Presentation
Pushbike accident. Patient pale.
Patient Data
"Shattered" left kidney with multiple areas of segmental non-enhancing parenchyma surrounded by large volume hemorrhage confined to the left renal and perirenal fascia. The main renal artery is patent and in continuity (no dissection) however there is likely injury to the segmental branches. The renal vein is in continuity and is demonstrated draining the relatively perfused lower pole however the segmental branches from the mid and upper pole cannot be clearly delineated. No obvious pseudo-aneurysm. On delayed imaging, emptying of contrast from a few of the renal calyces is seen however no definite opacification of the ureter is identified. Probable minor extravasation from the collecting system is seen at the upper pole. On the delayed run there is a minor amount of contrast pooling consistent with active bleeding posterior to the anteriorly displaced and fractured lower pole of the left kidney.
The pancreas enhances homogeneously with no evidence of transection. The left adrenal gland is intact - compressed medially. The spleen and splenic vessels are also intact.
The aorta and its main branches are patent. The liver, right adrenal gland and right kidney are normal in appearance. No free gas to suggest viscus injury. Plump IVC.
Bilateral dependent change seen within the lungs.
No lumbar spine or pelvic fracture.
Technique:
Right sided 5 Fr retrograde CFA puncture. A 5 Fr pigtail was used to perform initial DSA.
Findings:
Performed under local anesthesia with IV sedation and analgesia.
50% of kidney devascularised. Large truncated (transected/dissected) vessel. 3 false aneurysms demonstrated on main trunk/ upper/ lower polar arteries.
Embolization:
Truncated vessel inferior-midpolar region initially probed, however active extravasation therefore rapidly coiled with succession of IDC 018 microcoils (runs 5 & 6).
The pseudoaneurysms were subsequently probed however superselective embolization was not possible due to the arrangement/anatomy therefore the kidney was not salvageable. After discussion with surgeon it was decided to coil main renal artery. This was successfully occluded with combination of pushable 035 coils (runs 7 & 8).
Case Discussion
Angiography in this case was not only essential in treating continuing hemorrhage, but also was able to assess for the possibility of renal salvage, not possible in this case.
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