Intraarterial Ethanol for the Managementof Iatrogenic Renal Artery Pseudoaneurysm

Balbir Singh, 1* MD, Dinesh Sudan, 1 MD, Prithpal Singh, 2 MS, MCH, and Upendra Kaul, 1 MD

Intraarterial injection of absolute ethanol was employed for the management of apseudoaneurysm following percutaneous nephrolithotomy. The ethanol was deliveredselectively using a coronary angioplasty catheter. This seems to be a potentially usefulmethod for the management of severe hematuria following percutaneous renal proce-dures. Cathet. Cardiovasc. Diagn. 45:442–444, 1998. r 1998 Wiley-Liss, Inc.

Key words: ethanol; pseudoaneurysm; renal artery; percutaneous nephrolithotomy;hematuria

INTRODUCTION

Hematuria is a well-recognized complication follow-ing percutaneous renal procedures, including percutane-ous nephrolithotomy (PCNL). The hematuria followingPCNL usually results from the renovascular injury,leading to the formation of a pseudoaneurysm or anarterio-venous fistula [1]. A vast majority of these lesionsheal spontaneously; however, occasionally it may resultin severe hematuria, which could be life threatening.Percutaneous transcatheter embolization is the usualmode of therapy for these injuries [2,3]. We report the useof absolute ethanol delivered through an angioplastyballoon catheter for the management of a pseudoaneu-rysm following a PCNL procedure, which resulted in alife-threatening hematuria.

CASE REPORT

An 18-year-old girl was referred with severe hematuriastarting on third day following PCNL for a right renalcalculus. The PCN tube was removed on second postop-erative day and a right double stent was in situ. Thehematuria continued unabated with usual conservativemeasures and the hemoglobin value dropped to 5 gm%. Atotal of 15 units of blood had been transfused. The patientwas then subjected to selective renal angiography; the leftrenal angiogram was normal, the right renal angiogramlocalized a pseudoaneurysm in one of distal branches(Fig. 1). Several 4F and 5F catheters with different curves(Judkins right/multipurpose/renalcurve/cobra) were tried,but could not selectively cannulate the branch for thepurpose of gelfoam embolization. In view of the inability

to superselectively enter the branch, it was decided to usea 7F right coronary artery guiding catheter to engage theright renal artery and a floppy tip wire (0.014’’3 175 cm,Commander, Bard, Billerica, MA) was then positionedinto the pseudoaneurysm. A 2.0-mm over-the-wire bal-loon (Ranger, Scimed, Maple Grove, MN) was thenplaced in this branch and was inflated at 2 ATM (Fig. 2A).The guide wire was then removed and 2 ml of absoluteethanol was injected through the central lumen (Fig. 2B).The balloon was then deflated and contrast injectionrevealed that the distal branch was completely occluded(Fig. 3). The hematuria completely settled over the next24 hr and the hemtocrit was stabilized. After the proce-dure the patient was administered intravenous ceftriaoxne1 gm twice daily for 7 days. A repeat angiogram done 4days after the procedure showed no evidence of pseudoan-eurysm. The patient was then discharged and did not haveany hematuria subsequently. A repeat ultrasonography at1 month revealed no renal calculus with mild corticalthinning and maintained cortico medullary junction.

DISCUSSION

Renovascular injury leading to the formation of arterio-venous fistulas and pseudoaneurysms of the renal arteries

1Department of Cardiology, Batra Hospital, New Delhi, India2Department of Urology, Batra Hospital, New Delhi, India

*Correspondence to: Balbir Singh, Interventional Cardiology, BatraHospital and Medical Research Centre, 1 Tughlakabad InstitutionalArea, Mehrauli Badarpur Road, New Delhi 110062, India.

