Figure 1
Teaching Case
SectionInterventional radiology
Case TypeClinical Cases
Authors
Cabral P1, Donato P2, Caseiro-Alves F2
(1) Department of Radiology of Hospital Prof. Dr. Fernando Fonseca, Amadora, Portugal
(2) Department of Radiology of Hospital Universidade Coimbra, Coimbra, Portugal
Connected authors
53 years, female
A 53-year-old woman with nephrotic syndrome under investigation is submitted to an ultrasound guided right kidney biopsy. There were no immediate complications reported. Approximately 24h after the procedure the patient complains of right lumbar pain without haematuria and a decrease in the haematocrit and haemoglobin levels is noticed.
Post renal biopsy active haemorrhage from renal and lumbar artery
Post biopsy haematoma without active haemorrhage
Post biopsy arterio-venous fistula
Perirenal abscess
An ultrasound study (Fig. 1) was the first examination to be carried out showing a heterogeneous liquid collection in the right perirenal space, postero-lateral to the kidney, measuring 9 cm in diameter, raising the possibility of a post biopsy haematoma given the clinical context.
It was followed by a CE-CT (Fig. 2) revealing two large haematomas, one in the right lateral abdominal wall and another in the right perirenal space. Active contrast extravasation could be identified in both haematomas suggesting active haemorrhage.
The patient was immediately taken to the angiography room and active haemorrhage from a right lumbar artery and from a distal interlobular branch of the lower division of the right renal artery were documented (Fig. 3, 5a), followed by successful embolisation. The lumbar artery was embolised using two 3 x 30 mm (diameter x length) coils and the renal arterial branch using 500-700 µm microspheres (Fig. 4ab, 5b).
It was followed by a CE-CT (Fig. 2) revealing two large haematomas, one in the right lateral abdominal wall and another in the right perirenal space. Active contrast extravasation could be identified in both haematomas suggesting active haemorrhage.
The patient was immediately taken to the angiography room and active haemorrhage from a right lumbar artery and from a distal interlobular branch of the lower division of the right renal artery were documented (Fig. 3, 5a), followed by successful embolisation. The lumbar artery was embolised using two 3 x 30 mm (diameter x length) coils and the renal arterial branch using 500-700 µm microspheres (Fig. 4ab, 5b).
Renal haematomas are the most prevalent complication after percutaneous kidney biopsies but fortunately most of the times are self-limited situations without the need for active intervention [1]. Other complications like clinically significant arteriovenous fistula, infections or pneumothorax are considerably less frequent and life threatening complications are exquisitely rare being less than 0.1% [2]. These figures have improved much in recent years mainly due to the widespread use of ultrasound guidance and automated-gun biopsy devices [3].
One should be especially cautious with patients on anticoagulants or antiplatelet agents in spite of the lower risk reported in the literature for this last group. Extra care should be taken for patients with known haemorrhagic dyscrasias which have a very high risk of complicated bleeding after the procedure and should therefore be managed accordingly [4].
Persistent abdominal or lumbar pain, gross haematuria, new onset of oliguria, tachycardia and hypotension are the clinical indicators of major haemorrhage after a renal biopsy. At the slightest suspicion a kidney ultrasound can exclude the presence of a perirenal or subcapsular haematoma. The CT can help us characterise and precisely locate any ultrasound finding. With the use of contrast enhancement, active haemorrhagic leaks can be documented allowing the physician to decide whether a more aggressive approach is needed [5, 6].
We should be aware of false negative CT studies with slow bleeding below 0, 5ml/min [7].
The definitive diagnosis is made by selective renal arteriography.
A radiological interventional approach for acute bleeding complications after a percutaneous renal biopsy is currently, where available, the preferred choice, sparing patients nephrectomy. If not available, surgery will be the only option and nephrectomy inevitably necessary, partial or total, depending on the location of the bleeding artery [5, 6, 7].
The procedure can be extremely effective and even surprisingly simple in experienced hands. The Seldinger technique is used to catheterize the femoral artery, then a guide wire is passed into the renal artery and superselective catheterization of the most distal bleeding vessel is attempted. Next, transcatheter embolisation is performed and the immediate control of the bleeding is usually achieved. Metallic microcoils and acrylic microspheres are the most often used embolisation agents [8].
After a successful procedure a wedge-shaped infarct area can be observed with CE-CT and angiographically (Fig. 6).
In this case the percutaneous approach proved to be the best choice. The patient rapidly recovered. An abdominal CE-CT was repeated one week after the intervention and reduction of the haematomas without active bleeding was already evident.
One should be especially cautious with patients on anticoagulants or antiplatelet agents in spite of the lower risk reported in the literature for this last group. Extra care should be taken for patients with known haemorrhagic dyscrasias which have a very high risk of complicated bleeding after the procedure and should therefore be managed accordingly [4].
Persistent abdominal or lumbar pain, gross haematuria, new onset of oliguria, tachycardia and hypotension are the clinical indicators of major haemorrhage after a renal biopsy. At the slightest suspicion a kidney ultrasound can exclude the presence of a perirenal or subcapsular haematoma. The CT can help us characterise and precisely locate any ultrasound finding. With the use of contrast enhancement, active haemorrhagic leaks can be documented allowing the physician to decide whether a more aggressive approach is needed [5, 6].
