from 10 g/100ml to 8.1 g/100ml. On clinical examination there was a left loin mass, which was non-tender. Decreased urine output was noted and the nephrostomy catheter was blocked by blood clots. The urologist attempted to flush the catheter, but only a minimal amount of blood was aspirated. The drop in haemoglobin level was thought to be related to the patient's coagulation problem. CT demonstrated a perinephric haematoma. Conservative treatment was opted for and the patient's condition was stabilized after repeated blood transfusion.
However, the patient's haemoglobin level remained low (8 g/100ml) despite multiple blood transfusions. A total of 18 units of red cells, 32 units of FFP and 18 units of platelet concentrate were transfused over 4 days.
The patient developed sepsis 4 days following PCN. Urine culture from the left PCN catheter showed the presence of Escherichia coli. The surgeon was consulted, who requested CT to determine the cause of sepsis. CT of the abdomen and pelvis (Figure 1
) revealed a huge retroperitoneal haematoma in the left posterior pararenal space. The left kidney was displaced anteromedially. The left pelvicalyceal system was not dilated, but the pigtail catheter was dislodged and was located within the huge haematoma. There was also a small amount of contrast medium extravasation within the haematoma, indicating active bleeding. There were prominent vessels at the muscular layer just posterior to the areas of contrast medium extravasation.
View larger version (59K):
[in this window]
[in a new window]
|
Figure 1. (a) CT abdomen examination 4 days following percutaneous nephrostomy. There was a huge retroperitoneal haematoma in the left posterior pararenal space. The left kidney was displaced anteromedially and the perirenal space was clear. The pigtail catheter was dislodged and was within the haematoma. (b) Contrast medium extravasation (arrow) was noted within the haematoma. There were prominent vessels (arrowhead) just posterior to the area of contrast medium extravasation. CT appearances raised the possibility of bleeding from the lumbar artery.
|
|
An urgent angiogram was then performed. The flush aortogram (Figure 2) demonstrated no bleeding from the renal artery, but demonstrated contrast medium extravasation from the distal branch of the left first lumbar artery, which was best shown on the selective left first lumbar arteriogram (Figure 3). Embolisation was performed using histoacryl–lipodol mixture delivered by an 18 Tracker microcatheter system. Bleeding was controlled following embolisation (Figure 4).
View larger version (168K):
[in this window]
[in a new window]
|
Figure 2. Flush aortogram revealed active contrast medium leakage from the first left lumbar artery (arrow). The aorta was mildly displaced to the right side owing to the presence of a huge haematoma.
|
|
View larger version (154K):
[in this window]
[in a new window]
|
Figure 3. Selective arteriogram of the left first lumbar artery demonstrated active bleeding. The site of bleeding was below the percutaneous nephrostomy tract.
|
|
View larger version (149K):
[in this window]
[in a new window]
|
Figure 4. Selective arteriogram of the left first lumbar artery following embolisation. No further contrast medium leakage can be seen.
|
|
Unfortunately, the patient died the following day owing to multi-organ failure.
|
Discussion
|
|---|
In 1982, Stables [1] reported a total complication rate of 4% in a study of 1207 PCN procedures. Of these 1.3% were related to haemorrhage and only 0.2% were fatal. Another study of 454 PCN procedures in 1997 by Farrell and Hicks [2] showed that the overall complication rate was 6.5% and the rate of haemorrhage requiring blood transfusion was 2.8%. However, these studies did not state the source of bleeding.
Haemorrhage following PCN is usually related to injury of the renal artery and its branches such as the segmental or interlobar arteries. Injury to the lumbar artery owing to PCN is very rare. To our knowledge, there are only three reported cases of lumbar artery injury after ultrasound-guided renal biopsy [3–5]. There is also a reported case of lumbar artery pseudoaneurysm after percutaneous nephrolithotomy [6]. One patient required immediate laparatomy, while the rest were successfully treated by embolisation, confirmed by follow-up arteriography.
