Traumatic renal artery occlusion: a 15-year review

Bilateral traumatic renal artery dissection managed by endovascular therapy

We present the case of post-traumatic bilateral renal artery injury with renal perfusion disorder, successfully treated by endovascular treatment. This therapeutic approach avoided the need for long-term dialysis by maintaining a sufficient renal function. This case is an illustration of the feasibility and the efficiency of endovascular treatment in severe post-traumatic renal artery lesions.

Blunt renal trauma-induced hypertension in pediatric patients: a single-center experience

PURPOSE

Children have a greater chance of sustaining a renal injury than adults and higher odds of having a high-grade renal injury. Hypertension is a rare complication of blunt renal trauma, with risk being higher in cases of major renal trauma. We reviewed the cases of pediatric blunt renal trauma-induced hypertension in our tertiary referral center in an attempt to better understand this rare condition.

STUDY DESIGN

A retrospective evaluation of children under the age of 18 who were admitted to our department during the last 20 years and were diagnosed with blunt renal trauma.

RESULTS

Twenty-three children presented with blunt renal trauma, one of whom was treated with emergency nephrectomy. Four children (18%) developed post-traumatic hypertension. All four cases were associated with a reduction in blood flow to the kidney, either through injury to the renal artery (in three cases) or through extrinsic compression of the kidney by a large perirenal hematoma (Page kidney; in one case). The Page kidney case developed hypertension during the initial hospitalization, and it resolved spontaneously after five months through the gradual resorption of the perirenal hematoma. Among the three cases of renal artery injury, hypertension during the initial hospitalization was only observed in one case, with hypertension in the other two cases manifesting after two months and four years, respectively. All three cases of renal artery injury resulted in a complete loss of function of the injured kidney, and two cases were treated with nephrectomy. Following nephrectomy, the blood pressure level returned to normal within a few days.

DISCUSSION

Development of hypertension following a blunt renal trauma can be heterogenous, with the time of manifestation stretching between days after the accident and years thereafter. Children have a higher risk of renal trauma and, according to published data out of the National Trauma Data Bank, a 20-times higher risk of renal artery injury in comparison to the adult population. Large multicenter studies are required to answer the question of whether children are therefore more prone to blunt renal trauma-induced hypertension than adults.

CONCLUSIONS

Our study highlights the importance of blood pressure monitoring in children following blunt renal trauma, as post-traumatic hypertension can develop even years after the accident. In cases of a poorly functioning kidney, nephrectomy may be regarded as a curative therapy.

Epidemiology and management of isolated blunt renal artery injuries

BACKGROUND

Isolated blunt renal artery injury (BRAI) is uncommon. Treatment options include observation, nephrectomy, surgical reconstruction and endovascular stenting. Over the last decade, there has been an increasing use of angiointervention techniques in vascular trauma. Previous studies reported underutilization of endovascular stenting in BRAI, in favor of observation. The aim of this study was to examine the epidemiology and assess changes in the management of isolated BRAI over the last decade.

METHODS

Patients with BRAI identified from the National Trauma Data Bank (2016-2017). Deaths in the emergency department, transferral from outside hospital, and those with associated high-grade kidney injuries were excluded. Demographics, type of renal artery injury, and renal artery management were analyzed. Multivariate analysis was used to identify independent factors associated with isolated BRAI.

RESULTS

During the study period, there were 1,708,076 patients with blunt trauma and 873 (0.05%) of them had BRAI. After exclusions, 563 patients with isolated BRAI who met the criteria for inclusion in the analysis. Auto versus pedestrian mechanism and male sex were associated with the highest risk for isolated BRAI. Comorbidities, such as hypertension or diabetes, were not associated with an increased risk of BRAI. Seatbelt use had a protective effect against BRAI. In the majority of patients (534, 95%), the renal artery injury was treated with observation, 23 (4%) with nephrectomy, 5 (0.9%) with endovascular stent and 1 (0.2%) with open renal artery repair. Among the 103 patients with isolated major renal artery laceration, 91.2% were treated with observation, 7.8% with nephrectomy and 1% with stenting.

CONCLUSION

Isolated blunt renal artery trauma is rare. The vast majority of patients with BRAI is managed with observation with only a small number undergoing endovascular intervention. Endovascular stenting utilization has remained very low and has not changed in the last decade.

American Association for the Surgery of Trauma-World Society of Emergency Surgery guidelines on diagnosis and management of abdominal vascular injuries

Abdominal vascular trauma accounts for a small percentage of military and a moderate percentage of civilian trauma, affecting all age ranges and impacting young adult men most frequently. Penetrating causes are more frequent than blunt in adults, while blunt mechanisms are more common among pediatric populations. High rates of associated injuries, bleeding, and hemorrhagic shock ensure that, despite advances in both diagnostic and therapeutic technologies, immediate open surgical repair remains the mainstay of treatment for traumatic abdominal vascular injuries. Because of their devastating nature, abdominal vascular injuries remain a significant source of morbidity and mortality among trauma patients. The American Association for the Surgery of Trauma in conjunction with the World Society of Emergency Surgery seek to summarize the literature to date and provide guidelines on the presentation, diagnosis, and treatment of abdominal vascular injuries. LEVEL OF EVIDENCE: Review study, level IV.

