Massive retroperitoneal hemorrhage from a giant renal angiomyolipoma treated by selective arterial embolization with an Amplatzer Vascular Plug II
A 36-year-old Caucasian woman fell on her left side during a parking maneuver with her motor scooter. Shortly after the incident, the patient developed acute left flank pain and hematuria associated with tachycardia, hypotension, and diaphoresis. The pain worsened and she was brought to the emergency department of our institution.\nOn physical examination the patient was in acute distress with a tenderness of palpation of the left flank. The patient was otherwise healthy with no know history of benign or malignant medical conditions. On laboratory analysis, hemoglobin (Hb 9.8 mg/dL) and hematocrit (HCT 36%) were reduced. Conventional CT with i.v. contrast injection (Figs. and ) demonstrated a left renal mass containing fat with an extended retroperitoneal hematoma. The diagnosis of a massive retroperitoneal hemorrhage from a ruptured AML was made. Furthermore, CT revealed a duplicated left renal artery.\nAfter initial stabilization of the patient, she was then referred to our interventional radiology department for SAE. Using a right common femoral artery approach a diagnostic flush aortogram was performed to exclude extrarenal feeders to the tumor. A selective catheterization of the upper and lower pole left renal artery revealed that the upper renal artery was exclusively supplying the renal parenchyma not affected by the AML with no significant feeding of the tumor (Fig. ) whereas the lower renal artery solely supplied the giant AML (Fig. ). The diameter of the lower left artery was 6.5 mm. Embolization of the tumor-feeding lower left renal artery was performed with an 8-mm Amplatzer Vascular Plug (AVP; AGA Medical, Golden Valley, MN, USA). The AVP was deployed through a long 6-F envoy-guiding catheter (Codman & Shurtleff, Raynham, MA, USA) with 0.070” ID (1.8 mm). An instant and complete occlusion of the lower left renal artery was achieved (Fig. ).\nImmediately after embolization the patient complained of left-sided abdominal pain, which was treated with a single dose of 50 mg pethidine i.v. As a consequence of tumor devascularization the patient developed post-embolization syndrome characterized by acute pain, malaise, nausea, severe night sweats, and temperatures of up to 39°C 10 days following the procedure. A follow-up CT scan showed necrosis of AML with signs of abscess formation (Fig. ) 14 days post embolization. A nephron-sparing surgical resection of the residual AML was performed, preserving the healthy upper pole of the left kidney, which was supplied by the separate upper renal artery. The patient was discharged from hospital 4 days later.