Endovascular covered stenting for the management of post-percutaneous nephrolithotomy renal pseudoaneurysm: a case report

Abstract

IntroductionIntrarenal pseudoaneurysm is a rare, yet clinically significant, complication of percutaneous nephrolithotomy. A high index of clinical suspicion is necessary in order to recognize pseudoaneurysm as the cause of delayed bleeding after percutaneous nephrolithotomy and angiography confirms the diagnosis which allows endovascular management.Case presentationWe present a case of a 65-year old Caucasian woman who underwent percutaneous nephrolithotomy in the supine position for a two centimetre renal calculus. The postoperative course was complicated by persistent bleeding due to a renal pseudoaneurysm. The vascular lesion was successfully managed by endovascular exclusion through the use of a covered stent graft. We report the first successful use of this method for the management of iatrogenic pseudoaneurysm in a branch of the left renal artery and we focus on the imaging findings, technical details, advantages and limitations of this technique.ConclusionAs a result of its high efficacy, interventional radiology has largely replaced open surgery for the management of renal pseudoaneurysm related to percutaneous nephrolithotomy. Recent technical advancements have allowed the use of covered stent grafts as an alternative to embolisation for the angiographic management of visceral artery pseudoaneurysm located in other organs. This novel technique allows the endovascular exclusion of the pseudoaneurysm, without compromising arterial supply to the end-structures - an advantage of critical importance in organs supplied by segmental arteries - in the absence of collateral vasculature, such as the kidney.

A Rare Case of Spontaneous Asymptomatic Renal Artery Pseudoaneurysm Treated with Coil Embolization: A Case Report

“…14 Embolization of RAP has been reported to have high success rates exceeding 90%. 4,[14][15][16][17] The risk of rupture is estimated to be low, but is associated with a death rate as high as 80%. 18 Currently, no definite guidelines exist for the size at which an RAP should be repaired in an asymptomatic patient.…”

Renal Pseudoaneurysm after Flexible Ureterorenoscopy - An Unusual Complication

“…The pseudoaneurysm may eventually grow and become unstable, with erosion into the pelvicalyceal system or perinephric tissue [1]. Therapy of choice is angiographic embolization [2].…”

Incidental renal artery pseudoaneurysm after percutaneous native renal biopsy

“…If imaging findings are not conclusive and there is clinical suspicion of RAP or the patient is haemodynamically unstable, angiography should be undertaken. In addition to high sensitivity in identifying the RAP, the advantages of angiography include the potential to achieve simultaneous endovascular management of RAP 11. Embolisation of RAP has been reported to have high success rates exceeding 90% 11 12…”

“…In general, angiographic embolisation is the procedure of choice due to its minimally invasive and selective nature and the maximal preservation of renal parenchyma 3. However, embolisation for the management of RAP appears to have some shortcomings, such as possible reflux of embolic material into the normal proximal vessel if the distal branch has not been selectively cannulated and the risk of more generalised ischaemia resulting from thrombosis of a main feeding branch 9 11. In order to overcome these limitations, treatment with covered stent-grafts on RAP located in branches of visceral arteries has been suggested 11.…”

“…However, embolisation for the management of RAP appears to have some shortcomings, such as possible reflux of embolic material into the normal proximal vessel if the distal branch has not been selectively cannulated and the risk of more generalised ischaemia resulting from thrombosis of a main feeding branch 9 11. In order to overcome these limitations, treatment with covered stent-grafts on RAP located in branches of visceral arteries has been suggested 11. In selected cases, the use of ultrasound-guided thrombin injection into an extracapsular pseudoaneurysm following renal allograft biopsy can also be considered a treatment option 19…”