AJR 2002; 178:364-366
© American Roentgen Ray Society
Percutaneous Thrombin Injection for Treatment of an Intrarenal Pseudoaneurysm
Ofer Benjaminov1 and
Mostafa Atri
1
Both authors: Department of Medical Imaging, Sunnybrook and Women's College
Health Science Centre, University of Toronto, 2075 Bayview Ave., Toronto,
Ontario, M4N 3M5 Canada.
Received April 9, 2001;
accepted after revision June 12, 2001.
Address correspondence to M. Atri.
Introduction
Renal artery aneurysms constitute 22% of all visceral aneurysms, and their
prevalence in the population varies from 0.01% to 1.0%
[1]. Intrarenal aneurysms
constitute 17% of all renal artery aneurysms
[2]; the causes include
atherosclerosis, fibromuscular dysplasia, trauma (iatrogenic and
noniatrogenic), renal carcinoma, and periarteritis nodosa. Surgical repair or
transarterial coil placement is the technique preferred for treatment
[3]. Although sonographically
guided percutaneous thrombin injection is becoming accepted for the treatment
of femoral artery pseudoaneurysm
[4], only a few case reports
describe the treatment of other peripheral or visceral arterial aneurysms
[5,6,7].
We present a case in which an intrarenal artery pseudoaneurysm in a patient
with autosomal-dominant polycystic kidney disease was treated with
percutaneous direct injection of thrombin. To our knowledge, there is no
report of percutaneous thrombin injection for the treatment of renal artery
aneurysm.
Case Report
A 58-year-old man referred to the emergency department because of
hesitancy, urgency, and the new onset of macroscopic hematuria. He had a
history of autosomal dominant polycystic kidney disease and had been on
hemodialysis for 6 years. This episode of macroscopic hematuria was his first
and began after his most recent dialysis. Two days before his visit to the
emergency department, he fell and bruised his right lateral chest wall and
right flank. Since this incident, he had complained of pain in his right
chest, which was thought to be muscular in nature. There was no history of
interventional procedures performed on his kidneys.
On admission the patient was afebrile, his blood pressure was 125/80 mm Hg,
hemoglobin was 88 g/L, creatinine was 712 µmol/L, and urea was 17.5 mmol/L.
Physical examination revealed only superficial bruising in his left forearm
around the arteriovenous access. Sonography showed autosomal-dominant
polycystic kidneys with both kidneys completely replaced by multiple cysts. In
the upper pole of the right kidney anteriorly, an echogenic cyst measured 6
x 4 cm. Adjacent to this cyst, a pulsatile cystic mass was confirmed to
represent a pseudoaneurysm on color Doppler sonography. The pseudoaneurysm
originated from a branch of a segmental artery that showed a to-and-fro-type
flow on pulsed Doppler sonography (Figs.
1A and
1B). The pseudoaneurysm
measured 2.0 cm in diameter. Unenhanced
(Fig. 1C) and enhanced
(Fig. 1D) CT of the kidneys
performed during the vascular and early cortical nephrographic phases revealed
a cyst containing hyperdense material or hemorrhage. A well-defined mass with
enhancement similar to that of a vessel, consistent with an aneurysm, was
present in the center of the hemorrhagic cyst.
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Fig. 1C. —58-year-old man with autosomal-dominant polycystic kidney
disease and macroscopic hematuria. CT scan without IV contrast material shows
hyperdense mass (arrows) representing hyperdense or hemorrhagic
cyst.
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Fig. 1D. —58-year-old man with autosomal-dominant polycystic kidney
disease and macroscopic hematuria. CT scan with IV contrast material in
vascular phase shows hemorrhagic cyst. Note focal area of enhancement
(arrow) in center similar to vessel, consistent with
pseudoaneurysm.
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After obtaining the patient's consent, we made two separate percutaneous
injections of 500 U of bovine thrombin (Thrombostat; Parke-Davis,
Warner-Lambert Canada, Scarborough, Ontario, Canada) directly into the
pseudoaneurysm. Under sonographic guidance, a 25-gauge spinal needle was
placed in the periphery opposite the neck of the pseudoaneurysm. The thrombin
was diluted with normal saline (1000 U/mL). Five hundred units were injected
twice over a period of 5 sec each. Clotting began immediately after each
injection, but the thrombosis was incomplete after the first injection. The
pseudoaneurysm completely thrombosed after the second injection
(Fig. 1E). Hematuria stopped on
the day of the injections. However, 2 days after the injection, the patient
had a new episode of hematuria. Sonography revealed that the pseudoaneurysm
was patent. The procedure was repeated with the same dose, the same size
needle, and the same technique. The pseudoaneurysm immediately thrombosed. The
patient's gross hematuria stopped after the second injection, and no
microscopic hematuria was found on the day of discharge, 5 days after the
procedure. Follow-up CT (Fig.
