A partial nephrectomy is being used increasingly for the removal of renal cell carcinomas. A renal artery pseudoaneurysm (RAP) is a rare, potentially life threatening complication after a partial nephrectomy. This paper presents a case of spontaneous thrombosis of RAP after a partial nephrectomy. The presented case is believed to be the largest in diameter (59 mm) among the reported cases of spontaneous treatment of RAP by complete thrombosisope

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IntroductionA partial nephrectomy has become a much moreprevalent procedure due to the tremendous increasein tomographic imaging studies and improvements insurgical techniques [1]. The purpose of a partialnephrectomy is to preserve the maximum renalfunction without affecting the overall tumor-specificsurvival rate [1]. On the other hand, severalcomplications can occur during the postoperativeperiod after a partial nephrectomy. Some can bemanaged conservatively but serious complicationsrequire interventional treatment [2, 3]. A renal arterypseudoaneurysm (RAP) is one of the most seriouscomplications after renal surgery. This paper describesa case of RAP after a partial nephrectomy. The patientwas treated spontaneously by complete thrombosis ofthe RAP. The spontaneous treatment of a RAP in thepresent case is believed to be the largest in diameterreported thus far.Case ReportA 47-year-old woman underwent a computedtomography (CT) scan as part of an evaluation of leftflank discomfort. She had a solitary left kidney due tounilateral renal agenesis. Contrast CT demonstrated a54 × 49-mm solid mass in the lower pole of her leftkidney (Fig. 1). The preoperative diagnosis was renalcell carcinoma and the patient underwent a left partialnephrectomy under video-assisted mini-laparotomysurgery (VAMS) [4]. Tow incisions were made; one 6-cm muscle-splitting incision above the left kidney to- 281 -J Korean Soc Ultrasound Med 2011;30(4)부분 신절제술 후 발생한 신동맥 가성동맥류의 자연 치유: 증례 보고김여은1∙오 택1∙양승철2이도연11연세 학교 세브란스병원상의학과2연세 학교 세브란스병원비뇨기과J Korean Soc Ultrasound Med2011;30:281-285Received June 16, 2011; Revised July18, 2011; Accepted September 19, 2011.Address for reprints :Young Taik Oh, MD, Department ofDiagnostic Radiology, SeveranceHospital, 50 Yonsei-ro, Seodaemun-gu,Seoul 120-752, Korea.Tel. 82-2-2228-7400   Fax. 82-2-393-3035E-mail: oytaik@yuhs.acSpontaneous Treatment of Renal Artery Pseudoaneurysmafter Partial Nephrectomy: A Case ReportYeo-Eun Kim, MD1, Young Taik Oh, MD1, Seung-Choul Yang, MD2, Do Yun Lee, MD11Department of Diagnostic Radiology and Research Institute of Radiological Science,Severance Hospital, Yonsei University College of Medicine, Seoul, Korea2Department of Urology, Severance Hospital, Yonsei University College of Medicine, Seoul,KoreaA partial nephrectomy is being used increasingly for the removal of renal cell carci-nomas. A renal artery pseudoaneurysm (RAP) is a rare, potentially life threateningcomplication after a partial nephrectomy. This paper presents a case of spontaneousthrombosis of RAP after a partial nephrectomy. The presented case is believed to bethe largest in diameter (59 mm) among the reported cases of spontaneous treatmentof RAP by complete thrombosis. Key words : Renal artery pseudoaneurysm; Spontaneous thrombosis; Partial nephrectomyallow sufficient working space and a 1-cm incision forthe camera port. The procedure was performed undera combination of direct and laparoscopic views. Thelesion was removed after clamping the renal arteryand vein. The cold ischemic time was 64 minutes, andintraoperative hemostasis was achieved by electriccauterization. An open collecting system was securedby running a 4-0 Vicryl suture. No significant majorvessel injury was visible in the surgical field. The finalpathology examination revealed a stage T2N0M0,Furman grade 3, clear renal cell carcinoma. Onpostoperative day (POD) 8, the patient