We should be aware of false negative CT studies with slow bleeding below 0, 5ml/min [7].
The definitive diagnosis is made by selective renal arteriography.
A radiological interventional approach for acute bleeding complications after a percutaneous renal biopsy is currently, where available, the preferred choice, sparing patients nephrectomy. If not available, surgery will be the only option and nephrectomy inevitably necessary, partial or total, depending on the location of the bleeding artery [5, 6, 7].
The procedure can be extremely effective and even surprisingly simple in experienced hands. The Seldinger technique is used to catheterize the femoral artery, then a guide wire is passed into the renal artery and superselective catheterization of the most distal bleeding vessel is attempted. Next, transcatheter embolisation is performed and the immediate control of the bleeding is usually achieved. Metallic microcoils and acrylic microspheres are the most often used embolisation agents [8].
After a successful procedure a wedge-shaped infarct area can be observed with CE-CT and angiographically (Fig. 6).
In this case the percutaneous approach proved to be the best choice. The patient rapidly recovered. An abdominal CE-CT was repeated one week after the intervention and reduction of the haematomas without active bleeding was already evident.
References
[1] Lefaucheur C, Nochy D, Bariety J (2009) Renal biopsy: procedures, contraindications, complications. Néphrologie & Thérapeutique 5:331-9 (PMID: 19345174)
[2] Uppot RN, Harisinghani MG, Gervais DA (2010) Imaging-Guided Percutaneous Renal Biopsy: Rationale and Approach. American Journal of Radiology 194:1443–1449 (PMID: 20489082)
[3] Sinha MD, Lewis MA, Bradbury MG, Webb NJ (2006) Percutaneous renal real-time ultrasound-guided biopsy by automated biopsy gun in children: safety and complications. Journal of Nephrology 19:41-4 (PMID: 16523424)
[4] Atwell TD, Smith RL, Hesley GK, Callstrom MR, Schleck CD, Harmsen WS, Charboneau JW, Welch TJ (2010) Incidence of bleeding after 15,181 percutaneous biopsies and the role of aspirin. AJR American Journal of Roentgenology 194:784-9 (PMID: 20173160)
[5] Sadick M, Röhrl B, Schnülle P, Düber C, Diehl SJ (2007) Multislice CT-angiography in percutaneous postinterventional hematuria and kidney bleeding: Influence of diagnostic outcome on therapeutic patient management. Preliminary results. Archives of Medical Research 38:126-32 (PMID: 17174736)
[6] Jain V, Ganpule A, Vyas J, Muthu V, Sabnis RB, Rajapurkar MM, Desai MR (2009) Management of non-neoplastic renal hemorrhage by transarterial embolization. Urology 74:522-6 (PMID: 19589577)
[7] Mavili E, Dönmez H, Ozcan N, Sipahioğlu M, Demirtaş A. (2009) Transarterial embolization for renal arterial bleeding. Diagnostic and Interventional Radiology 15:143-7 (PMID: 19517386)
[8] Schwartz MJ, Smith EB, Trost DW, Vaughan ED Jr (2006) Renal artery embolization: clinical indications and experience from over 100 cases. BJU International 99:881-6 (PMID: 17166242)
[9] Toledo K, Pérez MJ, Espinosa M, Gómez J, López M, Redondo D, Ortega R, Aljama P (2010) Complications associated with percutaneous renal biopsy in Spain, 50 years later. Nefrologia 30:539-43 (PMID: 20882092)
[10] Janik V, Martinek V, Padr R, Lisy J, Neuwirth J, Pafcugova J, et al (2005) Embolization of lumbar artery due to retroperitoneal bleeding following renal biopsy. Nephrology Dialysis Transplantation 20:820—2 (PMID: 15772268)
[11] Wall B, Keller FS, Spalding DM, Reif MC (1986) Massive hemorrhage from a lumbar artery following percutaneous renal biopsy. American Journal of Kidney Diseases 7:250-3 (PMID: 3953574)
[12] Kim KT, Kim BS, Park YH, Cho KJ, Shinn KS, Bahk YW (1991) Embolic control of lumbar artery hemorrhage complicating percutaneous renal biopsy with a 3-F coaxial catheter system: case report. Cardiovascular and Interventional Radiology 14:175-8 (PMID: 1878910)
Case information
| URL: | https://eurorad.org/case/9614 |
| DOI: | 10.1594/EURORAD/CASE.9614 |
| ISSN: | 1563-4086 |
Figure 1
Department of Radiology of Hospital Universidade Coimbra
Figure 2
Department of Radiology of Hospital Universidade Coimbra
Figure 3
Department of Radiology of Hospital Universidade de Coimbra
Figure 6
Department of Radiology of Hospital Universidade Coimbra
Department of Radiology of Hospital Universidade Coimbra
Department of Radiology of Hospital Universidade Coimbra
Department of Radiology of Hospital Universidade Coimbra
Department of Radiology of Hospital Universidade Coimbra
Department of Radiology of Hospital Universidade Coimbra