Figure 1
CT
Pseudoaneurysm following percutaneous nephrolithotomy: CT demonstration and angiographic treatment
SectionCardiovascular
Case TypeClinical Cases
Authors
Lee PH.
Department of Radiology, Mid Essex Hospitals, Broomfield Hospital, Chelmsford, UK.
Connected authors
63 years, male
Clinical History
CT demonstrated a pseudoaneurysm in a patient with persistent haematuria following percutaneous nephrolithotomy. This was successfully embolised.
Imaging Findings
CT demonstrated a pseudoaneurysm in a patient with persistent haematuria following percutaneous nephrolithotomy. After undergoing percutaneous nephrolithotomy, the patient had persistent moderately severe haematuria for 2 weeks. He was clinically stable but required bladder irrigation via an indwelling catheter.
CT was carried out to investigate the source of bleeding. Noncontrast and arterial-phase postcontrast images were obtained with a 16-slice multidetector CT. In addition to multiplanar reconstructions, 3D volume rendered (VR) and maximum intensity projection (MIP) images were generated.
A 1 cm hyperattenuating lesion was present in the lower pole of the right kidney in the arterial phase, which was non present in the noncontrast images. Although the feeding artery could not be definitively traced to it, the lesion was considered to be a pseudoaneurysm. CT also showed that there were two renal arteries on the left side, with a smaller accessory artery supplying the lower pole. This was well demonstrated on the 3D volume rendered images.
The patient proceeded to angiography, where the presence of a small pseudoaneurysm in the lower pole of the right kidney was confirmed, and shown to be supplied by the accessory artery. Superselective catheterisation was carried out and the aneurysm was embolised with a coil, following which the bleeding ceased and the patient made a good recovery.
CT was carried out to investigate the source of bleeding. Noncontrast and arterial-phase postcontrast images were obtained with a 16-slice multidetector CT. In addition to multiplanar reconstructions, 3D volume rendered (VR) and maximum intensity projection (MIP) images were generated.
A 1 cm hyperattenuating lesion was present in the lower pole of the right kidney in the arterial phase, which was non present in the noncontrast images. Although the feeding artery could not be definitively traced to it, the lesion was considered to be a pseudoaneurysm. CT also showed that there were two renal arteries on the left side, with a smaller accessory artery supplying the lower pole. This was well demonstrated on the 3D volume rendered images.
The patient proceeded to angiography, where the presence of a small pseudoaneurysm in the lower pole of the right kidney was confirmed, and shown to be supplied by the accessory artery. Superselective catheterisation was carried out and the aneurysm was embolised with a coil, following which the bleeding ceased and the patient made a good recovery.
Discussion
Bleeding is a well recognised complication of percutaneous nephrolithotomy and other urological interventional procedures. Early haemorrhage may be venous or arterial in origin, and occur directly from the injured vessels. Delayed haemorrhage is usually due to post-traumatic pseudoaneurysm or a post-traumatic arteriovenous fistula [1-3].
The most appropriate method of treating iatrogenic renal vascular lesions is by superselective embolisation [3,4].
CT is useful prior to intervention for confirming and localising the source of haemorrhage. In many cases the vessel supplying the haemorrhagic lesion can be demonstrated. We carried out noncontrast and arterial phase imaging only, but other authors recommend additional delayed images [1-3] which may be useful for demonstrating continuing haemorrhage [2] or to evaluate the integrity of the collecting system [1].
In our patient the accessory artery was not well demonstrated in the initial flush arteriogram and could have been overlooked by a less experienced angiographer, had it not been clearly demonstrated in advance by CT.
The most appropriate method of treating iatrogenic renal vascular lesions is by superselective embolisation [3,4].
CT is useful prior to intervention for confirming and localising the source of haemorrhage. In many cases the vessel supplying the haemorrhagic lesion can be demonstrated. We carried out noncontrast and arterial phase imaging only, but other authors recommend additional delayed images [1-3] which may be useful for demonstrating continuing haemorrhage [2] or to evaluate the integrity of the collecting system [1].
In our patient the accessory artery was not well demonstrated in the initial flush arteriogram and could have been overlooked by a less experienced angiographer, had it not been clearly demonstrated in advance by CT.
Differential Diagnosis List
Iatrogenic renal pseudoaneurysm
Final Diagnosis
Iatrogenic renal pseudoaneurysm
References
[1]
Value of dual-phase multislice CT prior to minimally invasive therapy of iatrogenic renal injuries.
Kluner C, Rogalla P, Gralla O, Elgeti T, Hamm B, Kroencke T.
J Endovasc Ther. 2005 Aug;12(4):461-8. (PMID: 16048378)
[2]
Multislice CT-angiography in percutaneous postinterventional hematuria and kidney bleeding: Influence of diagnostic outcome on therapeutic patient management. Preliminary results.
Sadick M, R怀hrl B, Schnülle P, Düber C, Diehl SJ.
Arch Med Res. 2007 Jan;38(1):126-32. (PMID: 17174736)
[3]
Vascular injuries after percutaneous renal procedures: treatment by transcatheter embolization.
Vignali C, Lonzi S, Bargellini I, Cioni R, Petruzzi P, Caramella D, Bartolozzi C.
Eur Radiol. 2004 Apr;14(4):723-9. (PMID: 14625782)
[4]
Minimally invasive endovascular techniques to treat acute renal hemorrhage.
Breyer BN, McAninch JW, Elliott SP, Master VA.
J Urol. 2008 Jun;179(6):2248-52; discussion 2253. (PMID: 18423679)
Case information
| URL: | https://eurorad.org/case/7550 |
| DOI: | 10.1594/EURORAD/CASE.7550 |
| ISSN: | 1563-4086 |
Figure 2
Angio
Flush arteriogram. The main (superior) right renal artery is well opacified. The accessory (inferior) right renal artery and pseudoaneurysm in the lower pole are only faintly opacified and could be easily overlooked.
Right main renal arteriogram
Right accessory renal arteriogram. The pseudoaneurysm is clearly shown.
Superselective arteriogram
Deployment of coil
Coil depoyed.
Post embolisation superselective arteriogram. No bleeding or opacification of pseudoaneurysm.
Angio
Flush arteriogram. The main (superior) right renal artery is well opacified. The accessory (inferior) right renal artery and pseudoaneurysm in the lower pole are only faintly opacified and could be easily overlooked.
Right main renal arteriogram
Right accessory renal arteriogram. The pseudoaneurysm is clearly shown.
Superselective arteriogram
Deployment of coil
Coil depoyed.
Post embolisation superselective arteriogram. No bleeding or opacification of pseudoaneurysm.