Traumatic renal artery dissection: from imaging to management

Injury to the renal artery following blunt trauma is detected increasingly due to widespread and early use of multidetector computed tomography (CT), but optimal treatment remains controversial as no guidelines are available. This review illustrates the spectrum of imaging findings of traumatic renal artery dissection based on our experience, with the aim of understanding the physiopathology of ischaemic damage to the kidney, and the process of choosing the best therapeutic strategy (conservative, endovascular, surgical). Five main patterns of traumatic renal artery dissection are described: avulsion of renal hilum; dissection of the segmental renal branches; preocclusive main renal artery dissection; renal artery stenosis without flow limitation; thrombogenic renal artery intimal tear. In the polytrauma patient, management depends on various factors (haemodynamic status, associated lesions, time of diagnosis) rather than on the degree of renal artery stenosis. Non-operative management (NOM) is the preferred option in case of non-flow-limiting dissection of the renal artery and angio-embolisation is an important adjunct to NOM in cases of active bleeding. Embolisation of the renal artery stump may be the best option in cases of occlusive dissection, as catheter manipulation carries a high risk of vessel rupture. The therapeutic window for kidney revascularisation in cases of flow-limiting dissection of main renal artery may be variable. Endovascular stenting >4 h after trauma should be performed only if residual flow with preserved parenchymal perfusion is detected at angiography. Antiplatelet therapy administration is recommended in cases of stenting, but conditioned by the bleeding risk of the patient.

[Traumatic dissection of the left renal pedicle in a young adult]

Blunt trauma rarely causes renal pedicle dissection. Clinical signs are minimal and inconsistently reported. The diagnosis is based on computed tomographic angiography; arteriography is still useful when revascularization is considered. We report here a case of traumatic dissection with thrombosis of a juxta-aortic renal pedicle monitored in the intensive care unit. An endovascular procedure could not be proposed because of the juxta-aortic localization.

Percutaneous renal artery revascularization after prolonged ischemia secondary to blunt trauma: pooled cohort analysis

PURPOSE

We aimed to identify factors related to technical and clinical success of percutaneous revascularization for blunt renal arterial trauma.

METHODS

All cases of percutaneous revascularization for blunt renal arterial trauma were searched in the available literature. We included a case of iatrogenic renal artery occlusion at our institution treated by percutaneous stenting 20 hours after injury. A pooled cohort analysis of percutaneous revascularization for blunt renal artery injury was then performed to analyze factors related to technical and clinical success. Clinical failure was defined as development of new hypertension, serum creatinine rise, or significant asymmetry in split renal function.

RESULTS

A total of 53 cases have been reported, and 54 cases were analyzed including our case. Median follow-up was 6 months. Technical success was 88.9% and clinical success was 75%. Of 12 treatment failures (25%), 66.7% occurred during the first postprocedure month. Time from injury to revascularization was not a predictor of clinical success (OR=1.00, P = 0.681). Renal artery occlusion was significantly associated with clinical failure (OR=7.50, P = 0.017) and postintervention antiplatelet therapy was significantly associated with treatment success (OR=0.16, P = 0.043). At 37-month follow-up, the stented renal artery in our case remained patent and the patient was normotensive with preserved glomerular filtration rate.

CONCLUSION

Percutaneous revascularization for blunt renal arterial injury resulted in relatively high technical and clinical success. Time-to-revascularization was independent of successful outcomes. Clinical success was significantly associated with a patent renal artery at the time of intervention and with postprocedure antiplatelet therapy.

Contemporary Strategies in the Management of Civilian Abdominal Vascular Trauma

The evaluation and management of patients with abdominal vascular trauma or injury requires immediate and effective decision-making in these unfavorable circumstances. The majority of these patients arrive at trauma centers in profound shock, secondary to massive blood loss, which is often unrelenting. Moreover, ischemia, compartment syndrome, thrombosis, and embolization may also be life threatening and require immediate intervention. To minimize the risk of these potentially lethal complications, early understanding of the disease process and emergent therapeutic intervention are necessary. In the literature, the management of acute traumatic vascular injuries is restricted to traditional open surgical techniques. However, in penetrating injuries surgeons often face a potentially contaminated field, which renders the placement of prosthetic grafts inappropriate. Currently, however, there are sparse data on the management of vascular trauma with endovascular techniques. The role of endovascular technique in penetrating abdominal vascular trauma, which is almost always associated with severe active bleeding, is limited. It is worth mentioning that hybrid operating rooms with angiographic radiology capabilities offer more opportunities for the management of this kind of injuries by either temporary control of the devastating bleeding using endovascular balloon tamponade or with embolization and stenting. On the other hand, blunt abdominal injuries are less dangerous and they could be treated at most times by endovascular means. Since surgeons continue to encounter abdominal vascular trauma, open and endovascular techniques will evolve constantly giving us encouraging messages for the near future.

Endovascular treatment of renal arterial perforation after blunt trauma: Case report

INTRODUCTION

Isolated renal arterial perforation is a rare consequence of blunt abdominal trauma. Meticulous surgical control of retroperitoneal active bleeding is difficult due to oozing of soft connective tissue, the deep position of operative field, and the presence of friable vascular tissue. Therefore, endovascular treatment is often preferred.

PRESENTATION OF CASE

An 83-year-old man was transferred to our trauma center due to retroperitoneal active bleeding after a car accident, in which his right upper abdomen struck the steering wheel. Contrast-enhanced abdominal computed tomography (CT) showed a retroperitoneal hematoma behind the inferior vena cava and contrast medium extravasation on the medial side of the right kidney. Selective right renal arteriography confirmed a perforation in the proximal right main renal artery, approximately 3 cm from the ostium. We successfully placed a covered stent across the perforation site.

DISCUSSION

Endovascular management may reduce the likelihood of extensive abdominal surgery, surrounding organ damage, risk of bleeding, and postoperative morbidity. We regarded embolization as inappropriate for kidney salvage in our patient, and therefore used a self-expanding covered stent to treat the perforation.

CONCLUSION

Endovascular management of a traumatic renal arterial injury is the best approach to preserve renal function in hemodynamically stable patients who cannot tolerate laparotomy, due to risks associated with general anesthesia, and who can tolerate anticoagulation therapy.

