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Oct 26, 2004 - We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperi-.
CardioVascular and Interventional Radiology

ª Springer Science+Business Media, Inc. 2005 Published Online: 26 October 2004

Cardiovasc Intervent Radiol (2005) 28:93–94 DOI: 10.1007/s00270-004-0050-4

Iatrogenic Main Renal Artery Injury: Treatment by Endovascular Stent-Graft Placement Sam Heye,1 Dirk Vanbeckevoort,1 Danie¨l Blockmans,2 Andre´ Nevelsteen,3 Geert Maleux1 1

Department of Radiology, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium Department of Internal Medicine, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium 3 Department of Vascular Surgery, University Hospitals Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium 2

Abstract We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperitoneal drainage procedure. Only a small number of cases of iatrogenic main renal artery perforations have been reported, none of them due to a percutaneous drainage attempt. Endovascular treatment by means of a coronary stent-graft was successful. Key words: Renal artery—Injuries—Stent-graft

graft was then dilated up to 6 mm (Gazelle balloon, Boston Scientific, La Garenne Colombes, Paris, France). While leaving this 6/20 mm balloon in place in the stent-graft, the drainage catheter was carefully withdrawn. Control angiography with a deflated balloon showed no extravasation of contrast (Fig. 1E). A control CT scan 4 days later confirmed the good position of the stent-graft in the left renal artery, without leakage of contrast material. The patient underwent a thoracophrenicotomy and open biopsy of the peri-aortic mass, since previous percutaneous CT-guided needle biopsy was not successful. Histopathologic findings showed a large metastatic mass of transitional cell carcinoma of the bladder. Palliative therapy was started and the patient died 2 weeks later.

Case Report

Discussion

A 71-year old man with persistent abdominal pain and episodes of shaking chills underwent computed tomography (CT)-guided drainage of a periaortic mass at the level of the visceral and renal arteries, because of suspicion of peri-aortic abscess or periaortitis on CT and positron emission tomography (PET). Initial laboratory data demonstrated no elevation of the white blood cell count, but elevated concentrations of C-reactive protein (119 mg/l). His relevant medical history consisted of an aortic-bifemoral graft 11 years previously and an invasive transitional cell carcinoma of the bladder (TNM staging T3a) 4 months previously, treated by means of radiotherapy. The tip of the 8 Fr drainage catheter (Huisman drainage catheter, Cook Europe, Bjaeverskov, Denmark) was positioned in the peri-aortic mass after CT-guided left paralumbar puncture, using the one-step, single-puncture method. A contrast-enhanced control CT scan was needed, since there was initial massive arterial blood loss via the drainage catheter, which was clamped immediately. CT demonstrated that the catheter had perforated the left renal artery (Fig. 1A, B). The patient remained hemodynamically stable and was transferred immediately to the angiography suite. Aortography showed no extravasation of contrast material but confirmed the perforation of the postostial segment of the left renal artery by the drainage catheter (Fig. 1C). A 45 cm long, 8 Fr sheath (Super Arrow-Flex, Arrow International, Reading, MA, USA) was placed in the right femoral artery, with its tip at the level of the left renal artery. After selective catheterization of the ostium of the left renal artery by means of a 5 Fr Cobra C2 catheter, a 0.014-inch guidewire was placed in an interlobar branch of the left renal artery. Over this guidewire a self-expandable 5/20 mm expanded polytetrafluoroethylene (e-PTFE)-covered coronary stent (Symbiot covered stent, Boston Scientific, La Garenne Colombes, Paris, France) was positioned at the level of the drainage catheter tip (Fig. 1D). The stent-