Received 2 March 1998; Revision accepted 12 June 1998

Catheterization and Cardiovascular Diagnosis 45:442–444 (1998)

r 1998 Wiley-Liss, Inc.

is a well-recognized complication of percutaneous renalprocedures such as PCNL. The reported incidence ofpseudoaneurysms following PCNL is 0.6% to 1% [4].Patients with significant hematuria persisting 4 to 5 daysafter the primary procedure should be investigated withangiography. Transarterial embolization is an acceptedmode of therapy in these patients. In contrast to surgery,embolization is less invasive and helps in salvaging thekidney in many patients. Gelfoam is the preferred mate-rial used for embolization. However, gel foam emboliza-tion has several shortcomings, including: (1) reflux ofembolic material into the normal arteries, particularly if asmall distal vessel has not been super-selectively cannu-lated; (2) a larger vessel may be difficult to occlude and itmay also result in more generalized embolization of thearterial tree; and (3) Gel foam can undergo resorption andallow recannulation of the vessel. In moderate-sizedvessels, steel coils or detachable balloons may also beused.

In the present case, the inability to superselectivelycannulate the vessel because of an acute bend and markedtortousity of the distal branch necessitated the use of anangioplasty guide wire with a balloon catheter. Ethanolinjected intraarterially has been used to reduce thevascularity of tumors to facilitate their surgical resection;selective injections to the branches of coronary arterieshave been used for the ablation of ischemic ventriculartachycardia or for producing complete heart block[5]. Recently, ethanol has also been used for occlusionof septal artery in order to produce septal infarctionand cause a reduction of left ventricular outflow gradientin patients with hypertrophic obstructive cardiomyopa-thy [6].

After coronary injection of ethanol in the animalmodel, histopathologic examination of the myocardiumsupplied by these coronary arteries shows transmuralinfarction by coagulation necrosis due to immediatedehydration of myocardial cells. The coronary arteriesexhibit luminal thrombus with endothelial loss and vary-ing degrees of medial necrosis, leading to its occlu-sion [5]. In the present case, injection of a small dose

Fig. 1. Selective right renal angiogram shows evidence of apseudoaneurysm (arrow). Double right renal stent is in situ.

Fig. 2. A: A 2.0-mm balloon over a floppy tip guide wire (0.014 9 3175 cm) placed in the branch feeding the pseudoaneurysm. B:The guide wire has been removed and 2 ml of absolute ethanol isinjected through the central lumen.

Ethanol for Renal Artery Pseudoaneurysm 443

of ethanol was effective in completely occluding thebranch.

In conclusion, the present report describes a simpleand effective procedure for the management of renovas-

cular trauma. This would be particularly useful in manag-ing pseudoaneurysms or arterio-venous fistulas arisingfrom the distal small branches, as has been illustratedabove.

REFERENCES

1. Clayman RV, Surya V, Hunter D: Renal vascular complicationsassociated with the percutaneous removal of renal calculi. J Urol132:228–230, 1984.

2. Phadke RV, Sawlani V, Rastogi H, Roy S, Baijal SS, RameshBabu V, Ahlawat R, Kher V, Gujral RB: Iatrogenic renal vascularinjuries and their radiological management. Clin Radiol 52:119–123, 1996.

3. Szmigielshi W, Hanna RM, Dahniya MH: Life threateningpost-nephrolithotomy hemorrhage resulting in cessation of kidneyfunction, treated by transcatheter arterial embolisation with subse-quent restoration of excretory function. Acta Radiologica 32:47–49,1991.

4. Lang EK: Percutaneous nephrolithotomy and lithotripsy: Amulti-institutional survey of complications. Radiology 162:25–30,1987.

5. Nellens P, Brugada P: Alcohol injection ablation of ventriculartachycardia. In Sigwart U, Bertrand M, Serruys PW (eds): ‘‘Cardio-vascular Interventions.’’New York: Churchill Livingstone, 1996, pp265–271.

6. Sigwart U: Nonsurgical myocardial reduction: A new treatment forhypertrophic obstructive cardiomyopathy. Lancet 346:221, 1995.

Fig. 3. Angiogram at the end of procedure shows that thebranch is completely occluded with no evidence of pseudoaneu-rysm (arrow).

444 Singh et al.