Renal
artery pseudoaneurysm following retrograde endopyelotomy: case report
and literature review
(Portuguese
PDF version)
Sidnei
José Galego,1 Heraldo Barbato,2 João Antonio
Corrêa,1 Ohannes Kafejian,3 Afonso César
Polimanti,4 Rafael Vilhena de Carvalho Fürst,4 Adriana
Bertolami4
1.
Assistant professor, Faculdade de Medicina do ABC (FMABC), Santo André,
SP, Brazil.
2. Assistant physician, Service of Vascular Radiology, FMABC,
Santo André, SP, Brazil.
3.
Full professor, FMABC, Santo André, SP, Brazil.
4.
Medical student, FMABC, Santo André, SP, Brazil.
Correspondence:
Afonso César Polimanti
Av. Bosque da Saúde, 592,
CEP 04142-081 - São Paulo, SP
Brazil
Tel.: +55 (11) 577.5410
E-mail: afonso_sp@yahoo.com.br
ABSTRACT
The
treatment of ureteropelvic junction stenosis by retrograde endopyelotomy
is not free of complications. Among the least frequent complications
there is the formation of a pseudoaneurysm at the renal artery or
one of its branches. The authors report the case of a 41-year-old
male patient who presented with macroscopic hematuria with hemodynamic
instability shortly after retrograde endopyelotomy. The arteriography
evidenced a renal artery pseudoaneurysm. Embolization of the lesion
with two units of Gianturco coils was performed. Because of the
rarity of the case, and obscure treatment, we decided to report
it and review the literature on the subject.
Key-words:
therapeutic embolization, false aneurysm, renal artery.
Palavras-chave: embolização terapêutica,
pseudo-aneurisma, artéria
renal.
J
Vasc Br 2004;3(3):285-7
The formation of intrarenal pseudoaneurysms is relatively uncommon, and they are usually of traumatic or iatrogenic etiology.1 The incidence of iatrogenic renovascular lesions has increased significantly, with a consequent increase in the performance of minimally invasive urologic procedures.2 Intrarenal pseudoaneurysms are more commonly described as a complication of percutaneous procedures,1-4 and there are few reports of this complication following endourologic surgeries.3 The objective of this study was to report a case of pseudoaneurysm on the renal artery following an endourologic procedure.
CASE
REPORT
RSR, 41 years
old, presented with ureteropelvic junction stenosis on the left side and
was submitted to retrograde ureterostomy. One week after the procedure,
the patient returned to the service presenting macroscopic hematuria with
hemodynamic instability, characterized by a persistent decrease in hemoglobin
and hematocrit concentrations. Infusion of two units of red cell concentrate
was required to stabilize the patient. The patient did not develop hypertension
and did not show loss of renal function in laboratory control tests.
The patient was submitted to renal arteriography for diagnostic evaluation,
which revealed contrast extravasation on the left renal artery. The
finding was later identified as a 6-mm saccular lesion with no communication
with the peritoneal cavity or the caliceal system, located on the lower
pole of the left kidney, as shown in Figure 1. Treatment consisted of
endovascular correction through embolization of the lesion with Gianturco
coils (two units), with no intercurrences. A new arteriography carried
out at the end of the procedure showed absence of contrast inside the
pseudoaneurysm (Figure 2).
 Figure
1 - Selective arteriography of the left renal artery revealing a 6-mm
pseudoaneurysm (arrow) with the same topography as that of the ureter, which
presents a double-J catheter in its lumen.
Figure
2 - Aortography following embolization of the pseudoaneurysm. The lesion
is not filled with contrast, which suggests that the pseudoaneurysm was excluded
from the circulation and that the procedure was successful.
Hematuria ceased without loss of renal function. The patient is
currently under follow-up, and has remained asymptomatic for 8 months.
DISCUSSION
Renovascular
lesion is a well-known complication of percutaneous procedures. The
incidence of pseudoaneurysm reported in the literature following percutaneous
nephrolithotripsy ranges from 0.6 to 1%, and following percutaneous
renal biopsy, from 2 to 3.4%.2,4 Phadke
et al., in a retrospective study involving 2,108 percutaneous procedures,
observed the formation of pseudoaneurysms in only 0.9% of the cases.2
According to the literature, 71% of the population have an arterial
or venous vessel located 1.5 cm distant from the ureteropelvic junction.3
Therefore, it is important to keep in mind that a vascular lesion can
easily result from a transmural ureter incision.