A case of renal vein branch injury identified by multidetector computed tomography

A 39-year-old male fell from a forklift and was urgently transported to our hospital. His vital signs were stable at the initial visit. Contrast imaging computed tomography (CT) showed extravasation (Ev) of contrast medium emigrating outside of the renal capsule and hematoma around the right kidney, and he was diagnosed with traumatic right renal injury, Grade IV laceration [American Association for the Surgery of Trauma classification]. When imaging the inferior renal artery branch extremity perfusing the area where Ev was found in the following blood vessel contrast imaging, obvious Ev was not found in the arterial phase; however, massively spreading Ev was found in the area adjacent to the renal laceration in the venous phase after taking a contrast image of the renal parenchyma. Thus, he was diagnosed with a renal vein branch injury. The transcatheter arterial embolization (TAE) was performed to the area, resulting in the disappearance of Ev. The effectiveness of TAE for renal injury has been established; however, it is only performed for arterial hemorrhage. TAE for venous injury has not previously been considered because a tamponade is supposedly effective for hemostasis of venous hemorrhage due to the anatomy surrounding Gerota's fasciae. This is an extremely rare case in which only venous injury was identified, without obvious arterial hemorrhage. Gerota's fasciae were broken and hemostasis treatment was required. Because the renal artery is the end artery, the venous hemorrhage was controlled with arterial embolization. In our case, renal vein branch injury was identified on CT and hemorrhage was terminated using TAE for the renal artery branch. TAE can be used as a non-operative management for the successful treatment of renal vein branch injury.

Renal Artery Injury Secondary to Blunt Abdominal Trauma - Two Case Reports

BACKGROUND

Blunt abdominal trauma is routinely encountered in the Emergency Department. It is one of the main causes of morbidity and mortality amongst the population below the age of 35 years worldwide. Renal artery injury secondary to blunt abdominal trauma however, is a rare occurrence. Here, we present two such cases, encountered in the emergency department sustaining polytrauma following motor vehicle accidents.

CASE REPORT

We hereby report two interesting cases of renal artery injury sustained in polytrauma patients. In these two cases we revealed almost the entire spectrum of findings that one would expect in renal arterial injuries.

CONCLUSIONS

Traumatic renal artery occlusion is a rare occurrence with devastating consequences if missed on imaging. Emergency radiologists need to be aware of the CT findings so as to accurately identify renal artery injury. This case report stresses the need for immediate CT assessment of polytrauma patients with suspected renal injury, leading to timely diagnosis and urgent surgical or endovascular intervention.

Management of Renal Artery Occlusion Related to Multiple Trauma in Children: Two Case Reports

We report 2 successful treatment cases of renal artery occlusion (RAO) related to multiple trauma. A 4-year-old boy was diagnosed with right RAO and liver laceration after a traffic accident. Surgical thrombectomy and revascularization were performed, but the lacerated liver was not sutured. The lacerated liver was surgically repaired 6 days post operation because of delayed bleeding. Thirteen percent of the patient's right kidney function was conserved. Another 7-year-old boy was compressed by an agitator. Renal scintigraphy showed that the right kidney was nonfunctional. The patient underwent conservative observation without any complication. In stable patients with multiple trauma, RAO should be diagnosed as soon as possible.

Diagnosis and management of thoracic and abdominal vascular injuries

Thoracic and abdominal vascular injuries present a formidable challenge to the most experienced surgeon. As prehospital care improves, more patients with these injuries are reaching the hospital alive. Thus, the trauma surgeon must be prepared to deal with them rapidly and precisely. Hemodynamically unstable patients should be transferred directly to the operating room. In stable patients with penetrating thoracic wounds, chest X-ray and arteriography are typically employed to exclude vascular injury. Patients sustaining blunt chest trauma can be screened effectively with CT scanning. Incisions are chosen based on the injured vessel. Hemorrhagic shock is the usual presentation for abdominal vascular trauma. A high index of suspicion is critical in diagnosing occult injuries. This presentation reviews the etiology, diagnosis, and treatment of major thoracic and abdominal vascular injuries.

MDCT of blunt renal trauma: imaging findings and therapeutic implications

Objectives

To show the wide spectrum of computed tomography (CT) findings in blunt renal trauma and to correlate them with consequent therapeutic implications.

Methods

This article is the result of a literature review and our personal experience in a level II trauma centre. Here we describe, discuss and illustrate the possible CT findings in blunt renal trauma, and we correlate them with the American Association for the Surgery of Trauma (AAST) classification and their therapeutic implications.

Results

CT findings following blunt renal trauma can be grouped into 15 main categories, 12 of them directly correlated with the AAST classification and 3 of them not mentioned in it. Non-operative management, which includes the “watchful waiting” approach, endourological treatments and endovascular treatments, is nowadays widely adopted in blunt renal trauma, and surgery is limited to haemodynamically unstable patients and a minority of haemodynamically stable patients.

Conclusions

The interpretation of CT findings in blunt renal trauma may be improved and made faster by the knowledge of their therapeutic consequences.

Teaching Points

• The majority of blunt renal injuries do not require surgical treatment.

• CT findings in blunt renal injury must be evaluated considering their therapeutic consequences.

• Some CT findings in blunt renal trauma are not included in the AAST classification.

[Vascular ischemic lesions of the kidney in multiple trauma patients: incidence and management, a report of 7 cases]

AIMS

Study the incidence, type and outcome of traumatic ischemic arterial lesions of the kidney in multiple trauma patients.

MATERIALS AND METHODS

Retrospective study of 500 multiple trauma patients who underwent whole body 64 slice CT Scan (mean age 34 years old, sex ratio 4M/1W, mean ISS 29).

