A Case Of Percutaneous Angioplasty And Conservative Treatment For Bilateral Blunt Renal Artery Injury

Blunt renal artery injury is rare and no standard treatment has been established. We report a case of bilateral blunt renal artery injury in which percutaneous angioplasty and conservative treatment were performed. 4th generation male. While walking, he was hit by a truck and injured. Contrast-enhanced CT and angiography revealed disruption of the right renal artery, poor contrast in the right renal parenchyma, intimal damage to the dorsal branch of the left renal artery, and delayed contrast in the dorsal left renal parenchyma. Although we were able to place a stent in the dorsal branch of the left renal artery, the right renal artery occlusion could not be relieved percutaneously. Although surgical revascularization was considered, it was determined that sufficient renal function had already been preserved, and the right renal artery was treated conservatively. Hypertension that occurred postoperatively was treated with oral medication. Serum creatinine 4 months after injury was 1. The stent was found to be patent on contrast-enhanced CT at ₁₂mg/dl. Index terms: blunt renal artery injury, percutaneous angioplasty, conservative treatment

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Background

Blunt renal artery injury is a rare injury that complicates blunt trauma ₁) ₂). No standard treatment method has been established, and surgical revascularization and conservative treatment have been performed, but in recent years, the usefulness of percutaneous angioplasty has been recognized ₃) ₄). We report a case of bilateral blunt renal artery injury in which percutaneous angioplasty and conservative treatment were successfully performed to preserve sufficient renal function.

On the 4th and 13th hospital days, open reduction of the right acetabular fracture and vertebral subluxation was performed. Hypertension was observed from the 22nd hospital day and was controlled with oral antihypertensive drugs. Oral administration of aspirin ₁₀₀mg/day was started on the 33rd day of illness. She was transferred to the hospital on the 43rd hospital day without ever receiving hemodialysis. Serum creatinine 4 months after injury was 1. ₁₂mg/dl, eGFR is ₈₃mL/min/₁. It was ₇₃m₂. Contrast-enhanced CT showed that the stent placed in the dorsal branch of the left renal artery was patent, and there was no contrast delay or atrophy in the dorsal side of the left kidney, but the right kidney, where the blood flow obstruction could not be resolved, was severely atrophied.

It was shrinking (Figure 3). Hypertension was well controlled with oral medication.

Thoughts and observations

Renal artery injury is caused by blunt trauma. ₀₅︲₀． It is a rare injury that occurs in ₀₈%₁)₂). Depending on the type of injury, it can be divided into lacerations and ruptures that involve the entire thickness of the artery, and intimal damage that is localized only to the intima. Tears and ruptures affect life prognosis due to bleeding, and intimal injuries affect functional prognosis due to impaired blood flow. ．． Therefore, the urgency and contents of each treatment differ, but renal artery injury is not classified by injury type in the Japanese Society of Traumatology Organ Injury Classification ₂₀₀₈₅) and the American Association for Surgery of Trauma Kidney Injury Scale ₆). As a treatment, hemostasis is necessary when there is bleeding due to lacerations or ruptures. On the other hand, there is no established opinion regarding the optimal treatment for blood flow disorders caused by intimal damage as in this case.

Treatment of blunt renal artery intimal injury includes surgical revascularization, conservative treatment, and percutaneous angioplasty. Historically, surgical revascularization has been attempted, but the technical success rate and renal function preservation rate are only 3. ₃︲₈₀． ₀%,₀︲₄₂． ₉% is hardly a good result₂)₇)︲₉). For this reason, around 2012, surgical revascularization was attempted in cases of damage to one or both kidneys, but the function of the healthy kidney was preserved.

