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Transcatheter embolization of an isolated lumbar arterial bleeding complicating radical nephrectomy for renal infarction with infected perirenal haematoma

Lumbar arterial bleedings are rare but potentially life threatening. We report a case of an isolated right lumbar arterial bleeding after radical nephrectomy for renal infarction with infected perirenal haematoma. The diagnosis was suggested by
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  See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/23566889 Transcatheter embolization of an isolatedlumbar arterial bleeding complicating radicalnephrectomy for renal...  Article   in  JBR-BTR: organe de la Société royale belge de radiologie (SRBR) = orgaan van de Koninklijke BelgischeVereniging voor Radiologie (KBVR) · September 2008 Source: PubMed CITATIONS 2 READS 12 5 authors , including:Sam HeyeUniversitair Ziekenhuis Leuven 131   PUBLICATIONS   1,193   CITATIONS   SEE PROFILE Raymond OyenUniversitair Ziekenhuis Leuven 268   PUBLICATIONS   3,180   CITATIONS   SEE PROFILE All content following this page was uploaded by Sam Heye on 20 December 2016. The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the srcinal documentand are linked to publications on ResearchGate, letting you access and read them immediately.  The incidence of vascular injuriesarising from diagnostic or therapeu-tic laparoscopic procedures is lessthan 1%, but when they occur, theycan have potentially life threateningconsequences (1-4). We report a casein which renal surgery was severelycomplicated due to local infectionand multiple adhesions, which wereresponsible for perioperative injuryof the right fourth lumbar artery.Lumbar arterial bleedings are diffi-cult to access anatomically and tomanage operatively, especiallywhen the region of injury is infected.Therefore we opted for percuta-neous radiological embolization tostop the retroperitoneal bleeding. Case report A 60-year-old female was trans-ferred to our hospital after percuta-neous kissing balloon angioplastyand stenting of the left common iliacartery, complicated by massive rightrenal infarction with perirenalhaematoma and acute renal failuredue to hypovolemic shock. At thattime, conservative treatment withhemodialysis and resuscitation wassuccessful.Medical history was significant forarterial hypertension, obesity, type IIdiabetes with diabetic nephropathyand anticoagulation therapy afteraortic valve replacement and CABG.Follow-up CT after 2 monthsshowed gas in the slightly involutedAnatomopathologic examinationof the resected specimen showeddiabetic glomerulopathy and con-firmed extensive infarction of theright kidney with perirenalhematoma. There was no evidenceof underlying malignancy. No foamylipid-containing macrophages werefound in the resected specimen,which ruled out xanthogranuloma-tous pyelonephritis.One day after the operation a newCT scan was acquired, because of the persistent need for blood trans-fusion and drainage of bloodthrough the abdominal drain. Thisscan showed an extensive haema -toma centered in the region of rightnephrectomy with presence of acutehaemorrhage due to lower lumbararterial bleeding and a hemoperi-toneum (Fig. 2). Because of the com-plicated laparotomy due to infectionand secondary multiple adhesions,endovascular treatment of thisbleeding was proposed instead of asurgical relook exploration.perirenal hematoma, suggestingnecrosis, infarction or infection(Fig.1). Ultrasound guided punctureof this collection was performed withdrainage of pus, which confirmedthe hypothesis of infection.After cooling down the infection,nucleair examination (99mTc-DMSA) showed a practically afunc-tional right kidney. An electivelaparoscopic radical nephrectomy of the right kidney was proposed.During the operation it was decidedto convert to laparotomy because of multiple adhesions with the caudalborder of the liver, the psoas muscle,colon, duodenum and inferior venacava. Perforation of the duodenumoccurred during dissection, whichhad to be sutured.JBR–BTR, 2008, 91: 203-205. TRANSCATHETER EMBOLIZATION OF AN ISOLATED LUMBAR ARTERIALBLEEDING COMPLICATING RADICAL NEPHRECTOMY FOR RENAL INFARCTION WITH INFECTED PERIRENAL HAEMATOMA K. Geldof  1 , G. Maleux 1 , S. Heye 1 , B. Van Cleynenbreugel 2 , R. Oyen 2 Lumbar arterial bleedings are rare but potentially life threatening. We report a case of an isolated right lumbar arte-rial bleeding after radical nephrectomy for renal infarction with infected perirenal haematoma. The diagnosis was suggested by computed tomography and confirmed with angiography. Definitive treatment of this vascular injurywas obtained after percutaneous transcatheter embolization of the fourth right lumbar artery. General anaesthesia,further blood loss due to difficult surgical