RESULTS

There were seven cases of vascular lesions of the left kidney 1.4% of patients (men, median age 25 years old, mean ISS43.9). These were closed traumas with sudden deceleration and dissection of the renal artery trunk in three cases and injury to its branches in four cases with preserved excretion. Three patients died of associated injuries, including one patient who received a stent on D0. One patient underwent a nephrectomy and the three other patients were not treated which did not affect renal function or pressure (follow-up 19 months).

CONCLUSION

We found a high incidence of traumatic renal dissection in multiple trauma patients. Multidetector scan appears to provide the best results for the diagnosis of these lesions as well as the many associated lesions resulting in a very poor prognosis for these patients. Treatment is not well defined and management of these lesions is often of secondary importance because of the severity of associated injuries.

Isolated renal artery thrombosis because of blunt trauma abdomen: report of a case with review of the literature

BACKGROUND

Isolated renal trauma in case of blunt trauma abdomen (BTA) is not common. Renal artery occlusion by thrombosis in such cases is seen very rarely. These cases had been traditionally treated by early nephrectomy, but nowadays, renal preservation is considered whenever possible. Treatment options to do so are being developed.

METHODS

Recently we came across one such case of isolated unilateral renal artery thrombosis (RAT) because of BTA. Relevant literature especially on various therapeutic techniques has been critically reviewed briefly along with case presentation.

RESULTS

Isolated blunt traumatic RAT has an incidence of less than 1%. Only about 400 cases have been reported. It must be diagnosed and treated as soon as possible to avoid progressive permanent loss of renal function. Contrast-enhanced CT scanning is the preferred modality for evaluation and follow-up of RAT. Conservative treatment is reserved for unilateral cases. For bilateral cases and when RAT occurs in a solitary kidney, revascularization either surgically or more preferably by less invasive percutaneous techniques has been recommended.

CONCLUSION

Renal arterial thrombosis because of blunt abdominal trauma is still an underreported entity, treatment for which has not yet been established. Both early nephrectomy and delayed revascularization are not justified treatment options.

Intermediate-term follow-up of patients treated with percutaneous embolization for grade 5 blunt renal trauma

BACKGROUND

The short-term efficacy and safety of percutaneous embolization for the treatment of hemodynamically unstable patients with grade 5 renal injuries secondary to blunt trauma has been previously established; however, there has been no published intermediate-term follow-up. The purpose of this study is to report intermediate-term follow-up and complications for this treatment modality.

METHODS

A retrospective study was performed to determine intermediate-term outcomes in an observational cohort of patients who underwent percutaneous embolization for the management of grade 5 blunt renal trauma. Demographic and perioperative data were obtained. Follow-up was performed via mail and/or phone questionnaires.

RESULTS

Between October 2004 and July 2008, 10 hemodynamically unstable patients with grade 5 blunt renal trauma were treated with percutaneous embolization. Mean age of the cohort was 29 years (range, 5-50). Mean follow-up via phone and/or mail questionnaires was 2.7 years (1.5-5.1 years). One patient reported a new diagnosis of hypertension, which is well controlled by a single antihypertensive medication. There were no reported complications of refractory hypertension, altered renal function, new urolithiasis, chronic pain, urine leak, arteriovenous fistula, or pseudoaneurysm. No other procedures were required after the initial embolization for their renal trauma.

CONCLUSIONS

Management of grade 5 renal injuries with percutaneous embolization is safe and is not associated with intermediate-term adverse events.

A 10-year review of blunt renal artery injuries at an urban level I trauma centre

INTRODUCTION

Little consensus exists over the management of high-grade renal injuries, with continued debate over observation versus invasive surgery. Blunt renal artery injury (BRAI) is a high-grade injury that may result in renal dysfunction, hypertension, or failure.

MATERIALS AND METHODS

Management of BRAI at a level I trauma centre during a decade was retrospectively reviewed to determine incidence, assess management strategy, and evaluate hospital outcomes. Data collected included demographics, injury details, standardised scoring, renal injury grade, haemodynamic stability, diagnostic modalities, medical interventions, mortality, and hospitalisation length.

RESULTS

Thirty-eight BRAI patients (21 Grade IV and 17 Grade V injuries) were admitted, representing 0.16% of trauma admissions, and consisting primarily of young males. Ultrasonography and CT was performed in 92.1% and 76.3% of patients, respectively. Primary management included exploratory laparotomy in 42.9%, angiography and embolisation in 34.3%, and observation in 22.9%. Six nephrectomies and one revascularisation were performed. The incidence of BRAI and use of angiography are higher than those reported in previous studies.

CONCLUSION

Over the past decade, increased use of CT as a diagnostic tool for confirming renal injury in haemodynamically stable patients at our institution may have contributed to the increase in BRAI detection. Higher utilisation of angiography has enabled a more conservative approach. In this series, angiography had a success rate of 94.4%. Angiography and embolisation or observation with careful monitoring are viable management options in haemodynamically stable patients with isolated BRAI.

Percutaneous embolization for the management of grade 5 renal trauma in hemodynamically unstable patients: initial experience

PURPOSE

We evaluated the efficacy and safety of percutaneous embolization for the treatment of grade 5 renal injuries secondary to blunt trauma in patients who are hemodynamically unstable.

MATERIALS AND METHODS

This study was a retrospective analysis of grade 5 blunt renal trauma managed with percutaneous embolization between October 2004 and December 2007. Technical success was defined as complete occlusion of all renovascular bleeding at the end of the procedure. Clinical success was defined as the stabilization of vital signs and absence of need for further surgical or radiological intervention.

RESULTS

Nine patients (6 male and 3 female) with grade 5 renal injury secondary to blunt trauma were treated with percutaneous embolization. These patients did not require surgery for other intra-abdominal injuries. Mean patient age was 30 years (median 34, range 5 to 56, SD 15). Mean hospital length of stay was 18 days (median 13, range 5 to 46, SD 14). Mean units of packed red blood cells transfused for each patient was 6 (median 5, range 0 to 17, SD 5) with 2 receiving none. Technical success was achieved in all patients (100%) and all showed complete resolution of active extravasation on angiography. Clinical success was achieved in all patients (100%) with none requiring further intervention.

