May 9, 2002 - Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases .... Han et al.3 postulated that rapid deceleration leads.
CASE REPORT
RENAL PSEUDOANEURYSM AFTER BLUNT RENAL TRAUMA IN A PEDIATRIC PATIENT: MANAGEMENT BY ANGIOGRAPHIC EMBOLIZATION S. HALACHMI, P. CHAIT, J. HODAPP, D. G. BA¨GLI, G. A. MCLORIE, A. E. KHOURY, W. FARHAT
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ABSTRACT Renal pseudoaneurysm is a rare complication after blunt renal trauma. Only 18 cases have been reported in English-language published reports. We present a case of blunt renal trauma in an 11-year-old boy, complicated by delayed bleeding from a renal artery pseudoaneurysm. The patient was initially treated with conservative measures and was later treated with selective embolization of the pseudoaneurysm. The clinical presentation, management options, and clinical decisions are discussed. UROLOGY 61: 224xiii–224xv, 2003. © 2003, Elsevier Science Inc.
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rauma is the leading cause of morbidity and mortality among the pediatric and adolescent age groups. Renal injury occurs in 8% to 12% of all trauma patients, and blunt trauma accounts for 85% of all renal injuries. Children are more susceptible to kidney trauma than adults because of the paucity of the cushioning perirenal fat and underdeveloped rib cage and flank muscles. Advances in imaging modalities such as computed tomography (CT) and Doppler ultrasonography, provide accurate and noninvasive staging of renal injuries. Serial imaging also permits conservative management of renal trauma. Also, with minimal invasive procedures such as selective arterial embolization, treatment morbidity is minimized and preservation of renal tissue is maximized. A pseudoaneurysm, although well documented after penetrating renal injury, is a rare complication after blunt renal trauma. We describe a rare case of renal artery pseudoaneurysm after blunt renal injury managed successfully with selective embolization.
S. Halachmi is supported by grants from the Canadian section of the SIU, Canadian Urological Association, Israel Medical Association, and Israel Cancer Association. From the Division of Urology and Image Guided Therapy, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada Address for correspondence: Walid Farhat, M.D., Division of Urology, Hospital for Sick Children, 555 University Avenue, Toronto, Ontario M5G 1X8, Canada Submitted: May 9, 2002, accepted (with revisions): August 26, 2002 © 2003, ELSEVIER SCIENCE INC. ALL RIGHTS RESERVED
CASE REPORT An 11-year-old boy was admitted to the emergency room complaining of abdominal and leftsided flank pain a few hours after falling over a banister. The estimated fall height was approximately 1.2 m. On admission, his vital signs were stable and within the normal range for his age. The physical examination demonstrated tenderness over the left flank. The hemoglobin level was 100 g/L (normal range 120 to 160), creatinine was 66 mol/L (normal range less than 106), and urinalysis showed microscopic hematuria. Contrast-enhanced CT demonstrated a grade 2 spleen rupture and a grade 3 renal injury with a large perinephric hematoma. No definite evidence of urine extravasation or renal vascular injury was noted, and the bladder and ureters were normal. Because of the hemodynamically stable course, the patient was treated conservatively with bed rest, intravenous antibiotics, hydration, and continuous monitoring of his vital signs. Forty-eight hours after his admission, the patient developed a high fever (39°C) and abdominal tenderness. A repeat CT scan showed atelectasis of the left lung base and extravasation of contrast material from the left renal pelvis. Supportive measures were undertaken, and 24 hours later, repeat ultrasonography did not show any evidence of an expanding urinoma. On the seventh hospital day, the patient suddenly developed severe flank tenderness and gross hematuria, although his blood pressure remained within the 0090-4295/03/$30.00 PII S0090-4295(02)02104-0 224xiii
FIGURE 1. Contrast-enhanced CT scan showing intraparenchymal renal artery pseudoaneurysm (white arrow). Perirenal hematoma is also demonstrated with increased density due to fresh bleeding.
