Intrarenal artery pseudoaneurysm after blunt abdominal trauma: a case report of successful superselective angioembolization
A 54-year-old man was admitted to the Emergency Department of the Hospital de São João, Porto, Portugal, a trauma center, for right flank pain and gross hematuria. He was referred from a secondary level health care hospital, where he stayed for 4 days due to a right grade III renal traumatic injury (as per the Organ Injury Scaling Committee of the American Association for Surgery of Trauma), after falling from a height of 2 meters and sustaining blunt abdominal and right flank trauma. During this period, the patient was hemodynamically stable, without gross hematuria. He underwent conservative management, with bed rest, hydration, antibiotics, analgesics, and serial laboratory and imaging evaluations.\nOn arrival at our institution, the patient was hemodynamically stable (blood pressure: 102/71 mmHg, heart rate: 88 bpm), eupneic, and afebrile, complaining of right flank and abdominal pain. On physical examination, he had right costovertebral angle tenderness, regional ecchymosis, and grossly bloody urine. Blood analysis showed decreased hemoglobin (11.8 g/dL) and hematocrit (33.2%). He had normal electrolytes and coagulation tests, with a creatinine level of 1.17 mg/dL, corresponding to an estimated glomerular filtration rate (eGFR) of 84.9 mL/min/1.73 m2, as calculated by the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation.\nA computed tomography (CT) scan showed a 3 cm posteroinferior laceration of the right kidney, apparently entirely enclosing the thickness of renal parenchyma, clearly without involvement of the renal sinus or excretory system. Moreover, there was a significant delay in elimination of the intravenous contrast, and the right renal pelvic content was spontaneously hyperdense, suggesting hematic nature. During the arterial phase, the inferior third of the right renal parenchyma showed a hyperdense rounded lesion, of 16 mm at its greatest diameter, suggesting a posttraumatic RAP (). Finally, there was also a posteroinferior right perirenal hematoma, measuring 55×55×37 mm (). Selective angiography of ventral and dorsal branches of the right renal artery revealed a contusion focus in the upper two-thirds of the right kidney, with partial cortex devascularization. It also showed a RAP, of 16 mm diameter, from two interlobar branches of the posterior division of the right renal artery (). Superselective embolization of these branches was performed, using a 5F catheter, with 2×5 mm microcoils and gelfoam particles. Postembolization images confirmed the complete pseudoaneurysm devascularization, exclusion of other arterial afferents, and preservation of the remaining renal vasculature (). The patient’s postoperative course was uneventful (blood pressure: 132/84 mmHg, heart rate: 81 bpm). He was discharged 5 days after the procedure, with a normalizing hematocrit (hematocrit 38%, hemoglobin 12.8 g/dL) and a creatinine level of 1.02 mg/dL, corresponding to an eGFR of 84.9 mL/min/1.73m2.