There are now reports that recommend conservative treatment if the condition is present. Percutaneous angioplasty was first reported in 2012 (2015), and is considered a reasonable option because of its good technical success rate of 43% and renal function preservation rate of 20%. In this case, there is room for discussion as to what should be done when percutaneous revascularization of the right renal artery is impossible. We believed that adequate residual renal function could not be maintained if all injuries were treated conservatively, so we performed revascularization to the dorsal branch of the left renal artery. It has been reported that there is a correlation between renal parenchymal volume and renal function. After nephrectomy, residual renal function has been reported to increase compensatoryly by ₂₀︲₂₅%. In this case, when measured postoperatively, the renal parenchymal volume was ₁₄₀cm₃ on the right side and ₁₅₆cm₃ on the left side, indicating impaired blood flow.

No harm was observed in the ventral left kidney at ₉₃cm₃, and with conservative treatment alone, the residual renal function was eGFR ₃₇︲₃₉mL/min/₁. It was expected to be ₇₃m₂. After nephrectomy

eGFR<₄₅mL/min/₁. ₇₃m₂ is a poor prognostic factor (₁₁), suggesting that additional revascularization was necessary. Subsequently, a stent was successfully placed in the dorsal branch of the left renal artery, making it possible to preserve the entire left kidney. Considering the fact that one kidney had already been preserved in its entirety, the results of surgical revascularization, and the extent of the invasion, we concluded that the right renal artery was a unilateral renal artery injury before the advent of percutaneous angioplasty.

We judged that conservative treatment was appropriate in accordance with the recommendations of . Four months after the injury, renal function was sufficiently preserved, and our judgment was considered to be acceptable. Even in cases where there is blood flow obstruction due to blunt renal artery intimal injury on both sides, as in this case, it is possible that sufficient renal function preservation can be achieved with a minimally invasive approach through flexible treatment centered on percutaneous angioplasty. There is. In this case, although percutaneous angioplasty has been reported to have a high success rate, recanalization of the right renal artery was not achieved. It has been pointed out that prolonged warm ischemia and complete occlusion are associated with a decreased success rate in surgical revascularization, and in this case, it took a long time to revascularize, and the right renal artery was completely occluded. It cannot be denied that this may have contributed to the failure. On the other hand, in the case of complete occlusion in the paper summarizing percutaneous angioplasty mentioned above, the period until reperfusion was

The median time was ₆ hours, but the technical success rate was ₈₈%, suggesting other potential factors as well. Because the injury is rare and the number of cases is small, it is difficult to derive the contributing factors from the experience of a single institution, and we believe that it is necessary to aggregate the experience of multiple institutions.

Conclusion

I experienced a rare injury called bilateral blunt renal artery injury. By performing percutaneous angioplasty first and successfully achieving partial revascularization, we were able to preserve sufficient renal function for minimally invasive surgery without surgical revascularization. There is no conflict of interest.

Literature

1) Sangthong B, Demetriades D, Martin M, et al: Management and hospital outcomes of blunt renal artery injuries: analysis of 517 patients from the National Trauma Data Bank. J Am Coll Surg 2006; 203: 612︲617.

2) Bruce LM, Croce MA, Santaniello JM, et al: Blunt renal artery injury: incidence, diagnosis, and management. Am Surg 2001; 67: 550︲556.

3) Whigham CJ Jr., Bodenhamer JR, Miller JK: Use of the Palmaz stent in the primary treatment of renal artery intimal injury secondary to blunt trauma. JVIR 1995;₆:175︲178.

4) Beyer C, Zakaluzny S, Humphries M, et al: Multidisciplinary management of Blunt Renal Artery In jury with Endovascular Therapy in the Setting of Polytrauma: A Case Report and Review of it erature. Ann Vasc Surg 2017; 38:318.e11︲318.e16.

5) Japanese Society of Traumatology Organ Injury Classification Committee: Kidney Injury Classification 2008 (Japanese Society of Traumatology). Japanese Journal of Trauma 2008; 22:265.

6) Moore EE, Shackford SR, Pachter HL, et al: Organ injury modeling: spleen, liver, and kidney. J Trauma 1989; 29: 1664︲1666.