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AJR 2002; 178:736
© American Roentgen Ray Society

Trauma Cases from Harborview Medical Center

CT of a Renal Artery Pseudoaneurysm Caused By a Stab Wound

Xiaoming Chen1, John J. Borsa, Theodore Dubinsky and Arthur B. Fontaine

1 All authors: Department of Radiology, Harborview Medical Center, 325 Ninth Ave., Box 359728, Seattle, WA 98104-2499.

Received June 22, 2001; accepted after revision July 2, 2001.

 
This is another in the continuing series on radiology in trauma cases from the Harborview Medical Center. Editors: Fred A. Mann, Eric J. Stern, and Lee B. Talner.

Address correspondence to F. A. Mann.


Introduction
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 Introduction
References
 
Despite gross hematuria, a 38-year-old man was hemodynamically stable and had a soft, nontender abdomen after being stabbed in the left flank. CT showed a grade 4 left renal laceration with a small adjacent perinephric hematoma. The patient was discharged without hematuria 1 week later, after nonsurgical treatment and serial CT scans. A renal CT scan on day 20 (Figs. 1A and 1B) showed a renal pseudoaneurysm. Angiography (Fig. 1C) revealed the pseudoaneurysm and an arteriovenous fistula. The feeding artery was embolized with coils.



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  		Fig. 1A. —38-year-old man with renal pseudoaneurysm caused by stab wound. Arterial phase CT scan with triple contrast shows enhancing structure 1.5 cm in diameter (arrow) in renal sinus of left lower kidney.

 


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  		Fig. 1B. —38-year-old man with renal pseudoaneurysm caused by stab wound. Triple-contrast CT scan with 10-min delay shows washed out focal enhancement of pseudoaneurysm, compared with A.

 


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  		Fig. 1C. —38-year-old man with renal pseudoaneurysm caused by stab wound. Arteriogram shows segmental renal artery pseudoaneurysm (black arrow) and early draining vein (white arrow), characteristic of arteriovenous fistula.

 

Most renal artery pseudoaneurysms result from penetrating injuries, many of which are iatrogenic (e.g., associated with renal biopsy or nephrostomy tube placement) [1, 2]. Hypertension and rupture with hemorrhage are the most important complications [1, 3]. Delayed hemorrhage (days to weeks after the initial injury) is not rare and may be heralded by hematuria.

CT is highly reliable for diagnosing renal parenchymal and pyelocalyceal injuries, main renal arterial occlusion, and active bleeding. CT is not as accurate for diagnosing branch arterial injuries, including pseudoaneurysm or arteriovenous fistula. In kidneys that develop pseudoaneurysms, the initial CT scan often shows parenchymal laceration without pseudoaneurysm, because acute thrombus may temporarily seal the laceration. Over several days or weeks, clot lysis occurs with subsequent formation of a pseudoaneurysm. Communication with a renal vein branch creates an arteriovenous fistula. A typical pseudoaneurysm enhances in the arterial phase and washes out in the delayed phase (Figs. 1A and 1B).

Color-flow and gray-scale Doppler sonography can be used to diagnose and follow renal artery pseudoaneurysm and arteriovenous fistula. Pseudoaneurysm appears as a rounded anechoic structure on gray-scale images, with to-and-fro swirling on color-flow images. An arteriovenous fistula may be diagnosed if the renal vein shows an arterial waveform.

The usefulness of angiography in renal trauma was first shown in 1966 by Elkin et al. [4]. Angiography remains the diagnostic standard for renal vascular injuries; it is usually performed when CT or sonographic abnormalities are noted. On angiography, renal pseudoaneurysms are round or oval structures that opacify from the main renal artery or one of its branches. Early opacification of a draining vein indicates an arteriovenous fistula (Fig. 1C).

Many branch-vessel injuries heal spontaneously. Endovascular intervention and surgery are options for arterial injuries that need treatment because of persistent bleeding, large pseudoaneurysm, or hypertension [5]. Transcatheter embolization is the preferred therapy in patients who do not otherwise require surgical exploration. Renal embolization, usually performed with coils or Gelfoam (Upjohn, Kalamazoo, MI), has a success rate of greater than 80% in controlling or preventing hemorrhage, and it preserves renal parenchyma [2].


References
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 Introduction
 References
 

  1. Hassantash SA, Mock C, Maier RV. Traumatic visceral artery aneurysm: presentation as massive hemorrhage from perforation into an adjacent hollow viscus. J Trauma 1995;38:357 -360[Medline]
  2. Fisher RG, Ben-Menachem Y, Whigham C. Stab wounds of the renal artery branches: angiographic diagnosis and treatment by embolization. AJR 1989;152:1231 -1235[Abstract/Free Full Text]
  3. Heyns CF, van Vollenhoven P. Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J Urol 1992;147:1231 -1234[Medline]
  4. Elkin M, Meng CH, DeParedes RG. Roentgenologic evaluation of renal trauma with emphasis on renal angiography. AJR 1966;98:1 -26[Abstract/Free Full Text]
  5. Heyns CF, De Klerk DP, De Kock ML. Nonoperative management of renal stab wounds. J Urol 1985;134:239 -242[Medline]

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