Iatrogenic renal arteriovenous fistula and pseudoaneurysm

Case contributed by Dr Ammar Ashraf

Presentation

Recurrent left flank pain and hematuria. History of left partial nephrectomy for chromophobe RCC two years ago.

Patient Data

Age: 60 years
Gender: Male

Findings: A pseudoaneurysm measuring 22 x 17 mm is seen at the upper pole of the left kidney. A few prominent veins showing early opacification during the arterial phase of the scan are also noted at the upper pole of the left kidney. No active contrast extravasation is noted. Changes of previous left partial nephrectomy and two small non-obstructive left renal calculi are noted. Small retro-peritoneal lymph nodes at the level of renal hila, bilateral renal cysts, and segment VIII hepatic hemangioma are stable. Small omental fat-containing umbilical hernia.

Impression: Iatrogenic left renal arteriovenous fistula and pseudoaneurysm.

Follow-up CT Pyelogram after coil embolization

CT

Relatively smaller left kidney with mildly decreased parenchymal thickness. Status post coil embolization of the renal artery pseudoaneurysm. Small non-obstructive radiopaque stones in the lower pole calyx of the left kidney.  

Case Discussion

The patient had a history of wedge resection of a suspicious lesion at the upper pole of the left kidney two years ago which was diagnosed as chromophobe renal cell carcinoma on the histopathology (rID: 84337). An iatrogenic renal arteriovenous fistula and pseudoaneurysm were seen at the site of the previous resection of RCC at the upper pole of the left kidney on a follow-up CT scan. This iatrogenic complication was managed with endovascular coil embolization by an interventional radiologist.

Iatrogenic injury (particularly renal biopsy) is the commonest cause of traumatic renal arteriovenous shunts and has a reported incidence of 7.4-11% 1. These AV shunts are generally single, involve a direct communication be­tween a single artery and a single draining vein, and often have a co-existing pseudoaneurysm 1.

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