dissection, or even failure to find and ligate the injured artery, especially inredo-operations, can be avoided by this minimal invasive procedure. Endovascular embolization of a lumbar arteryinjured after radical nephrectomy might be a valuable treatment alternative in patients with postoperative retro -peritoneal bleeding. Key-words: Kidney, surgery – Kidney, hemorrhage – Arteries, therapeutic blockade. From: 1. Department of Radiology and 2. Urology, University Hospitals Leuven, Belgium. Address for correspondence: Dr K. Geldof, M.D., Department of Radiology, UniversityHospitals Leuven, Herestraat 49, B-3000 Leuven, Belgium.E-mail: koen.geldof@uz.kuleuven.ac.be Fig. 1. — Computed tomography reveals the presence of gas (star) in the residualperirenal haematoma (arrows), two months after renal infarction.  Puncture of the right commonfemoral artery was performed underlocal anaesthetics, followed bycatheterisation of the abdominalaorta with a pigtail catheter. A com-bination of CO 2 and iodine-enhancedangiography was used because of renal insufficiency. CO 2 was admittedin one single injection of 80 cc, bywhich 30 cc of iodinated contrastagent could be avoided and the totalamount of iodinated contrast agentcould be reduced to 50 cc. On theaortogram, a slight contrast extrava-sation could be depicted, especiallyon the late images (Fig. 3A). Amicrocatheter (Progreat 2.7, TerumoEurope, Leuven, Belgium) wasadvanced through the diagnostic 4French Cobra-catheter for super- Discussion Lumbar arterial bleedings are rarebut potentially life threatening (1).Trauma and iatrogenic complica-tions have been reported as majorcauses of lumbar artery pseudo-aneurysms, although the overallincidence of vascular injuries arisingfrom diagnostic or therapeuticlaparoscopic procedures is less than1% (1-4). One case report attributedruptured bilateral lumbar aneurysmsto the vascular manifestations of VonRecklinghausen’s disease, in whichspontaneous aneurysm formation isknown to occur (5). Spontaneousretroperitoneal haemorrhage is alsoa known complication of systemicanticoagulation therapy (6, 7).In common practice, retroperi-toneal haematoma is mostly detect-ed by ultrasound and computedtomography. If haemorrhage is sus-pected, a tri-phasic CT scan (withoutcontrast and arterial and venousphase after contrast administration)should be performed in order todetect active arterial or venousbleeding. The ability of multi-slice CTto make high-resolution multiplanarreconstructions can help us to iden-tify the region of interest, which cansave time during angiography. If noflow extravasation is depicted on CT,there is no need for angiographysince its sensitivity is not more accu-rate than CT.Abdominal aortogram and selec-tive angiograms of the involved lum-bar artery allowed precise identifica-tion of the bleeding source. In orderselective catheterisation of the lum-bar arteries, confirming extravasa-tion of contrast at the fourth rightlumbar artery (Fig. 3B). No otherbleeding sources were identified inthis area. Embolization of this lum-bar artery was performed withmicroparticles (Embosphere 300-500, Biosphere Medical, Rockland,MA, USA) and microcoils (Micro -tornado 2/3 and 4/3, William CookEurope ApS, Bjaeverskov, Denmark).Angiography after embolizationshowed no residual contrast extra -vasation and complete occlusion of this lumbar artery distal from thecoils (Fig. 3C). One year after theembolization, patient is doing wellwithout any recurrence of retroperi-toneal bleeding. 204JBR–BTR, 2008, 91 (5) Fig. 2. — Computed tomography 1 day after laparotomy shows extensivehaematoma centred in the region of right nephrectomy (full arrows) with presence of acute haemorrhage due to lower lumbar arterial bleeding (hollow arrow) and a hemo-peritoneum (star). Fig. 3. — Aortogram after pigtail catheterisation depicted a slight contrast extra vasation (arrow), clearly depicted on the lateimages. A microcatheter (Progreat 2.7) was used for super-selective catheterisation of the lumbar arteries, confirming extra vasationof contrast (arrow) at the fourth right lumbar artery after injection. No other bleeding sources were identified in this area. A B C  to achieve a definitive and safe pro-cedure, the interventionalist musthave an appreciation of lumbarartery anatomy and the complicatednetwork of lumbar arterial collater-als, prior to any attempt at emboliza-tion (1, 4). The lumbar arteries runalong the vertebrae before theydivide into an anterior and posteriorbranch at the medial border of thepsoas muscle. The latter supplies thevertebral column, the spinal cord,and the musculature and skin of theback (Fig. 4). There is an abundantcollateral network between the lum-bar arteries in the transverse andlongitudinal direction within andoutside of the vertebral canal. Thefourth and fifth lumbar arteries