|Year : 2015 | Volume
| Issue : 3 | Page : 292-293
Angioembolization for post-traumatic renal arteriovenous malformations
Francis Sridhar Katumalla1, Aparajita Sophia D'souza2, Rajneesh Calton3, Kim Jacob Mammen1
1 Department of Urology, Christian Medical College, Ludhiana, Punjab, India
2 Department of Obstetrics and Gynaecology, Christian Medical College, Ludhiana, Punjab, India
3 Department of Cardiology, Christian Medical College, Ludhiana, Punjab, India
|Date of Web Publication||12-Jun-2015|
Dr. Francis Sridhar Katumalla
Department of Urology, Christian Medical College, Ludhiana - 141 008, Punjab
Source of Support: None, Conflict of Interest: None
The risk of renal arteriovenous malformations (AVMs) must be kept in mind as a cause as sudden hematuria in patients with previous renal injury. Treatment of renal AVMs has evolved from nephrectomy to angioembolization, as it allows good control bleeding while preserving maximum renal function and appears to be the first treatment of choice. Hence, angioembolization facilities must be available in centers dealing with renal trauma.
Keywords: Angioembolization, arteriovenous malformations, renal trauma
|How to cite this article:|
Katumalla FS, D'souza AS, Calton R, Mammen KJ. Angioembolization for post-traumatic renal arteriovenous malformations. CHRISMED J Health Res 2015;2:292-3
|How to cite this URL:|
Katumalla FS, D'souza AS, Calton R, Mammen KJ. Angioembolization for post-traumatic renal arteriovenous malformations. CHRISMED J Health Res [serial online] 2015 [cited 2020 Aug 15];2:292-3. Available from: http://www.cjhr.org/text.asp?2015/2/3/292/158720
| Introduction|| |
Renal injury has historically been reported as 1.2-3.3% of trauma patients, with the major mechanism being blunt trauma.  The consequences of blunt renal trauma range from simple contusion or renal hematoma to complete shattering of the organ or avulsion of the vascular pedicle. In the vast majority of cases, renal injuries are minor and self-limiting. , Multiple studies have shown that even high-grade renal trauma can be successfully managed conservatively in most cases.  An arteriovenous malformation (AVM) is an aberrant vascular shunt between the arterial and venous systems due to the absence of an intervening capillary bed.  The prevalence of AVMs is 0.04% in the general population and can be congenital or acquired. Acquired renal AVMs have been associated with renal biopsy, trauma, and malignancy.  Angiographic procedures can be used to treat vascular injury including AVMs effectively besides open surgery. 
| Case Report|| |
A 65-year-old gentleman presented with dull aching abdominal pain following a blunt trauma over the abdomen, which he sustained 3 days prior to admission. His vitals were stable, and blood investigations were normal (Hb - 10.2 g%, Cr - 1.1 mg/dl). Urine routine examination showed microscopic hematuria and contrast-enhanced computed tomography (CECT) showed multiple nonenhancing areas in the mid portion and lower pole of the left kidney; suggestive of lacerations (Grade III renal trauma). The patient was managed nonoperatively with bed rest, strict vital signs, regular hemogram and renal function test monitoring. He was discharged on seventh hospital stay in a stable condition. Two days later he presented to the emergency department with gross hematuria. He was hemodynamically unstable, with an acute drop in hemoglobin requiring multiple blood transfusions. Emergency cystoscopy revealed profuse efflux of blood from left ureteric orifice. Emergency Renal angiogram showed multiple AVMs that were actively bleeding [Figure 1]. Angioembolization was performed with Gelfoam (Spongostan; absorbable gelatin sponge). Postembolization angiogram confirmed cessation of bleeding from the AVM [Figure 2]. He was discharged on the fifth postprocedure day. This case is being reported for its importance of being aware of bleeding AVMs postrenal trauma and its successful treatment with renal artery embolization. The patient is asymptomatic 2 months after embolization.
|Figure 1: Angiogram showing multiple leaking arteriovenous malformations|
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| Discussion|| |
The vast majority of renal injuries are managed conservatively. Successful management of renal trauma largely depends on accurate diagnostic staging of the injury and detection of vascular complications. Contrast-enhanced spiral computed tomography is the best modality for assessing the extent and severity of renal parenchymal injury.  Surgical intervention most commonly results in nephrectomy which is performed in only 5-10% of renal injuries and continues to decline in frequency with the increasing availability of minimally invasive techniques.  In renal trauma causing vascular damage, super selective catheter embolization can be used effectively. Hemodynamically unstable patients can also be offered this treatment modality. Angioembolization has the potential to salvage as much viable renal tissue as possible in cases where exploration would often result in nephrectomy. 
The diagnosis of Renal AVM must be considered in patients presenting with hematuria with the prior history of blunt trauma abdomen. Treatment for renal AVMs has evolved from open nephrectomy to transcatheter arterial embolization (TAE). TAE is safe, effective, and provides a good outcome with minimal morbidity.  Hence, centers dealing with renal traumas should be well equipped with facilities and personals for performing angioembolisations. If in case the center lack such facilities and in the presence of impending bleed of the AVM the patient needs to be referred to a center with angioembolization facilities provided the patient remains stable. This will decrease avoidable nephrectomy and increase nephron preservation.
| Acknowledgment|| |
Dr. Rejul raj, Department of Urology, Christian Medical College, Ludhiana.
| References|| |
Myers JB, Brant WO, Broghammer JA. High-grade renal injuries: Radiographic findings correlated with intervention for renal hemorrhage. Urol Clin North Am 2013;40:335-41.
Fisher RG, Ben-Menachem Y, Whigham C. Stab wounds of the renal artery branches: Angiographic diagnosis and treatment by embolization. AJR Am J Roentgenol 1989;152:1231-5.
Dinkel HP, Danuser H, Triller J. Blunt renal trauma: Minimally invasive management with microcatheter embolization experience in nine patients. Radiology 2002;223:723-30.
Fleetwood IG, Steinberg GK. Arteriovenous malformations. Lancet 2002;359:863-73.
Muraoka N, Sakai T, Kimura H, Uematsu H, Tanase K, Yokoyama O, et al.
Rare causes of hematuria associated with various vascular diseases involving the upper urinary tract. Radiographics 2008;28:855-67.
Danuser H, Wille S, Zöscher G, Studer U. How to treat blunt kidney ruptures: Primary open surgery or conservative treatment with deferred surgery when necessary? Eur Urol 2001;39:9-14.
McGeady JB, Breyer BN. Current epidemiology of genitourinary trauma. Urol Clin North Am 2013;40:323-34.
Murata S, Onozawa S, Nakazawa K, Akiba A, Mine T, Ueda T, et al.
Endovascular embolization strategy for renal arteriovenous malformations. Acta Radiol 2014;55:71-7.
[Figure 1], [Figure 2]