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Blunt Renal Trauma: Minimally Invasive Management with Microcatheter Embolization—Experience in Nine Patients¹

¹ From the Departments of Diagnostic Radiology (H.P.D., J.T.) and Urology (H.D.), University of Bern, Inselspital, Freiburgstrasse 20, CH 3010 Bern, Switzerland. Received July 18, 2001; revision requested September 11; revision received October 24; accepted November 13. Address correspondence to H.P.D. (e-mail: hans-peter.dinkel@insel.ch).

View larger version (149K): [in a new window]   Figure 1a. Patient 5. A 20-year-old man with grade III renal laceration sustained during a fall on a curbstone underwent therapeutic embolization with microcoils. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization depicts a pseudoaneurysm (black arrow) in the ventral upper third of the left kidney, as well as a large perirenal hematoma (white arrows). (b) Transverse CT scan obtained 3 months after embolization. There is only a small renal scar (short arrow); most of the hematoma has resolved. Note the streak artifact caused by the presence of metallic coils (long arrows). (c) Selective angiogram obtained in an anteroposterior projection after the successful embolization with microcoils of two upper-pole feeder vessels (arrows) of the pseudoaneurysm.

View larger version (160K): [in a new window]   Figure 1b. Patient 5. A 20-year-old man with grade III renal laceration sustained during a fall on a curbstone underwent therapeutic embolization with microcoils. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization depicts a pseudoaneurysm (black arrow) in the ventral upper third of the left kidney, as well as a large perirenal hematoma (white arrows). (b) Transverse CT scan obtained 3 months after embolization. There is only a small renal scar (short arrow); most of the hematoma has resolved. Note the streak artifact caused by the presence of metallic coils (long arrows). (c) Selective angiogram obtained in an anteroposterior projection after the successful embolization with microcoils of two upper-pole feeder vessels (arrows) of the pseudoaneurysm.

View larger version (136K): [in a new window]   Figure 1c. Patient 5. A 20-year-old man with grade III renal laceration sustained during a fall on a curbstone underwent therapeutic embolization with microcoils. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization depicts a pseudoaneurysm (black arrow) in the ventral upper third of the left kidney, as well as a large perirenal hematoma (white arrows). (b) Transverse CT scan obtained 3 months after embolization. There is only a small renal scar (short arrow); most of the hematoma has resolved. Note the streak artifact caused by the presence of metallic coils (long arrows). (c) Selective angiogram obtained in an anteroposterior projection after the successful embolization with microcoils of two upper-pole feeder vessels (arrows) of the pseudoaneurysm.

View larger version (175K): [in a new window]   Figure 2a. Patient 9. A 32-year-old man with bladder tamponade secondary to massive hematuria after laceration of the kidney. The patient had fallen 1 m onto the top of a wall, hitting his right flank. He was treated with microcoil embolization. (a) Selective angiogram obtained in an anteroposterior projection by using a cobra catheter 8 days after the trauma shows three traumatic aneurysms (arrows) in the lower pole of the right kidney. (b) Superselective angiogram obtained in an anteroposterior projection by using a 3-F microcatheter that was positioned proximal to the bifurcation of two of the bleeding branches. Three microcoils (arrows) have been deployed and have already led to complete occlusion of the first pseudoaneurysm and partial occlusion of the second. (c) Angiogram obtained in an anteroposterior projection by using the cobra catheter, which is in a superselective position in the lower branch of the renal artery, shows the progressive occlusion of two lesions, while a third lesion (arrow) is still patent. (d) Selective angiogram obtained in an anteroposterior projection at the conclusion of the intervention shows complete occlusion of all three lesions. There is no loss of parenchyma within the kidney except for a limited vascular territory of subsegmental branches that was occluded as a result of coil embolization.

View larger version (145K): [in a new window]   Figure 2b. Patient 9. A 32-year-old man with bladder tamponade secondary to massive hematuria after laceration of the kidney. The patient had fallen 1 m onto the top of a wall, hitting his right flank. He was treated with microcoil embolization. (a) Selective angiogram obtained in an anteroposterior projection by using a cobra catheter 8 days after the trauma shows three traumatic aneurysms (arrows) in the lower pole of the right kidney. (b) Superselective angiogram obtained in an anteroposterior projection by using a 3-F microcatheter that was positioned proximal to the bifurcation of two of the bleeding branches. Three microcoils (arrows) have been deployed and have already led to complete occlusion of the first pseudoaneurysm and partial occlusion of the second. (c) Angiogram obtained in an anteroposterior projection by using the cobra catheter, which is in a superselective position in the lower branch of the renal artery, shows the progressive occlusion of two lesions, while a third lesion (arrow) is still patent. (d) Selective angiogram obtained in an anteroposterior projection at the conclusion of the intervention shows complete occlusion of all three lesions. There is no loss of parenchyma within the kidney except for a limited vascular territory of subsegmental branches that was occluded as a result of coil embolization.

