|Year : 2003 | Volume
| Issue : 1 | Page : 68-70
Massive hematuria due to delayed spontaneous rupture of post-traumatic renal artery pseudoaneurysm : A case report
Uttam K Mete1, Pamposh Raina1, AK Mandal1, J Rajiv Bapuraj2, SK Singh1, AK Goswami1, SK Sharma1
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
Uttam K Mete
Department of Urology, PGIMER, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
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 May 31];20:68-70. Available from: http://www.indianjurol.com/text.asp?2003/20/1/68/37134
| Case Report|| |
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|| |
Autopsy studies have reported an incidence of renal artery aneurysms of 0.01 % to 0.09%.  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. 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. 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|| |
|1.||Charron J, Helanger R, Vauclair R, Leger C, Razavi A. Renal artery aneurysm : Polyaneurysmal lesion of kidney. Urology 1975; 5(1): 1-11. |
|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. |
|3.||Chazen MD, Miller KS : Intrarenal pseudoaneurysm presenting 15 years after penetrating renal injury. Urology 1997: 49(5): 774-776. |
[Figure - 1], [Figure - 2]