normal range for his age (115/80 mm Hg). However, his pulse rate was 110 beats/min and his hemoglobin level dropped to 65 g/L. He was resuscitated with 2000 mL of crystalloids and 2 U of packed red blood cells, which stabilized his vital signs. A repeat CT scan demonstrated a large perinephric hematoma. Contrast extravasation from the left kidney was not evident on delayed images, but, in the left renal hilum, adjacent to the left renal artery, a rounded, enhancing focus, measuring about 1 cm in diameter, was noted, which raised the probability of a pseudoaneurysm (Fig. 1). Doppler ultrasonography confirmed the presence of the aneurysm, and the patient was transferred to the intervention radiology suite, where renal angiography showed a renal pseudoaneurysm that was selectively embolized successfully (Figs. 2 and 3). The remainder of his hospital convalescence was unremarkable. He was discharged 5 days after the procedure. CT 3 weeks later showed preservation of the upper half of the kidney and the lower pole, with complete resolution of the perinephric hematoma. His blood pressure was 120/80 mm Hg, within the normal range for his age. COMMENT Trauma is the leading cause of death in the pediatric and young adult population. The kidney is involved in around 10% of all trauma cases. Most renal injuries (90%) are caused by blunt trauma and only 10% to 15% are classified as major injuries. Although several opinions regarding the man224xiv
FIGURE 2. Selective renal artery angiography demonstrating a pseudoaneurysm of the mid-segment artery, with preservation of arterial supply to the upper half and lower pole of kidney.
FIGURE 3. Selective embolization of the pseudoaneurysm with coils.
agement of blunt renal trauma exist, recent experience has demonstrated the advantage of conservative management even when major blunt renal trauma is noted.1– 4 Even extravasation of urine from the collecting system can be managed conservatively, unless it is expanding or a urinoma has failed to resolve with time.5,6 Renal pseudoaneurysms are frequently reported after penetrating UROLOGY 61 (1), 2003
renal trauma; however, they are rare after blunt trauma. Han and colleagues3 found only 10 cases described in published reports from 1717 to 1998. Additional cases have recently been reported.3,7,8 Han et al.3 postulated that rapid deceleration leads to arterial wall disruption and aneurysm formation. Symptoms secondary to renal pseudoaneurysm may include hematuria, abdominal tenderness, abdominal mass, hypertension, and shock. Treatment of a renal pseudoaneurysm consists of nephrectomy, open vascular surgery, or angiographic embolization, depending on patient status and the location of the pseudoaneurysm. The trend in most trauma centers is to manage even more severe renal injuries conservatively.9 Our initial conservative approach permitted later salvage of the kidney through minimally invasive means. Angiographic embolization allowed selective treatment with maximal preservation of renal parenchyma, and we believe that this procedure should be the treatment of choice in stable patients before considering surgical therapy for intraparenchymal renal pseudoaneurysms. Although we cannot make generalized recommendations on the basis of a case report, we believe it may be reasonable to observe patients with high-grade renal trauma for a longer period, with a repeat CT scan several days after the trauma, even in asymptomatic patients. Conservative management through bed rest, careful monitoring, and serial imaging studies is feasible, even for patients with higher grade renal trauma. Such measures will spare the renal parenchyma and will help screen for complications such as intrarenal pseudoaneurysm after blunt injury.
UROLOGY 61 (1), 2003
CONCLUSIONS Renal pseudoaneurysm is a rare complication of blunt renal trauma that can be managed successfully with minimally invasive techniques. ACKNOWLEDGMENT. To Marty and Susan Goldberg, Toronto, Ontario, Canada for fellowship support. REFERENCES 1. Altman AL, Haas C, Dinchman KH, et al: Selective nonoperative management of blunt grade 5 renal injury. J Urol 164: 27–30, 2000. 2. Danuser H, Wille S, Zoscher G, et al: How to treat blunt kidney ruptures: primary open surgery or conservative treatment with deferred surgery when necessary? Eur Urol 39: 9 –14, 2001. 3. Han KK, Goldstein DW, Pantuck AJ, et al: Angiographic management of pseudoaneurysm and arteriocalyceal fistula following blunt trauma: case report and review of the literature. Can J Urol 5: 654 –657, 1998. 4. Levy JB, Baskin LS, Ewalt DH, et al: Nonoperative management of blunt pediatric major renal trauma. Urology 42: 418 –424, 1993. 5. Matthews LA, Smith EM, and Spirnak JP: Nonoperative treatment of major blunt renal lacerations with urinary extravasation. J Urol 157: 2056 –2058, 1997. 6. Moudouni SM, Patard JJ, Manunta A, et al: A conservative approach to major blunt renal lacerations with urinary extravasation and devitalized renal segments. BJU Int 87: 290 –294, 2001. 7. Dinkel HP, Danuser H, and Triller J: Blunt renal trauma: minimally invasive management with microcatheter embolization experience in nine patients. Radiology 223: 723–730, 2002. 8. Miller DC, Forauer A, and Faerber GJ: Successful angioembolization of renal artery pseudoaneurysms after blunt abdominal trauma. Urology 59: 444, 2002. 9. Wessells H, McAninch JW, Meyer A, et al: Criteria for nonoperative treatment of significant penetrating renal lacerations. J Urol 157: 24 –27, 1997.
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