CONCLUSIONS

Percutaneous embolization for the management of grade 5 renal injuries is safe and effective with an excellent success rate in our series. The overall complication rate is minimal. Larger studies with long-term followup are needed to assure durability and efficacy.

[Bilateral traumatic dissection of the renal arteries]

The bilateral dissection of the renal arteries is uncommon after blunt trauma. The clinical symptoms are scarce and inconstant. The diagnosis is based on contrast-enhanced computed tomography with intravenous contrast and angiographic examination is required only if an endovascular revascularization is envisaged. We reported here, an exceptional case of bilateral traumatic dissection of the renal arteries associated with acute renal failure. The delayed revascularization does not allow the recuperation of a renal function.

Renal arterial injuries: a single center analysis of management strategies and outcomes

PURPOSE

Management of main and segmental renal artery injury following external trauma is controversial. After main renal artery injury the controversy surrounds nephrectomy vs revascularization, whereas after segmental renal artery injury the debate involves operative vs nonoperative management. We reviewed our experience with renal artery injury management at a single trauma center with the goal of identifying optimal clinical management strategies.

MATERIALS AND METHODS

Data on a total of 82 renal artery injuries in 81 patients collected between 1978 and 2006 were retrospectively reviewed. Patient demographics, length of stay, transfusion requirements and injury characteristics (artery subtype, grade, mechanism, and associated parenchymal, venous and nonrenal injuries) were recorded. Management strategies and outcomes for each renal artery injury subtype were compared.

RESULTS

Median patient age was 28 years (range 4 to 74) and 90% of the patients were male. Main renal artery injury occurred in 36 of 81 patients (43%) and segmental renal artery injury occurred in 45 (57%). Injury characteristics were similar for each renal artery injury subtype. For main renal artery injury the respective outcomes of nephrectomy vs vascular repair were a mean transfusion of 10,275 vs 6,125 ml (p = 0.39), length of stay 18 days for each, mortality rate 26% vs 13%, renal failure rate 8% vs 25% and renal insufficiency/impaired selective function by renal scintigraphy 4% vs 13% (each p not significant). For segmental renal artery injury operative vs nonoperative management was associated with a mean transfusion of 4,994 vs 820 ml (p = 0.01), length of stay 29 vs 11 days (p = 0.23) and mortality rate 8% vs 6% (p = 1.0). Renal failure and impaired selective renal function on scintigraphy were similar between the groups.

CONCLUSIONS

Nephrectomy for main renal artery injury has outcomes similar to those of vascular repair and it does not worsen posttreatment renal function in the short term. Nonoperative management for segmental renal artery injury results in excellent outcomes.

[Traumatic unilateral renal artery thrombosis and protein C deficiency. A case report]

Post traumatic renal artery thrombosis is rarely described in the literature. This pathology can result from stretch injury to inelastic intima of the renal artery, or by the direct flow to the abdomen causing compression injury to the renal artery against the vertebral column. However, the association of this pathology with hematologic diseases (in particular protein C deficit) was never described. We report an observation of a 28-year-old man with an uneventful history who was admitted to the intensive care unit for traumatic head injury associated with post traumatic renal artery thrombosis requiring nephrectomy. The etiologic investigation of this thrombo-embolic complication reveals a protein C deficit. Our patient was improved under treatment. This original observation confirms that post traumatic renal artery thrombosis can be associated with hematologic diseases (in particular protein C deficit).

Effects of blast injury on kidneys in abdominal gunshot wounds

OBJECTIVES

To determine the rate of renal fragmentation resulting from blast effects and perform microscopic examination of renal arteries after gunshot wounds resulting from a high-velocity bullet.

METHODS

A total of 194 patients with gunshot wounds due to blast effects underwent surgical exploration. Of the 194 patients, 35 (18%) had 37 renal unit injuries (2 patients had bilateral renal injury). Of the 37 renal units, 32 were treated with nephrectomy and 5 with renoraphy. During surgical exploration, 7 patients were found to have renal fragmentation resulting from blast effects. The distance between the bullet direction in the body and the renal parenchyma was evaluated. Also, the histologic changes in the renal artery were examined microscopically.

RESULTS

Although the renal injury rate from abdominal gunshot wounds due to high-velocity bullets was 18%, the renal fragmentation rate due to blast effect was 0.36%. The mean distance between the bullet direction in the body and the renal parenchyma in patients with renal fragmentation was 2.2 cm (range 1 to 5). Two patients had intimal lacerations and one had minimal thrombosis.

CONCLUSIONS

Renal fragmentation from the blast effect in these patients was closely related to the distance between the bullet direction in the body and the renal parenchyma. The possibility was greater for close-range (less than 50 m) gunshots. We believe that the histologic changes in the renal artery are not very important in the patients.

[Renal trauma. Treatment strategies and indications for surgical exploration]

Most renal injuries are blunt, involve a young patient population, and are caused by motor vehicle accidents or sport injuries. Renal trauma is classified into five grades with the majority of injuries being minor. CT scan has become the standard investigation method and should be performed in blunt trauma with macroscopic hematuria. Open trauma requires a radiological work-up in all forms of hematuria and in cases of clinical suspicion due to the wound entrance. Treatment management of most injuries has become conservative. Absolute indications for surgical revision are persistent life-threatening bleeding, renal pedicle injuries as well as an expanding, pulsatile retroperitoneal hematoma. Indications become relative in the presence of large devitalized renal tissue with urinary extravasation and other abdominal injuries, particularly of the pancreas and the colon. Surgical revision is more often indicated in open trauma, but surgery should enable renal reconstruction in the majority of cases.

Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank

BACKGROUND

Blunt renal artery injuries are rare and no single trauma center can accumulate substantial experience for meaningful conclusions about optimal therapeutic strategies. The purpose of this study was to assess the incidence of renal artery injuries after different types of blunt trauma, and evaluate the current therapeutic approaches practiced by American trauma surgeons and the effect of various therapeutic modalities on hospital outcomes.

STUDY DESIGN

This was a National Trauma Data Bank study including all blunt trauma admissions with renal artery injuries. Demographics, mechanism of injury, Injury Severity Score, Abbreviated Injury Score for each body area (head, chest, abdomen, extremities) injuries, type of management (nephrectomy, arterial reconstruction, or observation), time from admission to definitive treatment, and hospital outcomes (mortality, ICU, and hospital stay) were analyzed. Multiple and logistic regression analyses were used to examine the relationship between type of management and hospital outcomes.

RESULTS

Of a total of 945,326 blunt trauma admissions, 517 patients (0.05%) had injuries to the renal artery. Of the 517 patients, the kidney was not explored in 376 (73%), 95 (18%) patients had immediate nephrectomy, and 45 (9%) patients underwent surgical revascularization. In 87 of 517 (17%) patients, renal artery injury was the only intraabdominal injury. Of the 87 patients with isolated renal artery injuries, 73 (84%) were observed, 7 (8%) underwent surgical revascularization, and 7 (8%) had early nephrectomy. Multiple regression analysis demonstrated that patients who had surgical revascularization had a considerably longer ICU and hospital stay than observed patients. Patients who had nephrectomy had a considerably longer hospital stay than observed patients.

CONCLUSIONS

Blunt renal artery injury is rare. Nonoperative management should be considered as an acceptable therapeutic option.

Renal artery stent revascularization with embolic protection in patients with ischemic nephropathy

A prospective analysis of renal artery stent revascularization with distal embolic protection in a high-risk patient population with ischemic nephropathy is presented. A total of 63 patients (median age 70.2 years, range 54-86 years) had significant atherosclerotic stenosis of 83 renal arteries documented on pre-procedural imaging. All patients had baseline chronic renal insufficiency with a documented deterioration in renal function in the 6 months before revascularization. The endovascular technique used in all patients involved primary passage of an embolic filter into the distal main renal artery followed by primary stent deployment with a balloon expandable stainless steel stent. The filter baskets were recaptured and contents submitted for pathological analysis. At 6 months post-intervention, 97% of patients demonstrated stabilization or improvement in renal function. Only 3% of patients had an inexorable decline in renal function, unchanged by the intervention. After a mean follow up of 16.0 months (6-27), 94% of patients demonstrated stabilization or improvement in renal function. One patient suffered an acute post-procedural deterioration in renal function. In total, 60% of the filter baskets contained embolic material. This study confirms the technical feasibility of renal artery stent deployment with adjuvant embolic protection. The excellent results for renal preservation at 6 months post-intervention also suggest that a distal embolic protection device may improve the impact of percutaneous renal revascularization on progressive deterioration in renal function. The postulated mechanism is through the prevention of atheromatous embolization and the embolic yield from the distal filters supports this hypothesis. Patients most likely to receive the greatest benefit are those with mild baseline chronic renal insufficiency and a recent decline in renal function.

Thrombolytic therapy for traumatic unilateral renal artery thrombosis

We report a case of traumatic unilateral renal artery thrombosis that was successfully treated by thrombolytic therapy. The patient was a 17-year-old woman, who had put her left upper abdomen between a wall and the handle of a ground roller when using it. A computed tomography scan with intravenous contrast showed a lack of contrast in the left kidney. Angiography showed complete occlusion of the left renal artery, and the diagnosis was traumatic left renal artery thrombosis. Following angiography, thrombolytic therapy was performed. Urokinase was administered into the left renal artery, and 360,000 units per 1.5 h was required. Thrombus disappeared and flow of left renal artery was observed. Recovery of left renal function was seen on renoscintigraphy. Surgical maneuvers for traumatic renal artery thrombosis are autotransplantation or thrombectomy generally, but we think that thrombolytic therapy following angiography is a less invasive method and saves warm ischemic time.

The Literature Increasingly Supports Expectant (Conservative) Management of Renal Trauma — A Systematic Review

BACKGROUND

The perfect degree of operative intervention in renal trauma is unknown. However, expectant management for most blunt renal trauma is the standard of care, and nonoperative management is increasingly accepted for stab wounds. The best treatment of gunshot wounds and vascular injuries is still unclear; however, recent data indicates that a trial of nonoperative therapy may be warranted in those not exsanguinating from the kidney. Conservative management has many benefits, the greatest of which is decreasing the rate of iatrogenic nephrectomy. We have reviewed the world's literature to determine the level of support for expectant management of renal injury.

METHODS

The English language literature concerning renal trauma was identified with the assistance of Medline, and additional cited works not picked up in the initial search were obtained. One hundred and ten citations were ultimately reviewed dating back to 1947.

RESULTS

Most modern citations support at least a trial of expectant management for renal trauma patients not exsanguinating from the kidney, and without ureteral or renal pelvis injuries. The treatment of renovascular injuries has less consensus, but it appears that 'conservative' management by the application of nephrectomy is often the best approach, although renovascular repair may be attempted in rare cases.

CONCLUSION

Dozens of papers going back as far as 50 years seem to support the wider use of nonoperative therapy of renal injuries, although for unclear reasons, this approach is not yet universally accepted.

Evaluation and management of renal injuries: consensus statement of the renal trauma subcommittee

OBJECTIVE

To determine the optimal evaluation and management of renal injuries by review of the world's English-language literature on the subject.