Iatrogenic main renal artery injuries with perforation or rupture are rare and almost exclusively reported after renal artery angioplasty or stenting [1, 2], with an incidence of 1.6% [1]. One case of an iatrogenic renal artery perforation as a complication of cardiac catheterization has been reported [3]. Other arteries more commonly affected by iatrogenic trauma are the subclavian artery after central venous catheter placement [4], the iliac artery after angioplasty, stenting or insertion of intra-aortic balloon pumps [5], the vertebral artery after neck manipulations [6] and the hepatic artery or the internal carotid artery after surgery [7, 8]. Since most iatrogenic renal artery lesions occur during endovascular procedures, there are no reports on the clinical symptoms, but only on the the angiographic findings. Arteriovenous fistulae, pseudoaneurysms, arterial dissection or contrast extravasation are the possible radiological findings in these traumatic vascular lesions. Surgery has been the definitive treatment for traumatic renal artery rupture, but nowadays the treatment for acute iatrogenic rupture of the main renal artery is balloon tamponade [1]. However, in case of failure immediate availability of a stent-graft is vital [1–3]. Although frank contrast extravasation was not seen by any image modality, CT and angiography showed perforation of the main renal artery by the drainage catheter. Since the drainage catheter tamponaded the perforation, it was important to leave it in place prior to further treatment. At the time of the urgent procedure the only type of covered stent available was the Symbiot coronary e-PTFE-covered stent-graft. For maximal safety we inflated a balloon in the stent-graft before and while removing the drainage catheter. Another reason for the use of a balloon is dilatation of the

Correspondence to: Sam Heye; email: [email protected]

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S. Heye et al.: Stent-Graft for Iatrogenic Renal Artery Injury

Fig. 1. A 71-year-old man with perforation of the left main renal artery by a malpositioned drainage catheter. A Axial and B coronal CT scans after paralumbar puncture of the peri-aortic mass showing the close contact between drainage catheter (arrow) and left renal artery (arrowhead). C Aortogram demonstrating the left renal artery

(arrowhead) perforated by the drainage catheter (arrow). D Angiogram showing the coronary stent-graft (arrows) positioned at the level of the drainage catheter. E Control aortogram showing good positioning of the stent-graft without extravasation of contrast material.

Symbiot coronary e-PTFE-covered stent-graft up to 6 mm diameter, since it is only available with a maximal diameter of 5 mm and the diameter of the left main renal artery measured more than 5 mm de visu. According to the manufacturer the stent-graft is capable of expansion to a maximum diameter 1.30 mm greater than the labeled diameter. In summary, an unusual case of iatrogenic vascular injury to the left main renal artery is described. Minimally invasive treatment, consisting of percutaneous placement of a stent-graft, can be an effective treatment option.

3. Bates MC, Shamsham FM, Faulknier B, Crotty B (2002) Successful treatment of iatrogenic renal artery perforation with an autologous vein covered stent. Catheter Cardiovasc Interv 57:39–43 4. Wicky S, Meuwly JY, Doenz F, Uske A, Schnyder P, Denys A (2002) Life-threatening vascular complications after central venous catheter placement. Eur Radiol 12:901–907 5. Nyman U, Uher P, Lindh M, Lindblad B, Brunkwall J, Ivancev K (1999) Stent-graft treatment of iatrogenic iliac artery perforation: Report of three cases. Eur J Vasc Endovasc Surg 17:259–263 6. Priestley R, Bray P, Bray A, Hunter J (2003) Iatrogenic vertebral arteriovenous fistula treated with a Hemobahn stent-graft. J Endovasc Ther 10:657–663 7. Venturini M, Angeli E, Salvioni M, De Cobelli F, Trentin C, Carlucci M, Staudacher C, Del Maschio A (2002) Hemorrhage from a right hepatic artery pseudoaneurysm: Endovascular treatment with a coronary stentgraft. J Endovasc Ther 9:221–224 8. Kocer N, Kizilkilic O, Albayram S, Adaletli I, Kantarci F, Islak C (2002) Treatment of iatrogenic internal carotid artery laceration and carotid cavernous fistula with endovascular stent-graft placement. AJNR Am J Neuroradiol 23:442–446

References 1. Morris CS, Bonnevie GJ, Najarian KE (2001) Nonsurgical treatment of acute iatrogenic renal artery injuries occurring after renal artery angioplasty and stenting. AJR Am J Roentgenol 177:1353–1357 2. Gaxotte V, Laurens B, Haulon S, Lions C, Mounier-VGhier C, Beregi J-P (2003) Multicenter trial of the Jostent balloon-expandable stent-graft in renal and iliac artery lesions. J Endovasc Ther 10:361–365