Figure 1
Aortography
Aortography shows a lower polar artery with an A-V fistula.
Clinical History
Post-renal biopsy hematuria
Imaging Findings
Long history of chronic nephropathy. After percutaneous biopsy for hystologic characterization of the patological condition of the kidney, clinical evidence of massive hematuria was found.
US and CT studies demonstrated the presence of an A-V fistula in the biopsy site.
Abdominal aorta DSA, selective catheterization of the renal branches, and CT study (Fig.1-5) showed the presence of A-V fistula in the area of inferior renal artery independently arising from the abdominal aorta, while the upper renal artery territory is normal.
After super selective catheterization of the renal branch supplying the A-V fistula the last one was embolized with non-absorbable material (gelfoam), obteining complete occlusion of the fistula (Fig.4).
Hematuria completely stopped after the treatment, no complications due to the procedure were seen.
Follow-up is negative after six months.
Discussion
Arteriovenous fistulae (AVF) are a quite frequent sequel to percutaneous biopsy of the kidney. In the past, diagnosis was usually made when clinical signs of an AVF occurred but doppler ultrasonography has now enabled non-invasive diagnosis. AVF are characterized by a very pulsatile (arterialized) venous flow. On colour flow Doppler the most characteristic appearance is a mosaic of colour due to a combination of tissue vibration and turbulence.
When no spontaneous regression of the fistula is observed, embolization therapy should be performed (even when the fistula is asymptomatic) in order to prevent late onset of complications. Transcatheter embolization can be used to control bleeding, but unless it is sufficiently selective, the procedure results in loss of significant amounts of renal parenchyma.
Our experience suggests that superselective embolization with coaxial catheter techniques is an effective method of treating bleeding from postbiopsy renal AVFs with minimal loss of renal parenchyma. CT study provides optimal visualization of the bleeding, but, compared to angiography, it can delay embolization treatment (with consequent high risk for these often unstable patients).
Differential Diagnosis List
Iatrogenic renal A-V fistula
Final Diagnosis
Iatrogenic renal A-V fistula
References
[1]
Merkus JW, Zeebregts CJ, Hoitsma AJ, van Asten WN, Koene RA, Skotnicki SH
High incidence of arteriovenous fistula after biopsy of kidney allografts.
Br J Surg 1993 Mar;80(3):310-2Deane. (PMID: 8472136)
[2]
deSouza NM, Reidy JF, Koffman CG
Arteriovenous fistulas complicating biopsy of renal allografts: treatment of
bleeding with superselective embolization.
AJR Am J Roentgenol 1991 Mar;156(3):507-10. (PMID: 1899745)
[3]
Perini S, Gordon RL, LaBerge JM, Kerlan RK Jr, Wilson MW, Feng S, Ring EJ
Transcatheter embolization of biopsy-related vascular injury in the transplant kidney: immediate and long-term outcome.
J Vasc Interv Radiol 1998 Nov-Dec;9(6):1011-9. (PMID: 9840051)
[4]
Riccabona M, Schwinger W, Ring E
Arteriovenous fistula after renal biopsy in children.
J Ultrasound Med 1998 Aug;17(8):505-8. (PMID: 9697953)
Case information
| URL: | https://eurorad.org/case/657 |
| DOI: | 10.1594/EURORAD/CASE.657 |
| ISSN: | 1563-4086 |
Figure 2
Selective angiography of the upper polar renal artery
Selective catheterization of upper polar artery shows normal vascularization of the upper pole.
Figure 3
Lower polar renal artery catheterization
Selective angiography of the lower polar artery confirms the presence of an A-V fistula with intraparenchymal bleeding.
Figure 4
Selective embolization of the lower feeding artery
After selective embolization of the feeding artery, there is no longer evidence of bleeding.
Figure 5
CT scan
CT scan during arteriography shows a large perirenal and periuretheral hematoma with laceration of the renal capsula as confirmed by the passage of the contrast agent from the parenchyma to the hematoma.
Aortography
Aortography shows a lower polar artery with an A-V fistula.
Selective angiography of the upper polar renal artery
Selective catheterization of upper polar artery shows normal vascularization of the upper pole.
Lower polar renal artery catheterization
Selective angiography of the lower polar artery confirms the presence of an A-V fistula with intraparenchymal bleeding.
Selective embolization of the lower feeding artery
After selective embolization of the feeding artery, there is no longer evidence of bleeding.
CT scan
CT scan during arteriography shows a large perirenal and periuretheral hematoma with laceration of the renal capsula as confirmed by the passage of the contrast agent from the parenchyma to the hematoma.