METHODS

A consensus conference convened by the World Health Organization and the Societé Internationale d'Urologie met to critically review reports of the diagnosis and treatment of renal trauma. The English-language literature about renal trauma was identified using Medline, and additional cited works not detected in the initial search obtained. Evidence-based recommendations for the diagnosis and management of renal trauma were made with reference to a five-point scale.

RESULTS

There were many Level 3 and 4 citations, few Level 2, and one Level 1 which supported clinical practice patterns. Findings of nearly 200 reviewed citations are summarized.

CONCLUSIONS

Published reports on renal trauma still rely heavily on expert opinion and single-institution retrospective case series. Prospective trials of the most significant issues, when possible, might improve the quality of evidence that dictates the behaviour of practitioners.

Pediatric Blunt Trauma Resulting in Major Arterial Injuries

Ten children, aged 4 to 14 years, sustaining blunt arterial trauma from motor vehicle collisions (6), bicycle accidents (2), and falls (2) were identified over a 10-year period. The arteries injured included the common iliac (3), abdominal aorta (2), carotid (2), brachial (2), and the subclavian, renal, and femoral artery (1 each). One patient had three arterial injuries. Six patients had associated injuries including a pelvic and lumbar spine fracture, Horner's syndrome, liver laceration, skull fracture, open humerus fracture, small bowel serosal tear, and a brachial plexus injury. Definitive diagnosis was made using arteriography (6), computed tomography (CT) scan (2), and physical examination (2). The types of arterial injuries found included incomplete transection, complete transection with pseudo-aneurysm formation, traumatic arteriovenous (AV) fistulas, complete occlusion, and dissection. Repair was accomplished by hypogastric artery interposition or bypass grafting, synthetic grafting with polytetrafluoroethylene (PTFE), reverse saphenous vein grafting, or primary repair, depending on the circumstances. An AV fistula between the carotid artery and cavernous sinus was embolized. All grafts remained patent with exception of the aorto-renal bypass graft at follow-up ranging from 1 month to 3 years. The principles for repairing vascular injuries in children are slightly different than those in adults. Every effort should be made to use autogenous tissue such as the hypogastric artery or saphenous vein for repair if possible. If not, PTFE grafts can be used, although the long-term patency of these grafts in growing children is not known.

Imaging of renal trauma

Trauma is a major cause of death and disability and renal injuries occur in up to 10% of patients with significant blunt abdominal trauma. Patients with penetrating trauma and hematuria, blunt trauma with shock and hematuria, or gross hematuria warrant imaging of the urinary tract specifically and CT is the preferred modality. If there is significant perinephric fluid, especially medially, or deep laceration, delayed images should be obtained to evaluate for urinary extravasation. Most renal injuries are minor, including contusions, subcapsular and perinephric hematoma, and superficial lacerations. More significant injuries include deep lacerations, shattered kidney, active hemorrhage, infarctions, and vascular pedicle and UPJ injuries. These injuries are more likely to need surgery or have delayed complications but may still often be managed conservatively. The presence of urinary extravasation and large devitalized areas of renal parenchyma, especially with associated injuries of intraperitoneal organs, is particularly prone to complication and usually requires surgery. Active hemorrhage should be recognized because it often indicates a need for urgent surgery or embolization to prevent exsanguination.

Major renal injuries in children: the real incidence of kidney loss

BACKGROUND

The prognosis of major renal injuries appears to have improved since a conservative approach has been promoted. The overall prognosis might be less optimistic if all cases are pooled, whatever the type of initial injury (parenchymal or vascular) or the type of treatment (operative or conservative).

METHODS

The records of 32 children were reviewed. Six patients had a vascular injury, and 26 had a parenchymal injury. Ten were operated on within one month after trauma, and 3 (including one previously operated) underwent delayed surgery for sequelae. Parenchymal loss from atrophy was estimated on echography, computerized tomography, or radionuclide scintigraphy.

RESULTS

Fourteen patients (44%) recovered a functioning kidney. Nine (28%: all 6 patients with vascular injury and 3 with parenchymal trauma) lost their kidney from nephrectomy (n = 3) or atrophy (n = 6). Seven patients had severe or moderate sequelae from either partial nephrectomy or partial atrophy. Two had a minimal loss from polar hypotrophy. The incidence of kidney loss or sequelae was 56% (18 of 32 patients).

CONCLUSION

In keeping with the literature data provided all cases are analyzed, at least one out of 4 kidneys will be lost or severely damaged after major kidney trauma in children.

Hypertension in an adolescent boy

We report the case of an adolescent boy who presented with hypertension and hypokalemia. A systematic work-up revealed hyperreninemic hyperaldosteronism. Further study revealed Page kidney caused by trauma-associated renal hematoma. The evaluation and management of hyperaldosteronism and Page kidney are discussed.

TNF-alpha-dependent bilateral renal injury is induced by unilateral renal ischemia-reperfusion

While tumor necrosis factor (TNF)-alpha is an important mediator of renal ischemia-reperfusion (I/R) injury, its role in contralateral renal injury after isolated renal ischemia remains unknown. We therefore investigated the effect of isolated left renal ischemia on the nonischemic contralateral kidney. To study this, male Sprague-Dawley rats were anesthetized and exposed to varying degrees of left renal I/R injury. Both kidneys were subsequently harvested, serum samples were obtained, and TNF-alpha protein expression (ELISA), TNF-alpha mRNA content (RT-PCR), TNF-alpha immunolocalization, and neutrophil infiltration (myeloperoxidase assay) were determined. The effect of TNF-alpha on neutrophil infiltration was assessed by neutralizing TNF-alpha with TNF binding protein (TNF-BP) before left renal I/R injury. TNF-alpha protein expression, TNF-alpha mRNA induction, and neutrophil infiltration increased significantly in both kidneys after unilateral renal I/R injury. Furthermore, the administration of TNF-BP before unilateral renal I/R substantially reduced the degree of neutrophil infiltration bilaterally. These results constitute the initial demonstration that unilateral renal I/R induces bilateral TNF-alpha production and neutrophil infiltration through a TNF-alpha-dependent mechanism.

