Endovascular management of blunt traumatic renal artery dissection

Endovascular salvage of occluded renal artery after >15 hours of ischemic time

In severe cases of acute traumatic injury to the kidney, immediate intervention is necessary to avoid irreversible ischemic damage. This case involves a 24-year-old woman who presented with signs of right renal devascularization after a high-speed all-terrain vehicle accident. Due to transport from an outside hospital, there was >15-hour delay before evaluation by vascular surgery. Considering her young age, we elected to salvage this patient's kidney via percutaneous endovascular stenting to mitigate any further prolongation of renal artery occlusion and prevent long-term sequelae. After intervention, her acute kidney injury resolved, and her creatinine levels normalized. As illustrated in this case, recovery of the renal parenchyma remains a possibility despite an extended warm ischemic time, providing evidence for future young patients to be considered for renal salvage.

Traumatic renal artery occlusion secondary to blunt trauma in a second-trimester pregnant woman who managed successfully with non-operative management: A rare case report

Blunt renal injuries in pregnancy are seldom isolated, with resultant renal vascular injury following this type of injury being extremely rare. We present a rare case of complete blockage of the left renal artery about 1 cm from the aortic opening in a second-trimester pregnant woman after she sustained a motor-vehicle-accident. She was managed successfully with NOM. Traumatic renal artery blockage is a rare condition with devastating consequences if missed on imaging. Although blunt renal trauma during pregnancy is a rare condition, NOM has become increasingly popular to reduce morbidity associated with nephrectomy resulting in higher rates of renal salvage.

Traumatic Urinary Bladder and Renal Artery Disruption with Kidney Salvage—A Case Report

Motor vehicle accidents continue to cause thousands of life threatening injuries or mortality (nearly 45,000 deaths in 2021) in the United States. A sixteen year-old young man riding a motorcycle was severely injured when struck by an automobile driven by an individual under the influence of alcohol. Multiple long bone fractures, the left renal artery torn off the aorta, with non-function of the left kidney, urinary bladder rupture with cystourethral injury, thoracic aortic disruption, and splenic fracture injuries were present. Emergency repair of the thoracic aorta, splenectomy, and left renal artery bypass were all completed. Absorbable suture repair of the urinary bladder and cystouretheral junction injuries followed Foley and suprapubic bladder decompression. All long bone fractures were stabilized and corrected. Normal urinary function of the left kidney returned, and urinary bladder control accompanied the four-month recuperation. Six and twelve month follow-up showed almost normal mobility with normal bilateral renal and urinary bladder function.

The Role of Renal Artery Embolisation in the Management of Blunt Renal Injuries: A Review

Renal injuries are the most common urinary tract injury secondary to external abdominal trauma. They are caused by blunt, penetrating and iatrogenic mechanisms. Despite the high number of blunt renal injuries, little evidence is available to guide management, especially with the evolution of embolisation as a minimally invasive treatment. Consequently, clinical practice is driven by results of observational studies and anecdote. We have reviewed the current trends in practice when using renal artery embolisation in the management of blunt renal injuries. Three key principles are highlighted. First, high-grade blunt renal injuries can be successfully managed with embolisation. Second, embolisation should be considered when there is radiological evidence of active contrast extravasation, pseudoaneurysm or arteriovenous fistula. Third, embolisation can be used to manage blunt renal injuries in haemodynamically unstable patients. Beyond this, evidence regarding optimal technique, CT indications, clinical status, comorbidities and complications are inconclusive. We discuss the implications for clinical practice and how these findings should define the agenda for future clinical research.

Abdominal vascular hemorrhage

Major abdominal vascular injuries are noted in 5%–10% of patients undergoing laparotomy for blunt trauma. In contrast, injuries to named abdominal vessels are present in 20%–25% of patients undergoing laparotomy after gunshot wounds and in 10% after stab wounds. Hence, all surgeons performing laparotomies after abdominal trauma must be familiar with techniques for exposure and management of these injuries.

Endovascular embolization in renal trauma: a narrative review

Approximately 1–3% of all trauma patients have a renal injury. Eighty percent of renal trauma is due to blunt injury, with the remainder due to penetrating trauma which is most often iatrogenic. Contrast enhanced computed tomography is used to triage patients and offers a quick and accurate assessment of any potential organ injury. If injury is present, The American Association for the Surgery of Trauma grading system can both grade renal injuries and be used to help guide management and intervention. Grades are assigned based on imaging and clinical features of renal trauma, and have prognostic and treatment implications for patients. The objective of this narrative review is to identify optimal management of patients with renal trauma, specifically which patients can be treated with endovascular interventions following renal trauma, which can be observed, and which would be best managed surgically. For hemodynamically stable patients with renal trauma, endovascular angiography and embolization is a non-invasive approach that can be used to control bleeding and potentially avoid surgery or nephrectomy in select cases. Future research is needed to determine if a specific antibiotic regimen is needed prior to or following embolization. Further research is needed to evaluate the effectiveness of endovascular management of high-grade renal trauma (grade V). Complications of renal embolization include short-term hypertension, long term hypertension in cases of significant ischemia, acute kidney injury, and infection.

[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.

Endovascular management of arterial injuries after blunt or iatrogenic renal trauma

The kidney is the third most common abdominal organ to be injured in trauma, following the spleen and liver, respectively. The most commonly used classification scheme is the American Association for the Surgery of Trauma (AAST) classification of blunt renal injuries, which grades renal injury according to the size of laceration and its proximity to the renal hilum. Arteriovenous fistula and pseudoaneurysm are the most common iatrogenic biopsy-related or surgery-related vascular injuries in native kidneys. The approach to renal artery injuries has changed over time from more aggressive intervention to more conservative observational or endovascular management, including selective transcatheter arterial embolization (TAE) and the placement of stents/stent grafts. In this article, we describe the role and technical aspects of endovascular interventions in the management of arterial injuries after blunt or iatrogenic renal trauma.