1F) and sonography within 10 days after the procedure confirmed
persistent thrombosis of the pseudoaneurysm; CT and sonography 4 months after
the procedure showed no evidence of the pseudoaneurysm.
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Fig. 1E. —58-year-old man with autosomal-dominant polycystic kidney
disease and macroscopic hematuria. Seconds after injection of thrombin, pulse
Doppler sonogram shows thrombosed pseudoaneurysm (arrows).
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Fig. 1F. —58-year-old man with autosomal-dominant polycystic kidney
disease and macroscopic hematuria. Five days after injection, CT scan with IV
contrast material shows residual renal hematoma and confirms persistent
thrombosis of pseudoaneurysm.
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Discussion
Renal artery aneurysm is uncommon. It accounts for 22% of all visceral
aneurysms, most being extrarenal. The most common causes are atherosclerosis,
fibromuscular dysplasia, vasculitis, and neoplasm; these conditions could
occur after trauma or could be iatrogenic.
We describe a pseudoaneurysm in a peripheral branch of the renal artery. To
our knowledge, no previous report has been made of renal artery aneurysm
associated with autosomal-dominant polycystic kidney disease. Whether this
patient's pseudoaneurysm is related to his primary renal disease, possibly
being atherosclerotic, or to his trauma is unclear. We can only speculate that
trauma was the cause because of history, although no other imaging finding in
this patient suggests a serious trauma to cause a pseudoaneurysm.
Complications of renal artery aneurysms include peripheral dissection,
thrombosis, renal infarction, and rupture. The incidence of rupture is thought
to increase as the diameter of the aneurysm exceeds 1.0 cm. The indications
for treatment are clinical symptoms (back pain, hypertension, and hematuria),
aneurysm size, and renal dysfunction
[2].
Treatment consists of surgical resection or transcatheter arterial
embolization. Surgery is mainly aneurysmectomy, which may require partial
nephrectomy. Transcatheter embolization is a safe and effective alternative to
surgery; however, it may result in segmental infarction and impaired renal
function if the feeding vessel is embolized
[3]. A potential complication
is occlusion of the main renal artery from migration of the embolizing agent.
Superselective embolization of the aneurysm itself results in preservation of
the proximal and distal arterial flow, avoiding renal infarction.
Percutaneous direct thrombin injection of an aneurysm has mainly been
described in relation to the treatment of femoral artery pseudoaneurysms
[4]. It has not been widely
studied in visceral arteries with only a few case reports being published
[5,6,7].
These cases were usually the result of unsuccessful transarterial embolization
attempts. Rothbarth et al. [5]
reported success with a case of percutaneous transhepatic injection of
thrombin into a large intrahepatic aneurysm after embolization with coils had
failed. Luchs et al. [6]
described a case of pseudoaneurysm in the pancreatic head in which
embolization with a superselective catheter was technically unsuccessful and
percutaneous thrombin injection was the only alternative for treatment.
Kemmeter et al. [7] recently
published two case reports of percutaneous direct thrombin injection of
splanchnic arterial aneurysms with real-time fluoroscopic guidance and
arteriographic images.
Concerns have been raised regarding the safety of injecting thrombin into
the arterial system with respect to downstream embolization. With continuous
sonographic guidance and positioning the needle away from the neck and in the
periphery of the aneurysm, downstream embolization is unlikely to occur.
Thrombosis occurs in seconds and can be confirmed on realtime sonography. With
femoral artery pseudoaneurysm, the technique is a safe and a highly effective
procedure with a success rate between 93% and 100%. Pezzullo et al.
[4] reported temporary
paresthesia and loss of dorsalis pulse immediately after thrombin injection,
thought to be the result of an extensively diseased arterial system. In
another report, brachial thrombosis complicated thrombin injection in one
patient [8]. Complications were
also not reported in the few cases of direct percutaneous thrombin injection
of the visceral arterial aneurysms described previously. In our patient, we
were less concerned about the possibility of distal renal thromboembolism
because this procedure was performed on an underlying malfunctioning
kidney.
As described in the literature, percutaneous thrombin injection was quick
and simple. After the tip of the small needle was identified within the
aneurysm, it took only seconds to complete the procedure. All previous reports
show that one injection of 1000 U is usually sufficient, and some authors have
used less [4,
8]. In our patient, the
aneurysm reopened 2 days after the first session of injections, and a second
session of injections was needed. We have no explanation for the initial
failure. The immediate success of the procedure is reported to depend on the
size of the pseudoaneurysm, on thrombin concentration, and on the degree of
stasis in the aneurysm, because any residual slow flow in the aneurysm can
further dilute the thrombin concentration
[5].
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