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Saudi Journal of Kidney Diseases and Transplantation
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Table of Contents   
LETTER TO THE EDITOR  
Year : 2012  |  Volume : 23  |  Issue : 4  |  Page : 838-840
Endovascular management of iatrogenic renal artery aneurysm and arteriovenous fistula


1 Department of Radiology, Hacettepe Hospital, Ankara, Turkey
2 Adana Training and Research Hospital, Adana, Turkey
3 Department of Urology, Hacettepe Hospital, Ankara, Turkey

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Date of Web Publication9-Jul-2012
 

How to cite this article:
Yakup Y, Bora P, Barbaros C, Bozkurt G, Burak D, Cenk BY. Endovascular management of iatrogenic renal artery aneurysm and arteriovenous fistula. Saudi J Kidney Dis Transpl 2012;23:838-40

How to cite this URL:
Yakup Y, Bora P, Barbaros C, Bozkurt G, Burak D, Cenk BY. Endovascular management of iatrogenic renal artery aneurysm and arteriovenous fistula. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2020 Dec 3];23:838-40. Available from: https://www.sjkdt.org/text.asp?2012/23/4/838/98180
To the Editor,

Renal artery aneurysm is a rare condition, and its estimated incidence ranges from 0.09% to 0.3% in the general population. [1] Many cases are asymptomatic and found incidentally, and their incidence has recently been increasing with the advancement of imaging techniques. [2] The etiology of renal artery aneurysms may be idiopathic, mycotic or traumatic, but, in most cases, there is an underlying diffuse systemic disease. [3] Predisposing factors include arterio­sclerosis, fibromuscular dysplasia (FMD), con­genital malformations of the kidney, renal angiomyolipoma, pregnancy and trauma. [4] Trau­matic and iatrogenic renal artery pseudoaneurysms represent yet another pathophysiologic entity. [5] Renal arteriovenous fistulas (AVFs) are anomalous connections between the arterial and the venous system. The prevalence is less than 0.04%, with causes being iatrogenic or traumatic (around 70%), congenital (25%) and idiopathic (3-5%). [6] The acquired form is secondary to kidney biopsy, surgery, trauma, tumor and/or inflammatory diseases, and its incidence has increased due to the increasing number of kidney biopsies. [7] Congenital renal AVFs consist of multiple irregular vessels without an associated elastic component. [8] Ac­quired and idiopathic subtypes are characte­rized by a single communication between the artery and the vein. [9]

We herewith report on a 20-year-old male patient who visited our hospital with com­plaints of hematuria (with clots) and abdo­minal pain one month after undergoing a per­cutaneous nephrolithotomy for the treatment of nephrolithiasis. Hematomas within the right kidney and the urinary bladder were detected on initial computed tomographic (CT) exami­nation. A double-J stent was placed for drai­nage by the urologist. A digital subtraction angiography (DSA) was performed, which revealed a pseudoaneurysm and an accompa­nying AVF in the branch of the renal artery supplying the right lower pole [Figure 1]. A micro-catheter was used to catheterize the injured renal artery branch. The aneurysm was embolized by the utilization of 0.018 coils. Immediate post-interventional check-up injec­tions revealed a preserved renal parenchyma, and there was no sign of a filling of a fistula or an aneurysm [Figure 2]. Clinical follow-up two months later revealed no hematuria with stable hemoglobin level. Some patients with renal artery aneurysms present with symptoms of hypertension, pain, hematuria or rupture, but the majority are asymptomatic. [10] Complications of renal artery aneurysms include renovascular hypertension, thrombosis with renal infarction, AVF, dec­reased renal function and spontaneous rupture. [11] A size of over 1.5 cm and calcifications within the wall are risk factors for rupture. [12] Prevention of rupture is the main reason for therapy. It is recommended that the lesion be treated when greater than 1.5-3 cm, although most authors accept 2 cm as the reference size for treatment. [5] Treatment may be by surgery or endovascular approach. Endovascular approach is a good alternative to invasive surgical pro­cedures. Stent grafting, coil embolization and a combination of these techniques and materials are utilized as a feasable, safe and effective means of endovascular treatment of renal artery aneurysms. [5]
Figure 1: Digital subtraction angiography showing a pseudoaneurysm and an accompanying arteriovenous fistula in the branch of the right renal artery that fed the lower pole of the right kidney.

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Figure 2: Post-interventional check-up injections that revealed no signs of a filling of a fistula or an aneurysm.