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.

Abdominal vascular trauma

Abdominal vascular trauma, primarily due to penetrating mechanisms, is uncommon. However, when it does occur, it can be quite lethal, with mortality ranging from 20% to 60%. Increased early mortality has been associated with shock, acidosis, hypothermia, coagulopathy, free intraperitoneal bleeding and advanced American Association for the Surgery of Trauma Organ Injury Scale grade. These patients often arrive at medical centers in extremis and require rapid surgical control of bleeding and aggressive resuscitation including massive transfusion protocols. The most important factor in survival is surgical control of hemorrhage and restoration of appropriate perfusion to the abdominal contents and lower extremities. These surgical approaches and the techniques of definitive vascular repair can be quite challenging, particularly to the inexperienced surgeon. This review hopes to describe the most common abdominal vascular injuries, their presentation, outcomes, and surgical techniques to control and repair such injuries.

Evaluation of characteristics, associations and clinical course of isolated spontaneous renal artery dissection

BACKGROUND

Spontaneous renal artery dissection (SRAD) is a rare entity of unknown etiology. We aimed to study the clinical course and outcomes and compare the characteristics of patients with SRAD with those of the general population.

METHODS

All cases of isolated renal artery dissection diagnosed at the University of Michigan Hospitals between January 2000 and July 2012 were identified by the ICD-9 code. Cases were matched by age, gender and race with individuals from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Characteristics and awareness of comorbid conditions were compared. Information about the clinical course after diagnosis was retrieved from the case group to ascertain their outcomes.

RESULTS

Overall, 17 patients with SRAD with a mean age of 38.6 years (SD = 8.3) were identified. Eleven patients were male and 14 were white. The most common presenting symptom was excruciating sudden-onset flank pain ipsilateral to the site of dissection. Fibromuscular dysplasia, Ehlers-Danlos and polyarteritis nodosa were present in 4, 4 and 1 patients, respectively. After adjusting in a multivariable model, the case group was more likely to report history of hypertension, cancer and connective tissue disorders (P < 0.001), and less likely to have obesity (BMI ≥30 kg/m(2)) compared with the general population. Supportive medical treatment, endovascular intervention and surgery were required in 8, 5 and 4 cases, respectively. After discharge from the hospital, hypertension was adequately controlled in all the patients but one.

CONCLUSION

SRAD may be part of a syndrome having multi-organ involvement. With appropriate medical or surgical management, long-term clinical outcome appears favorable.

The role of interventional radiology in urologic tract trauma

The kidney is the third most common abdominal organ to be injured in trauma, following the spleen and liver, respectively. Several classification systems convey the severity of injury to kidneys, ureter, bladder, and urethra. The most commonly used classification scheme is the American Association for the Surgery of Trauma (AAST) classification of blunt renal injuries, which grades renal injury according the size of laceration and its proximity to the renal hilum. Ureteral injury is graded according to its extent relative to the circumference of the ureter and the extent of associated devascularization. Bladder injury is graded according to its location relative to the peritoneum. Urethral injury is graded according to the extent of damage to surrounding anatomic structures. Although these classification schema may not be always used in common parlance, they do help delineate most important features of urologic tract injury that impact patient management and interventions.

Bilateral traumatic renal artery dissection

We present a case of bilateral renal artery dissection, with the related computed tomographic images, caused by blunt torso trauma. Discussion includes the etiologies of this type of injury, the diagnostic modalities, and treatment options.

Value of dual-phase multislice CT prior to minimally invasive therapy of iatrogenic renal injuries

PURPOSE

To evaluate the diagnostic impact of multislice computed tomography (MSCT) in treatment planning prior to transarterial coil embolization of iatrogenic renal injuries.

METHODS

Nine patients (median age 54 years, range 36-66) with iatrogenic renal vascular injury were treated with superselective coil embolization. Prior to therapy, a dual-phase (40 and 120 seconds) contrast-enhanced MSCT was applied in 6 patients. Seven patients underwent renal ultrasonography. Multiplanar reconstructions of the MSCT scans were used to affirm ongoing bleeding and to localize the bleeding site at the level of the segmental or interlobar artery. MSCT and angiographic findings were compared to evaluate the accuracy of MSCT in the detection of the bleeding source prior to therapy.

RESULTS

Multiplanar reconstructions of early-phase MSCT scans allowed precise identification of the bleeding interlobar or segmental artery in all 6 cases prior to angiography. In one case, MSCT was even able to detect a source of bleeding that was not revealed by selective renal angiography.

CONCLUSIONS

Multiplanar reconstructions of MSCT data demonstrate not only the presence of hematoma but also confirm ongoing bleeding and the location of the feeder artery prior to minimally invasive therapy.

Long-Term Results of Blunt Traumatic Renal Artery Dissection Treated by Endovascular Stenting

A 20-year-old man was admitted to the emergency department after falling 15 m onto the roof of a car and landing on his back. Imaging by computed tomography (CT) showed delayed perfusion of the right kidney and no excretion of contrast from that kidney on delayed images. Angiography confirmed a localized intimal dissection in the right main renal artery. We inserted a balloon-expandable stent using a transfemoral approach to successfully repair the dissection. At 4 year follow-up, Doppler ultrasound of the right renal artery and renal scintigraphy demonstrated preserved function of the right kidney. Our findings support endovascular stenting as a safe, effective and efficient treatment for blunt renal artery injury.