complained ofleft flank discomfort and gross hematuria. Her- 282 -J Korean Soc Ultrasound Med 2011;30(4)Fig. 1. Transverse CT image of the arterial phase shows a roundhypervascular mass in the left kidney.A BFig. 2. A. Transverse CT image of the arterial phase shows a collection of contrast medium (arrow) near the renal sinus of the leftkidney that is compatible with a pseudoaneurysm. A large intraperitoneal hematoma (arrowheads) is noted along the left anteriorabdominal wall.B. Color Doppler sonography shows a mass with swirling blood flow in the left kidney, which is the typical appearance of apseudoaneurysm.Fig. 3. Follow-up CT scan was performed three months aftersurgery. Transverse CT image of the arterial phase shows a 59mm sized pseudoaneurysm with partial thrombosis (arrows) inthe left kidney. hemoglobin level dropped to 6.7 g/dL (10.0 g/dL onPOD 1). Contrast CT revealed a large intraperitonealhematoma along the left abdominal wall and a 32-mmcontrast-filled sac in the hilum of the left kidney (Fig.2A). Color Doppler ultrasonography (US) showedswirling blood flow connected through a small trackto an adjacent artery in the left kidney, indicating aRAP (Fig. 2B). In view of these findings, endovasculartreatment was recommended but the patient refused.She became hemodynamically stable and herabdominal pain improved with time. Her hemoglobinstabilized at 10.1 g/dL on POD 14 and was maintainedbetween 10.0-10.9 g/dL for three months. At thethree months follow-up CT, the RAP grew to 59 mmin size and showed an enlarged contrast-filled sac (43mm) and partial thrombosis (Fig. 3). Therefore,endovascular treatment strongly recommended again.She underwent angiography for embolization 2 weeks- 283 -Yeo-Eun Kim, et al : Spontaneous Treatment of Renal Artery Pseudoaneurysm after Partial NephrectomyA BC DFig. 4. A, B. Left renal angiogram demonstrates two left renal arteries with displacement by an avascular mass (arrows) in the lowerpole of the left kidney.C. Color Doppler sonography immediately after a renal angiogram shows a complete thrombosis of the pseudoaneurysm.D. Transverse CT image of the arterial phase shows complete thrombosis of the left renal artery pseudoaneurysm.after the CT scan. Renal artery angiography revealed adisplacement of two left renal arteries by theavascular mass in the lower pole of the left kidney(Fig. 4A, B). Selective renal artery angiography wasperformed but no pseudoaneurysm could be found. Itwas surmised that the pseudoaneurysm might havethrombosed spontaneously. Color Doppler US wasperformed immediately to verify the thrombosis ofthe pseudoaneurysm; there was no internal vascularflow in the low echoic thrombosis (Fig. 4C). After onemonth, a CT scan confirmed the complete thrombosisof the pseudoaneurysm (Fig. 4D).DiscussionA range of complications can occur during thepostoperative period after a partial nephrectomy. Somecomplications, including urinary fistula or smallperinephric hematoma, can be managed conserva-tively but serious complications, including acute renalfailure, large hematoma or perinephric abscess, requireintensive care unit admission and/or immediateintervention [3]. RAP is one of the most seriouscomplication. The condition is normally recognizedafter percutaneous renal procedures [5], renal trauma[6] and renal transplantation [7]. RAP after an openpartial nephrectomy is a rare complication with areported incidence of 0.43% [8]. The natural history of a pseudoaneurysm variesfrom spontaneous resolution to a free rupture.Rupture is the most serious cause of morbidity frompseudoaneurysms. Pseudoaneurysms can undergospontaneous thrombosis, but there is no generallyknown method to predict it [5, 8]. The largest reporteddiameter of a spontaneously thrombosed RAP after apartial nephrectomy was 33 mm [8]. This case showedcomplete spontaneous thrombosis of a RAP, 59 mm indiameter. To our knowledge, the