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The most common symptom of renal AVF is hematuria; other clinical manifestations include hypertension, left ventricular hypertrophy, car­diac failure and abdominal pain. [13] Angiography is said to be the gold standard in the diag­nosis of renovascular injuries, and it has an additional advantage, as it possesses the po­tential of therapeutic intervention. [14] In our pa­tient also, the diagnosis was initially made by angiography. Transarterial embolization was first described by Bookstein and Goldstein in 1973, [6] and nowadays it is being performed as a first-line treatment for AVF. [9]

CT angiography is to be considered as the first tool for diagnosis of renal artery injury after any invasive urological procedure. [12],[13] Renal functions, together with patient's age and gender, are the major concerns in tailoring the diagnostic and treatment approaches.

Renal artery aneurysms and AVFs are rare conditions. Their incidence has increased due to larger numbers of renal biopsies and the administration of high-technology imaging modalities. Endovascular approach can be used in the treatment of even large aneurysms and fistulas. Endovascular coil embolization the­rapy should always be kept in mind as a prac­tical and non-invasive means of therapy in the treatment of patients who suffer from the si­multaneous presence of a renal artery aneurysm and a renal AVF.

 
   References Top

1.Castillo OA, Vitagliano GJ, Sanchez-Salas R, Chamorro H, Fava M, Díaz MA. Laparoscopic repair of renal artery aneurysm a description of the technique and results in 2 cases. Surg Laparosc Endosc Percutan Tech 2008;18:379-83.  Back to cited text no. 1
    
2.Soga Y, Sakai K, Nobuyoshi M. Renal artery aneurysm treatment with coil embolization. Catheter Cardiovasc Interv 2007;69:697-700.  Back to cited text no. 2
[PUBMED]  [FULLTEXT]  
3.Gümüºtaº S, Ciftçi E, Bircan Z. Renal artery aneurysm in a hypertensive child treated by percutaneous coil embolization. Pediatr Radiol 2010;40:1285-7.  Back to cited text no. 3
    
4.Marwah S, Singla S, Kalra R, Marwah N, Singh SP. Is it renal colic or ruptured dissecting aneurysm of renal artery?: A case report. Cases J 2009;2:9398.  Back to cited text no. 4
    
5.Abath C, Andrade G, Cavalcanti D, Brito N, Marques R. Complex renal artery aneurysms: liquids or coils?. Tech Vasc Interv Radiol 2007;10:299-307  Back to cited text no. 5
    
6.Shih CH, Liang PC, Chiang FT, Tseng CD, Tseng YZ, Hsu KL. Transcatheter embolization of a huge renal arteriovenous fistula with Amplatzer Vascular Plug. Heart Vessels 2010;25:356-8.  Back to cited text no. 6
    
7.Melo NC, Mundim JS, Costalonga EC, Lucon AM, Santello JL, Praxedes JN. Three cases of hypertension and renal arteriovenous fistula with a de Novo fistula. Arq Bras Cardiol 2009; 92:e36-e8.  Back to cited text no. 7
    
8.An HS, Kang TG, Yun HJ, et al. Hypertension caused by renal arteriovenous fistula. Korean Circ J 2009;39:548-50.  Back to cited text no. 8
    
9.Nagahara A, Nishimura K, Okuyama A. A giant idiopathic renal arteriovenous fistula associated with high-output heart failure. Int J Urol 2009;16:648-9.  Back to cited text no. 9
    
10.Gutta R, Lopes J, Flinn WR, Neschis DG. Endovascular embolization of a giant renal artery aneurysm with preservation of renal parenchyma. Angiology 2008;59:240-3.  Back to cited text no. 10
    
11.Lupattelli T, Garaci FG, Manenti G, Belli AM, Simonetti G. Gýant hýgh-flow renal arterio-venous fistula treated by percutaneous embolization. Urology 2003;61:837.  Back to cited text no. 11
    
12.Zhang LJ, Yang GF, Qi J, Shen W. Renal artery aneurysm: diagnosis and surveillance with multidetector-row computed tomography. Acta Radiol 2007;48:274‐9.  Back to cited text no. 12
    
13.Dönmez FY, Coºkun M, Uyuºur A, et al. Non-invasive imaging findings of idiopathic renal arteriovenous fistula. Diagn Interv Radiol 2008; 14:103-5.  Back to cited text no. 13
    
14.Rokni Yazdi H, Moharamzad Y. Endovascular treatment of renal arteriovenous fistula follo­wing a stab wound. Urol J 2008;5:129-31.  Back to cited text no. 14
    

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Correspondence Address:
Yesilkaya Yakup
Department of Radiology, Hacettepe Hospital, Ankara
Turkey
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DOI: 10.4103/1319-2442.98180

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