M ajor renal vascular injuries are an uncommon result of trauma. Renal trauma occurs in approximately 8 to 10% of individuals with abdominal trauma, 1,2 and of these, the incidence of major vascular injury is typically less than 3%. A renal vein pseudoaneurysm is apparently not a previously described phenomenon resulting from either blunt or penetrating trauma. We present a case report of a patient with a renal vein pseudoaneurysm secondary to blunt trauma sustained in a motor vehicle crash, along with our management strategy and review of the literature.
CASE REPORTA 23-years-old male was transported via Airlife after a MVC. He was an unrestrained backseat passenger in a van carrying 15 other people that rolled at high speed. There was major vehicular deformity, a death at the scene, and six others were injured. He was hemodynamically stable en route and he arrived with a chief complaint of right hip and back pain, as well as pain with inspiration. The patient had no significant past medical or surgical history. On arrival, his blood pressure was 129/90, heart rate was 103, respiratory rate was 18 and his oxygen saturation was 96% on room air. His physical examination revealed a somewhat somnolent patient with clear breath sounds but with tenderness over the right chest wall. There were multiple abrasions over the right side of the torso, left anterior abdominal wall, bilateral thighs, and the chin. Plain films of the cervical spine, chest, and pelvis were negative for injury, as was the head computed tomography (CT) scan. The CT scan of the abdomen and pelvis revealed a contained active extravasation in the region of the right renal hilum with an associated perinephric hematoma extending medially to involve the pericaval and periduodenal areas (Fig. 1). There was also a right adrenal hematoma and a grade I liver laceration. Labs obtained on arrival revealed: ABG 7.37/36/179/21/-3, Cr 1.2, Hct 43.7, Plt 291, Total bilirubin 1.8, Ast 386, Alt 311, Alk phos 89, GGT 23, amylase 139, INR 1.3, PTT 26, EtOH Ͻ10 mg/dL, Urine toxicology was negative. The urinalysis demonstrated, 2 to 4 WBCs and too numerous to count RBCs. Suspecting a renal artery injury Interventional Radiology (IR) was consulted to perform an angiogram. The arterial phase revealed a small upper pole infarct but no extravasation or pseudoaneurysm; however, the venous phase (indirect venography) revealed a large right renal vein pseudoaneurysm (Fig. 2). Because of the pericaval hematoma, a direct inferior vena cavogram was performed which showed no caval injury. With these findings in this stable patient, we elected to pursue nonoperative management and the patient was admitted to the surgical intensive care unit for serial hematocrits and hemodynamic monitoring. The patient demonstrated an initial decline in his hematocrit over the first 24 hours, down to 32.5 but then remained stable over the following day. His creatinine decreased with hydration and remained stable at 0.9. A right renal duplex performed on hospital day 2 noted a significant perinephr...