is the largestspontaneous thrombosed RAP reported thus far.The diagnosis of RAP requires a high degree ofclinical suspicion because most patients presentinitially with non-specific symptoms. RAP should beconsidered in a differential diagnosis of any patientwith gross hematuria and flank pain at the surgerysite.Angiography is considered the “gold”standard fordiagnosis but it is an invasive procedure. Othermodalities, such as Doppler US, CT angiography andmagnetic resonance angiography, are useful fornoninvasive detection and diagnosis of pseudo-aneurysm. CT is a valuable diagnostic tool because ithas a short acquisition time, enables imaging of theentire urinary tract, and is the technique of choice forfollow-up. A pseudoaneurysm may resemble acontrast material-filled sac on contrast-enhanced CT,and It can resemble a cystic mass on grey-scale US.Color Doppler US shows characteristic “to-and-fro”flow within the mass [9]. Depending on the clinical status of the patient, themanagement options for RAPs include a nephrectomy,open vascular surgery or coil embolization. Amongthese, percutaneous angiography with selective coilembolization should be the initial treatment of choicebecause it is minimally invasive [10]. RAP is a rare but potentially life-threateningcomplication after a partial nephrectomy. Thediagnosis of RAP is often difficult. Therefore, a highclinical suspicion is needed in patients with grosshematuria or showing signs of internal bleeding toinitiate early intervention and prevent fatal rupture.On the other hand, this case shows that a spontaneousocclusion can occur in large sized RAP when invasivetreatment has not been performed.요 약신세포암의 제거를 위해 최근 부분 신절제술이 점점 증가하고 있다. 부분 신절제술 후 발생할 수 있는 신동맥 가성동맥류는 드물지만 생명을 위협하는 합병증이다. 우리는부분 신절제술 후 발생한 신동맥 가성동맥류에 자연적으로 혈전이 형성된 증례가 있어 보고 하고자 한다. 지금까지보고된 신동맥 가성동맥류의 혈전형성으로 자연 치유된증례 중 직경(59 mm)이 가장 크다.- 284 -J Korean Soc Ultrasound Med 2011;30(4)References1. Nieder AM, Taneja SS. The role of partial nephrectomy forrenal cell carcinoma in contemporary practice. Urol ClinNorth Am 2003;30:529-5422. Stephenson AJ, Hakimi AA, Snyder ME, Russo P.Complications of radical and partial nephrectomy in alarge contemporary cohort. J Urol 2004;171:130-1343. Pasticier G, Timsit MO, Badet L, De La Torre Abril L,Halila M, Fassi Fehri H, et al. Nephron-sparing surgery forrenal cell carcinoma: detailed analysis of complicationsover a 15-year period. Eur Urol 2006;49:485-4904. Yang SC, Rha KH, Byun YJ, Kim WY. Video-assisted mini-laparotomy in urology. J Endourol 2003;17:465-467; dis-cussion 467-4685. Phadke RV, Sawlani V, Rastogi H, Kumar S, Roy S, BaijalSS, et al. Iatrogenic renal vascular injuries and their radio-logical management. Clin Radiol 1997;52:119-1236. Jebara VA, El Rassi I, Achouh PE, Chelala D, Tabet G,Karam B. Renal artery pseudoaneurysm after blunt ab-dominal trauma. J Vasc Surg 1998;27:362-3657. Dodd GD, 3rd, Tublin ME, Shah A, Zajko AB. Imaging ofvascular complications associated with renal transplants.AJR Am J Roentgenol 1991;157:449-4598. Albani JM, Novick AC. Renal artery pseudoaneurysm af-ter partial nephrectomy: three case reports and a literaturereview. Urology 2003;62:227-2319. Mitchell DG, Needleman L, Bezzi M, Goldberg BB, KurtzAB, Pennell RG, et al. Femoral artery pseudoaneurysm: di-agnosis with conventional duplex and color Doppler US.Radiology 1987;165:687-69010. Hidas G, Croitoru S, Wolfson V, Moskovitz B, Nativ O.Renal artery pseudoaneurysm after partial nephrectomycomplicated by rupture into the collecting system, man-aged by selective angiographic embolization. Isr MedAssoc J 2005;7:410-411- 285 -Yeo-Eun Kim, et al : Spontaneous Treatment of Renal Artery Pseudoaneurysm after Partial Nephrectomy

부분 신절제술 후 발생한 신동맥 가성동맥류의 자연 치유: 증례 보고

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부분 신절제술 후 발생한 신동맥 가성동맥류의 자연 치유: 증례 보고

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