View larger version (177K): [in a new window]   Figure 2c. Patient 9. A 32-year-old man with bladder tamponade secondary to massive hematuria after laceration of the kidney. The patient had fallen 1 m onto the top of a wall, hitting his right flank. He was treated with microcoil embolization. (a) Selective angiogram obtained in an anteroposterior projection by using a cobra catheter 8 days after the trauma shows three traumatic aneurysms (arrows) in the lower pole of the right kidney. (b) Superselective angiogram obtained in an anteroposterior projection by using a 3-F microcatheter that was positioned proximal to the bifurcation of two of the bleeding branches. Three microcoils (arrows) have been deployed and have already led to complete occlusion of the first pseudoaneurysm and partial occlusion of the second. (c) Angiogram obtained in an anteroposterior projection by using the cobra catheter, which is in a superselective position in the lower branch of the renal artery, shows the progressive occlusion of two lesions, while a third lesion (arrow) is still patent. (d) Selective angiogram obtained in an anteroposterior projection at the conclusion of the intervention shows complete occlusion of all three lesions. There is no loss of parenchyma within the kidney except for a limited vascular territory of subsegmental branches that was occluded as a result of coil embolization.

View larger version (193K): [in a new window]   Figure 2d. Patient 9. A 32-year-old man with bladder tamponade secondary to massive hematuria after laceration of the kidney. The patient had fallen 1 m onto the top of a wall, hitting his right flank. He was treated with microcoil embolization. (a) Selective angiogram obtained in an anteroposterior projection by using a cobra catheter 8 days after the trauma shows three traumatic aneurysms (arrows) in the lower pole of the right kidney. (b) Superselective angiogram obtained in an anteroposterior projection by using a 3-F microcatheter that was positioned proximal to the bifurcation of two of the bleeding branches. Three microcoils (arrows) have been deployed and have already led to complete occlusion of the first pseudoaneurysm and partial occlusion of the second. (c) Angiogram obtained in an anteroposterior projection by using the cobra catheter, which is in a superselective position in the lower branch of the renal artery, shows the progressive occlusion of two lesions, while a third lesion (arrow) is still patent. (d) Selective angiogram obtained in an anteroposterior projection at the conclusion of the intervention shows complete occlusion of all three lesions. There is no loss of parenchyma within the kidney except for a limited vascular territory of subsegmental branches that was occluded as a result of coil embolization.

View larger version (158K): [in a new window]   Figure 3a. Patient 6. A 22-year-old man who underwent coil embolization for grade V vascular pedicle avulsion. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization reveals a huge retroperitoneal hematoma (arrowheads) and complete transection of the right renal artery (long straight arrow), which is actively bleeding and feeding the hematoma. The short straight arrow indicates the compressed inferior vena cava, and the curved arrow points to a spot of contrast material that represents active extravasation. Note the absence of the left kidney. (b) Nonselective angiogram obtained in an anteroposterior projection after embolization of the stump of the avulsed right renal artery shows the microcoils (arrow). The absence of a left renal artery indicates left-sided renal agenesis.

View larger version (133K): [in a new window]   Figure 3b. Patient 6. A 22-year-old man who underwent coil embolization for grade V vascular pedicle avulsion. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization reveals a huge retroperitoneal hematoma (arrowheads) and complete transection of the right renal artery (long straight arrow), which is actively bleeding and feeding the hematoma. The short straight arrow indicates the compressed inferior vena cava, and the curved arrow points to a spot of contrast material that represents active extravasation. Note the absence of the left kidney. (b) Nonselective angiogram obtained in an anteroposterior projection after embolization of the stump of the avulsed right renal artery shows the microcoils (arrow). The absence of a left renal artery indicates left-sided renal agenesis.

View larger version (164K): [in a new window]   Figure 4a. Patient 7. A 32-year-old woman who underwent embolization with PVA particles for a grade V renal laceration (shattered kidney) sustained during a motorbike accident. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization shows a viable remnant of tissue (white arrows), arterial extravasation of contrast material (black arrow), and a large hematoma (arrowheads) in and around the shattered left kidney. (b) A nonselective angiogram obtained in an anteroposterior projection shows active extravasation of contrast material (arrow) in the lacerated left kidney. Roughly 20% of viable tissue (arrowheads) remains in the lower part of the left kidney. (c) Radiograph obtained in an anteroposterior projection shows massive extravasation of contrast material in the left perirenal space. (d) Selective angiogram obtained in an anteroposterior projection after embolization with PVA particles demonstrates occlusion of the previously bleeding branches but preservation of the viable tissue remnants (arrowheads). (e) Delayed-phase CT scan obtained 1 week after embolization depicts the viable lower pole and demonstrates that the residual renal tissue (thin arrows) is functioning in that it is excreting contrast material. However, a small urinoma (thick arrow), which was not opacified on the unenhanced scan or during the portal venous phase, is present near the posterior aspect of the left kidney.