arefrequently connected by a precostalanastomosis. In addition, the lumbararteries communicate with the supe-rior and inferior epigastric arteries,the lowest intercostal and subcostalarteries, the iliolumbar, and the later-al sacral arteries (1). Before emboliz-ing a lumbar artery, the arteria radic-ularis magna (also called the arteryof Adamkievicz) should be identifiedin order to avoid potential emboliza-tion of this artery, which can result insevere neurological damage.Another concern in embolizinglumbar arteries is the presence of the abundant collateral networkbetween the lumbar arteries, whichmakes it necessary to evaluate ves-sels above and below the identifiedinjured lumbar artery, in order todecrease the risk of rebleeding byMost cases in literature of lumbarartery embolization were uneventful,but retroperitoneal infarction canoccur. In the acute phase, the patientmight experience rhabdomyolysisfrom lumbar muscle infarction.Creatine kinase and potassium lev-els must be followed closely, asacute rise of these levels can ensuerenal failure. A late complication of retroperitoneal infarction is infec-tion(4). In our case there were noearly or late complications after tran-scatheter embolization of the rightlumbar artery.In summary, this case illustratesthe potential value of transcatheterembolization of a retroperitonealhaematoma, srcinating from ableeding lumbar artery one dayafterradical nephrectomy for renalin farction with infected perirenalhaematoma. References 1.Marty B., Sanchez L.A., Wain R.A.,Ohki T., Marin M.L., Bakal C., et al.:Endovascular treatment of a rupturedlumbar artery aneurysm: case reportand review of the literature. Ann Vasc Surg  , 1998, 12: 379-383.2.Heianna J., Miyauchi T., Takano Y.,Hashimoto M., Watarai J.: Successfultreatment of a ruptured infectedaneurysm of the lumbar artery withtranscatheter embolization. Abdom Imaging  , 2005, 30: 270-273.3.Maleux G., Vermylen J., Wilms G.:Lumbar artery pseudoaneurysm andarteriovenous fistula as a complica-tion of laparoscopic splenectomy:treatment by transcatheter emboliza-tion. Eur Radiol  ,2002, 12: 1401-1404.4.Sofocleous C.T., Hinrichs C.R.,HubbiB., Doddakashi S.,Bahramipour P., Schubert J.:Emboliza tion of isolated lumbarartery injuries in trauma patients. Cardiovasc Intervent Radiol  , 2005, 28:730-735.5.Shimizu Y., Tanaka T., Nakae A., Itoi H.,Matsui S., Fujita M., et al.: A casereport of spontaneous rupture of bilateral lumbar artery in a patientwith Von Recklinghausen disease. Nippon Geka Gakkai Zasshi  , 1993, 94:420-423.6.Basile A., Medina J.G., Mundo E.,Medina V.G., Leal R.: Transcatheterarterial embolization of concurrentspontaneous hematomas of the rec-tus sheath and psoas muscle inpatients undergoing anticoagulation. Cardiovasc Intervent Radiol  , 2004,27: 659-662.7.Isokangas J.M., Perälä J.M.:Endovascular embolization of sponta-neous retroperitoneal hemorrhagesecondary to anticoagulant treat-ment. Cardiovasc Intervent Radiol  ,2004, 27: 607-611. collateral blood supply. An aor-togram alone is not sufficient toevaluate collateral flow or to demon-strate adjacent arterial injury. Thus,selective arteriography of all arterialbranches must be performed in thearea of the injury (4).As we mentioned earlier, a combi-nation of CO 2 and iodine-enhancedangiography can be used, not toimprove diagnosis but to make diag-nosis and endovascular treatmentpossible in patients with impairedrenal function.Besides coils and microparticles,glue is another embolic agent thatcan be used for occluding visceral orlumbar arteries. Because of the lack of experience with this embolic agent in our department and the potentialrisk of reflux of glue into the abdom-inal aorta, this option was excluded.Advantages of this minimal invasiveprocedure are the avoid ance of general anaesthesia and a major sur-gical procedure in patients who areunstable or have severe co-existingcomorbidities. Additionally, redo-operations for postoperative bleed-ing after retro peritoneal surgery canbe hazardous and potentially can failto find the bleeding artery, which canbe very small and unfindable in alarge retroperitoneal haematoma,like in the presented case. Inthesecircumstances, a percutaneoustrans catheter approach might be amore elegant solution to definitivelytreat this postoperative haemor-rhage. RETROPERITONEAL HAEMORRHAGE AFTER RENAL SURGERY — GELDOF et al205 Fig. 4. — Lumbar arterial anatomy at cross section throughthe abdominal aorta (AA): the lumbar artery (LA) divides into ananterior branch (AB) and a posterior branch (PB). The latterdivides into arterial branches to the vertebral corps (VB), aradiculomedullary artery (RMA) and a muscular artery (MA),providing the paralumbar muscles and the skin of the back. View publication statsView publication stats
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