The treatment of traumatic renal lesions is usually conservative,1
with follow-up of lesions through image tests, such as computed tomography.5
Nevertheless, in cases of severe bleeding or significant vascular lesion,
intervention is indicated.1
Rudnick & Dretler report the late development of macroscopic hematuria
as an initial symptom of intrarenal pseudoaneurysm, with caliceal fistulization
21 days after ureterorenoscopy - similarly to what was observed in our
case. Treatment consisted of embolization with two steel coils, with
resolution of symptoms.6 The same technique
was used in the treatment of our patient.
Ansari et al. described the occurrence of a giant pseudoaneurysm on
the posterior division of the renal artery as a possible complication
of pyelolithotomy; the lesion presented as a pulsatile mass and was
associated with macroscopic hematuria and systemic hypertension. In
this case, embolization was not possible, and the authors decided to
carry out a surgical procedure, namely total nephrectomy.4
Benjaminov & Atri treated a chronic dialysis patient who presented with
macroscopic hematuria secondary to closed renal trauma. The authors
performed embolization of a pseudoaneurysm through percutaneous thrombin
injection, a method that was presented by the author as an alternative
to endovascular embolization.7
There are few studies in the literature showing the association of pseudoaneurysms
with endourologic procedures. In the present review, we found only two
cases, both following retrograde endopyelotomy aimed at the correction
of ureteropelvic junction stenosis.3 In
one case, the patient showed hemodynamic instability in the immediate
postoperative period, and was treated with ligature of an aberrant branch
of the renal artery (open surgery). The patient also developed severe
hypertension, which was controlled with the use of captopril and nifedipine,3
suggesting a renovascular etiology.
The other case, reported by the same author, presented with flank pain,
fever and progressive decrease in hemoglobin and hematocrit concentrations.
In this case, a lesion on the lower branch of the renal artery was also
observed, and endovascular embolization of the pseudoaneurysm was carried
out upon diagnosis, similarly to what occurred in our case. The patient
evolved showing significant pain, in addition to deterioration of renal
function, and was therefore submitted to laparoscopic nephrectomy.3
The case described by the author is different from ours, since our patient
presented a more favorable evolution, with the complete resolution of
symptoms.
CONCLUSION
Endovascular
embolization of pseudoaneurysms on the renal artery is a possible option
for the treatment of traumatic vascular lesions observed on this vessel.
REFERENCES
1.
Cantasdemir M, Adaletli I, Cebi D, Kantarci N, Selcuk D, Numan F. Emergency
endovascular embolization of traumatic intrarenal arterial pseudoaneurysm
with n-butyl cyanoacrylate. Clin Radiol 2003;58:560-5.
2.
Phadke RV, Swalani V, Rastogi H, et al. Iatrogenic renal vascular injuries
and their radiological management. Clin Radiol 1997;52:119-23.
3.
Angelsen A, Talseth T, Mjones JG, Hedlund H. Hypertension and pseudoaneurysm
on the renal artery following retrograde endopyelotomy (Acucise®).
Scand J Urol Nephrol 2000;34:79-80.
4.
Ansari MS, Dodamani D, Seth A. Giant pseudoaneurysm of posterior division
of renal artery: a rare complication of pyelolithotomy. Int Urol Nephrol
2001;32:337-40.
5. Mizobata Y, Yokota J, Fujimura I, Sakashita K. Successful
evolution of pseudoaneurysm formation after renal injury with dual-phase
contrast enhanced helical CT. AJR Am J Roengenol 2001;177:136-8.
6. Rudnick DM, Dretler SP. Intrarenal pseudoaneurysm
following ureterorenoscopy and electrohydraulix lithotripsy. J Urol
1998;159:1290-1.
7.
Benjaminov O, Atri M. Percutaneous thrombin injection for treatment
of an intrarenal pseudoaneurysm. AJR Am J Roengenol 2002;178:364-6.
|