View larger version (196K): [in a new window]   Figure 4b. Patient 7. A 32-year-old woman who underwent embolization with PVA particles for a grade V renal laceration (shattered kidney) sustained during a motorbike accident. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization shows a viable remnant of tissue (white arrows), arterial extravasation of contrast material (black arrow), and a large hematoma (arrowheads) in and around the shattered left kidney. (b) A nonselective angiogram obtained in an anteroposterior projection shows active extravasation of contrast material (arrow) in the lacerated left kidney. Roughly 20% of viable tissue (arrowheads) remains in the lower part of the left kidney. (c) Radiograph obtained in an anteroposterior projection shows massive extravasation of contrast material in the left perirenal space. (d) Selective angiogram obtained in an anteroposterior projection after embolization with PVA particles demonstrates occlusion of the previously bleeding branches but preservation of the viable tissue remnants (arrowheads). (e) Delayed-phase CT scan obtained 1 week after embolization depicts the viable lower pole and demonstrates that the residual renal tissue (thin arrows) is functioning in that it is excreting contrast material. However, a small urinoma (thick arrow), which was not opacified on the unenhanced scan or during the portal venous phase, is present near the posterior aspect of the left kidney.

View larger version (198K): [in a new window]   Figure 4c. Patient 7. A 32-year-old woman who underwent embolization with PVA particles for a grade V renal laceration (shattered kidney) sustained during a motorbike accident. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization shows a viable remnant of tissue (white arrows), arterial extravasation of contrast material (black arrow), and a large hematoma (arrowheads) in and around the shattered left kidney. (b) A nonselective angiogram obtained in an anteroposterior projection shows active extravasation of contrast material (arrow) in the lacerated left kidney. Roughly 20% of viable tissue (arrowheads) remains in the lower part of the left kidney. (c) Radiograph obtained in an anteroposterior projection shows massive extravasation of contrast material in the left perirenal space. (d) Selective angiogram obtained in an anteroposterior projection after embolization with PVA particles demonstrates occlusion of the previously bleeding branches but preservation of the viable tissue remnants (arrowheads). (e) Delayed-phase CT scan obtained 1 week after embolization depicts the viable lower pole and demonstrates that the residual renal tissue (thin arrows) is functioning in that it is excreting contrast material. However, a small urinoma (thick arrow), which was not opacified on the unenhanced scan or during the portal venous phase, is present near the posterior aspect of the left kidney.

View larger version (173K): [in a new window]   Figure 4d. Patient 7. A 32-year-old woman who underwent embolization with PVA particles for a grade V renal laceration (shattered kidney) sustained during a motorbike accident. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization shows a viable remnant of tissue (white arrows), arterial extravasation of contrast material (black arrow), and a large hematoma (arrowheads) in and around the shattered left kidney. (b) A nonselective angiogram obtained in an anteroposterior projection shows active extravasation of contrast material (arrow) in the lacerated left kidney. Roughly 20% of viable tissue (arrowheads) remains in the lower part of the left kidney. (c) Radiograph obtained in an anteroposterior projection shows massive extravasation of contrast material in the left perirenal space. (d) Selective angiogram obtained in an anteroposterior projection after embolization with PVA particles demonstrates occlusion of the previously bleeding branches but preservation of the viable tissue remnants (arrowheads). (e) Delayed-phase CT scan obtained 1 week after embolization depicts the viable lower pole and demonstrates that the residual renal tissue (thin arrows) is functioning in that it is excreting contrast material. However, a small urinoma (thick arrow), which was not opacified on the unenhanced scan or during the portal venous phase, is present near the posterior aspect of the left kidney.

View larger version (168K): [in a new window]   Figure 4e. Patient 7. A 32-year-old woman who underwent embolization with PVA particles for a grade V renal laceration (shattered kidney) sustained during a motorbike accident. (a) Transverse contrast-enhanced spiral CT scan obtained before embolization shows a viable remnant of tissue (white arrows), arterial extravasation of contrast material (black arrow), and a large hematoma (arrowheads) in and around the shattered left kidney. (b) A nonselective angiogram obtained in an anteroposterior projection shows active extravasation of contrast material (arrow) in the lacerated left kidney. Roughly 20% of viable tissue (arrowheads) remains in the lower part of the left kidney. (c) Radiograph obtained in an anteroposterior projection shows massive extravasation of contrast material in the left perirenal space. (d) Selective angiogram obtained in an anteroposterior projection after embolization with PVA particles demonstrates occlusion of the previously bleeding branches but preservation of the viable tissue remnants (arrowheads). (e) Delayed-phase CT scan obtained 1 week after embolization depicts the viable lower pole and demonstrates that the residual renal tissue (thin arrows) is functioning in that it is excreting contrast material. However, a small urinoma (thick arrow), which was not opacified on the unenhanced scan or during the portal venous phase, is present near the posterior aspect of the left kidney.