British Journal of Radiology (2005) 78, 161-163
© 2005 British Institute of Radiology
doi: 10.1259/bjr/68507140
Renal artery pseudoaneurysm following partial nephrectomy treated with stent-graft
M D Horwitz, MRCS1,
D C Hanbury, MS, FRCS (Urol)1 and
C M King, MRCP, FRCR2
Departments of 1 Urology and 2 Radiology, Lister Hospital, Stevenage, Hertfordshire SG1 4AB, UK
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Abstract
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Haemorrhagic complications due to pseudoaneurysms of branch arteries can be treated by selective embolisation. Injuries to the main renal artery cannot be treated in this way without sacrificing the kidney. We report the successful percutaneous treatment of a main renal artery pseudoaneurysm with a stent-graft in a patient with a solitary kidney.
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Introduction
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A 58-year-old man presented with frank haematuria and left sided flank pain. Renal ultrasound and CT showed bilateral 6 cm solid renal tumours; upper pole on the right and mid pole on the left (Figure 1
). Pre-operative arteriography demonstrated a single right renal artery bifurcating approximately 3 cm from the aorta. The position of the left sided tumour made nephron sparing surgery impossible. An immediate left radical nephrectomy was therefore performed.
7 weeks later the patient underwent a right upper pole partial nephrectomy. The tumour was found to be adherent to the adrenal gland, main hilar vessels and a disc of peritoneum. The calices and vessels were oversewn and the renal defect closed in a standard manner using haemacell rolls tied over with 2/0 monocryl.
Histology confirmed moderately differentiated clear cell carcinoma on both sides with no capsular or vascular invasion and clear resection margins. The patient made an uneventful recovery, going home on the 9th day with a creatinine of 200 µmol l–1 indicating a significant degree of renal impairment consistent with resection of three-quarters of his functioning renal tissue.
On the 11th post-operative day he developed right flank pain, the side of the partial nephrectomy. He was found to be hypotensive by the attending paramedics and was resuscitated with intravenous fluids. On admission his blood pressure was normal and stable and there was a tender mass palpable in the right flank. Ultrasound demonstrated a 13 cm haematoma in this region. As the patient was stable he was initially managed conservatively. His pain resolved and a follow up ultrasound showed no increase in the size of the haematoma. However 5 days later he had further pain and his haemoglobin fell from 10 g dl–1 to 8 g dl–1 despite a two-unit blood transfusion.
An emergency arteriogram demonstrated a pseudoaneurysm arising from the superior aspect of the main right renal artery, the site of origin of the previous upper pole branch (Figure 2). Embolisation of the main renal artery would have destroyed the remaining kidney so a decision was made to exclude the leak with a covered stent. A 17 mm Jostent peripheral stent graft (Jomed; Abbot Vascular Instruments, Rangendingenn, Germany) was hand-crimped onto a 5 mm x 2 cm Cordis Opta-Pro angioplasty balloon (Cordis Europa N.V., Roden, The Netherlands). It was positioned across the defect via a 7 French 40 cm Balkin Introducer Sheath (William Cook Europe, Bjaeverskov). Following deployment the pseudoaneurysm no longer filled but renal perfusion was maintained (Figure 3).
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Figure 2. Selective right renal arteriogram (20°C left anterior oblique) showing a pseudoaneurysm arising from the main renal artery. The patient's only remaining renal tissue is demonstrated.
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Figure 3. Following deployment of a stent graft, the pseudoaneurysm no longer fills and renal perfusion is maintained (same projection as Figure 2 ).
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Following the procedure, the patient had no further clinical episodes of bleeding and the haematoma slowly resolved. His creatinine level stabilized and at discharge was 270 µmol l–1. A CT scan at 4 months showed a cystic collection at the site of the previous haematoma with some mural calcification, but no evidence of pseudoaneurysm or tumour recurrence. The patient has remained asymptomatic for 15 months and has a creatinine of 230 µmol l–1 indicating stable but suboptimal renal function.
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Discussion
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The incidence of haemorrhage after partial nephrectomy is between 1% and 2% [1, 2] and may occur into the perirenal tissues or into the collecting system thereby causing haematuria. It is usually self-resolving and treatment is expectant and includes supportive therapies such as blood transfusion and bed rest. Haemorrhage in this particular case may have been due to an arterial injury at resection that was not identified because of vessel spasm at the ice cooling stage of the operation.
Pre-operative arteriography was performed in our case because the patient had bilateral tumours and a knowledge of the vascular anatomy was particularly important for planning the feasibility of nephron sparing surgery. It is also important in larger lesions and those that occupy a more central position close to the renal hilum, especially in a solitary kidney. Less invasive modalities such as multidetector array CT are now of sufficient accuracy that most urologists do not now routinely request arteriography before partial nephrectomy. In patients with suspected haemorrhage post partial nephrectomy the timing and method of investigation must be tailored to the patients' clinical condition. In our case angiography with contrast was initially avoided in an attempt to reduce possible contrast toxicity as he had impaired renal function. If a bleeding source is identified a variety of techniques, such as temporary balloon occlusion and embolisation with detachable coils may then be employed [3, 4].
Bleeding following partial nephrectomy is usually from a branch artery [5], which can be identified angiographically and embolised super-selectively with coils. This technique is well established for haemorrhage following renal biopsy. Where the main renal artery is involved, embolisation would devascularize the entire kidney. In our case the only alternative to this procedure would have been an open re-exploration, and would almost certainly have resulted in an emergency nephrectomy.
The literature reports more frequent use of covered stents for the treatment of renal artery aneurysm [6, 7]. As this case shows, it is possible to safely and effectively treat such a lesion with a covered stent (stent graft). The Jostent® used combines a balloon-expandable steel stent with an expandable PTFE (polytetrafluoroethylene) graft material [8, 9]. The Jomed stent has the advantage that it can be hand crimped onto the appropriate size balloon within the size range given, and is short enough to overcome any rigidity problems that may be encountered in an angulated renal artery.
Other causes of pseudoaneursym that may be amenable to similar treatment include: percutaneous renal biopsy, sharp trauma to the kidney and more rarely infection and atherosclerosis. It must however be noted that the majority of pseudoaneursyms developing after renal biopsy are either asymptomatic or show only transient symptoms [10] and resolve spontaneously.
There is no evidence regarding long-term patency of stent-grafts with respect to the treatment of pseudoaneurysm in the renal vasculature. The risk of stent stenosis due to intimal hypertrophy is unknown and these patients may need reviewing in the future. A previous study using stent grafts to preserve renal function in patients with renal artery stenosis and solitary functioning kidneys showed good patency results as well as good renal function at 24 months [11].
Most departments performing angioplasty keep similar stent grafts in stock in case of arterial rupture during angioplasty. The non-surgical treatment of acute iatrogenic renal artery injuries after stenting has been shown to be very successful [12]. Radiologists should be prepared to treat both main trunk and branch vessel injuries where haemorrhage occurs after nephron-sparing surgery [13].
Received for publication February 11, 2004.
Revision received October 4, 2004.
Accepted for publication October 26, 2004.
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References
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Abstract
Introduction