Renal vascular injuries

Even today, most renal vascular injuries result in loss of renal function. Kidney salvage is not possible because of late diagnosis and the presence of severe associated injuries. Physical exam and basic laboratory tests are not sensitive; thus, a high index of suspicion is required. Repair should be attempted for all solitary kidneys and for patients sustaining bilateral injuries. All viable kidneys should be revascularized in order to increase the chances of obtaining adequate functional renal tissue. In the event that revascularization is not feasible, nephrectomy can be performed at a later time, if hypertension develops. In some cases, delayed return of function is possible, but in most cases the kidney will atrophy without producing hypertension. Most importantly, maintaining a high index of suspicion, prompt diagnostic evaluation, and judicious treatment can optimize outcome lowering the significant morbidity and mortality of renal vascular injuries.

Genitourinary trauma

Injuries to the GU system commonly occur in patients with high-energy lower abdominal or pelvic trauma. The emergency physician should be well versed in the diagnosis and management of GU trauma, although these injuries are not usually life threatening because of the potential for loss of urinary or sexual function. In the setting of hemodynamic instability, diagnosis and treatment of GU injuries is often accomplished in the operative setting. In the stable patient, diagnostic testing is directed by the type of suspected injury and must proceed in a reverse manner, i.e., external injury then urethral injury then bladder, and finally urethral and renal damage. Treatment focuses on a team approach between the emergency physician, general, orthopedic, and urologic surgeon. The decision for operative repair is often dictated more by other associated injuries than urologic injuries, and the urologic surgeon often provides temporizing measures with definitive repair at a later time. Prompt diagnosis and treatment of injuries to the external genitals results in excellent long-term outcome, minimizing the devastating consequences of impotence, urinary incontinence, and sexual disfiguration.

Outcome after major renovascular injuries: a Western trauma association multicenter report

BACKGROUND

Major renal vascular injuries are uncommon and are frequently associated with a poor outcome. In addition to renal dysfunction, posttraumatic renovascular hypertension may result, although the true incidence of this complication is unknown. The objective of this study was to describe the factors contributing to outcome after major renovascular trauma. We hypothesized that the highest percentage of renal salvage would be achieved by minimizing the time from injury to repair.

METHODS

This was a retrospective chart review over a 16-year period conducted at six university trauma centers of patients with American Association for the Surgery of Trauma grade IV/V renal injuries surviving longer than 24 hours. Postinjury renal function with poor outcome was defined as renal failure requiring dialysis, serum creatinine greater than or equal to 2 mg/dL, renal scan showing less than 25% function of the injured kidney, postinjury hypertension requiring treatment, or delayed nephrectomy. Data collected for analysis included demographics, mechanism of injury, presence of shock, presence of hematuria, associated injuries, type of renal injury (major artery, renal vein, segmental artery), type of repair (primary vascular repair, revascularization, observation, nephrectomy), time from injury to definitive renal surgery, and type of surgeon performing the operation (urologist, vascular surgeon, trauma surgeon).

RESULTS

Eighty-nine patients met inclusion criteria; 49% were injured from blunt mechanisms. Patients with blunt injuries were 2.29 times more likely to have a poor outcome compared with those with penetrating injuries. Similarly, the odds ratio of having a poor outcome with a grade V injury (n = 32) versus grade IV (n = 57) was 2.2 (p = 0.085). Arterial repairs had significantly worse outcomes than vein repairs (p = 0.005). Neither the time to definitive surgery nor the operating surgeon's specialty significantly affected outcome. Ten percent (nine patients) developed hypertension or renal failure postoperatively: three had immediate nephrectomies, four had arterial repairs with one intraoperative failure requiring nephrectomy, and two were observed. Of the 20 good outcomes for grade V injuries, 15 had immediate nephrectomy, 1 had a renal artery repair, 1 had a bypass graft, 1 underwent a partial nephrectomy, and 2 were observed.

CONCLUSION

Factors associated with a poor outcome following renovascular injuries include blunt trauma, the presence of a grade V injury, and an attempted arterial repair. Patients with blunt major vascular injuries (grade V) are likely to have associated major parenchymal disruption, which contributes to the poor function of the revascularized kidney. These patients may be best served by immediate nephrectomy, provided that there is a functioning contralateral kidney.

Management of complex violent trauma to the upper urinary tract

Since abdominal and retroperitoneal trauma may endanger both the kidney and ureter, urologists are frequently called upon to evaluate an injured patient in the emergency department or in the operating room. In this setting, the suspicion of urological injury begins a clinical cascade of decision making and diagnostic testing. The recognized injury, if appropriately managed, usually heals without incident. The unrecognized injury may jeopardize the recovery of the trauma patient, such as the patient who has sustained an occult ureteral laceration and continues to have an ‘unexplained’ ileus or fever. Although urinary injury is not usually the sole compelling event in severe trauma, thoughtful consideration and treatment of renal and ureteral injuries, collectively referred to as upper urinary tract injuries, will help the surgeon to avoid troublesome management complications.

As urological surgeons, we owe a debt to early pioneers in surgical traumatology who provided the groundwork for acute care management and the management of solid and hollow organ injuries. Upon this framework, the management of urological trauma has blossomed through experience and introspection. Advances in imaging modalities, improvements and renovations of surgical technique, and critical review of outcomes data have influenced the management of genito-urinary trauma and will certainly alter the way we treat trauma patients in the next millennium. This paper illustrates some important concepts in acute genito-urinary trauma and helps towards an improved understanding of acute urological care.