The lumbar arteries arise from the aorta. They supply the psoas, quadratus lumborum and sarcospinalis muscles as well as the spinal cord. The posterior branches of the lumbar arteries (which supply the sacrospinalis muscles) cross over the posterior aspect of the lower pole of the kidney and can therefore be traumatized during invasive interventional procedures such as renal biopsy and PCN, resulting in a haematoma in the posterior pararenal space.
In our case, the PCN procedure was straightforward and only a single puncture was attempted. However, the bleeding source was located in the first lumbar artery, which was inferior to the entry site of the pigtail catheter (Figure 3
). Such a discrepancy between the site of bleeding and the point of nephrosotomy is related to the injection of local anaesthesia using a 21 G needle. We suggest the possibility of lumbar artery injury by this needle. The needle tip was advanced in many directions in order to infiltrate lignocaine to different layers of the puncture site for maximal anaesthetic effect. This multi-direction needle movement may lead to lumbar vessel injury, particularly if the needle tip is deep to the back muscle layer in a thin patient or a patient with a coagulation disorder.
Barth and Matsumota [7] suggested a reasonable method for correction of coagulation problems before an interventional procedure. Abnormal PT or APTT can be corrected by administration of vitamin K or by FFP transfusion. The interventional procedure should be performed soon after the FFP transfusion since the half-lives of some of the coagulation factors are limited. Prophylactic platelet transfusion is required if the platelet count is <50 x 109 l–1. In general, 10 units of transfused platelet will increase the platelet count by 50–100 x 109 l–1. The half-life of transfused platelet varies from hours to days, therefore the interventional procedure should be performed soon after the platelet transfusion.
Management of patients with a coagulation disorder undergoing an interventional procedure in our department is as follows. Routinely, we check the recent (not more than 2 days) results of PT, INR, APTT and platelet count. If the INR >1.5 or APTT >1.5 times the reference range, 4 units of FFP is transfused. If the platelet count is less than 50 x 109 l–1, 4 units of platelet concentrate should be transfused. The transfusion should be completed and the clotting profile should be re-checked before the procedure. Further transfusion of FFP or platelet concentrate is required if the clotting profile is still abnormal.
|
Conclusion
|
|---|
In conclusion, although lumbar artery injury following PCN is rare, it can occur and may lead to a lethal consequence if it is not properly identified and treated. In a patient with a coagulation disorder, needle puncture or even local anaesthetic injection should be performed carefully. We advocate that CT examination should be routinely performed for severe bleeding complication in PCN. Focal accumulation of blood in the posterior pararenal space demonstrated displacing the kidney on CT is suggestive of lumbar artery injury. The diagnosis can be confirmed by angiography, and embolisation is an effective way to the control bleeding.
Received for publication February 3, 2003.
Revision received December 2, 2003.
Accepted for publication February 20, 2004.
|
References
|
|---|
- Stables DP. Percutaneous nephrostomy: techniques, indications and results. Urol Clin North Am 1982;9:15–29.[Medline]
- Farrell TA, Hicks ME. A review of radiologically guided percutaneous nephrostomies in 303 patients. J Vasc Interv Radiol 1997;8:769–74.[Medline]
- Wall B, Keller FS, Spalding DM, Reif MC. Massive hemorrhage from a lumbar artery following renal biopsy. Am J Kidney Dis 1986;7:250–3.[Medline]
- Jamison MH, Coward RA. Severe hemorrhage from a lumbar artery as a complication of percutaneous renal biopsy. Postgrad Med J 1985;61:69–70.[Abstract/Free Full Text]
- Kim KT, Kim BS, Park YH, Cho KJ, Shin KS, Bahk YW. Embolic control of lumbar artery complicating percutaneous renal biopsy with a 3-F coaxial catheter system: case report. Cardiovasc Intervent Radiol 1991;14:175–8.[Medline]
- Jain R, Kumar S, Phadke RV, Baijal SS, Gujral RB. Intra-arterial embolization of lumbar artery pseudoaneurysm following percutaneous nephrolithotomy. Australas Radiol 2001;45:383–6.[CrossRef][Medline]
- Barth KH, Matsumoto AH. Patient care in interventional radiology: a perspective. Radiology 1991;178:11–17.[Free Full Text]
Top
Abstract
Introduction
