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CASE REPORT
Year : 2003  |  Volume : 20  |  Issue : 1  |  Page : 68-70
 

Massive hematuria due to delayed spon­taneous rupture of post-traumatic renal artery pseudoaneurysm : A case report


1 Department of Urology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Correspondence Address:
Uttam K Mete
Department of Urology, PGIMER, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


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Keywords: Renal artery, pseudo-aneurysm, hematuria, spontaneous rupture.


How to cite this article:
Mete UK, Raina P, Mandal A K, Bapuraj J R, Singh S K, Goswami A K, Sharma S K. Massive hematuria due to delayed spon­taneous rupture of post-traumatic renal artery pseudoaneurysm : A case report. Indian J Urol 2003;20:68-70

How to cite this URL:
Mete UK, Raina P, Mandal A K, Bapuraj J R, Singh S K, Goswami A K, Sharma S K. Massive hematuria due to delayed spon­taneous rupture of post-traumatic renal artery pseudoaneurysm : A case report. Indian J Urol [serial online] 2003 [cited 2020 Sep 27];20:68-70. Available from: http://www.indianjurol.com/text.asp?2003/20/1/68/37134



   Case Report Top


A 22-year-old man sustained stab injury to the left side of his back near the renal angle. The wound was sutured by a local doctor. Three weeks later he developed a palpa­ble mass in the left iliac fossa. It was incised by the local doctor and it drained altered blood. Three years later he developed gross hematuria and was admitted to a local hospital with hypotension. He was treated conservatively. Two weeks after this episode he developed massive hae­maturia and was referred to our institution. He was resus­citated with intravenous fluids and blood transfusions. Physical examination revealed a pulsatile mass in the left side of upper abdomen with an audible bruit over it. Scar marks of the stab injury on the left side of his back and that of the drainage of hematoma in the left iliac fossa were evident.

Investigation revealed hemoglobin of 5 mg/dl with nor­mal renal biochemical parameters. An ultrasound of the abdomen showed a cystic mass in relation to inferomedial aspect of the kidney. CECT abdomen [Figure - 1] revealed a normally functioning right kidney. The small hydroneph­rotic poorly functioning left kidney had been pushed superolaterally by a contrast enhancing cystic mass.

Renal angiography demonstrated a left renal artery pseudoaneurysm with leakage of contrast from the left main renal artery. Left renal artery embolisation with microcoil was not successful [Figure - 2]. The patient contin­ued to have severe hematuria and was explored through a midline incision. The surgical procedure included left ne­phrectomy, evacuation of contents of the pseudoaneurysm and excision of its wall. The patient had an uneventful postoperative recovery.


   Comments Top


Autopsy studies have reported an incidence of renal artery aneurysms of 0.01 % to 0.09%. [1] Due to its rarity, very few vascular surgeons have extensive experience with the clinical management of renal artery aneurysms even in referral centres.

Historically, pseudoaneurysms most frequently resulted from penetrating trauma. Now-a-days they more frequently result from iatrogenic injury during arterial catheteriza­tion or arterial graft anastomotic disruption. Complete or tangential laceration of the artery usually causes hypoten­sion due to blood loss either externally or internally. Hy­potension and clotting at the injured site may cause temporary cessation of bleeding. With time, the clot liq­uefies, adjacent dead tissue loses integrity and a commu­nication is established between the intra and extra vascular spaces with the formation of a pseudoaneurysm whose wall contains fibrous tissue. This pseudoaneurysm may eventually erode into the adjacent viscera. Major clinical manifestations of renal artery aneurysms include pain, hypertension, rupture and hematuria.[2] Multiple diagnos­tic modalities are now available, although conventional renal angiography remains the gold standard.

The patients may becomes symptomatic even many years after the occurrence of diagnosis.[3] Hematuria is due to aneurysmal erosion into the collecting system. Super­selective embolisation is the first option to treat this con­dition due to its low morbidity and limited invasiveness. Pseudoaneurysm with short necks may be treated by sur­gical repair and reconstruction. Nephrectomy is indicated only when embolisation is unsafe or unsuccessful.

Deep penetrating stab injury in the back should be evalu­ated thoroughly at initial presentation, otherwise underly­ing visceral arterial injury could be missed. High index of suspicion is the only means to detect it early when con­servative and organ saving procedures could be performed. Delayed rupture into the collecting system though uncom­mon is a life-threatening event that mandates immediate surgical intervention to prevent exsanguination and death.

 
   References Top

1.Charron J, Helanger R, Vauclair R, Leger C, Razavi A. Renal ar­tery aneurysm : Polyaneurysmal lesion of kidney. Urology 1975; 5(1): 1-11.  Back to cited text no. 1    
2.Tham G, Ekelund L, Herrlin K, Lindstedt EL, Olin T; Bergentz SE. Renal artery aneurysm : Natural history and prognosis. Ann Surg 1983; 197; 348-352.  Back to cited text no. 2    
3.Chazen MD, Miller KS : Intrarenal pseudoaneurysm presenting 15 years after penetrating renal injury. Urology 1997: 49(5): 774-776.  Back to cited text no. 3    


    Figures

  [Figure - 1], [Figure - 2]



 

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