Arteriovenous fistula as a complication of renal biopsy

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					218                                         Bratisl Lek Listy 2005; 106 (6–7): 218 – 220

                                                           CASE REPORT

             Arteriovenous fistula as a complication of renal biopsy

                                             Kopecna L, Mach V, Prochazka J

 1st Department of Paediatrics, Faculty of Medicine, Masarykiensis University, Brno, Czech


            Background: We evaluated the incidence and history of arteriovenous fistula (AVF) after kidney biopsy
            and assessed the use of superselective embolisation for treatment.
            Methods: Case report of a 10-year-old boy with nephrotic syndrome. Renal biopsy (RB) in this patient
            was complicated with AVF. Immediately after RB was undertaken, microscopic haematuria was ob-
            served, within 48 hours after the biopsy life-threatening haematuria due to pseudoaneurysm started.
            Renal angiography was carried out, which demonstrated a hyperthrophic aberrant artery in the region
            of the bottom pole of the left kidney, from which blood was instantaneously flowing through a high-flow
            arteriovenous fistula (AVF).
            Results: Embolization was carried out using small platinum coils (MWCE-18S-3/2,-18S-4/2,-18S-5/2-
            TORNADO Embolization Microcoil) and the tissue adhesive Histoacryl.
            Conclusions: The technique of superselective embolisation using coaxial catheter is a safe method in the
            treatment of post biopsy AVFs and pseudoaneurysm (Fig. 3, Ref. 6).
            Key words: renal biopsy, arteriovenous fistula, therapy, childhood.

    Percutaneous renal biopsy (RB) is a standard examination           showed a haematoma at the lower pole of the left kidney. There
method used to diagnose renal parenchymal diseases. Its develop-       was an audible murmur above the left kidney detected during
ment has been enabled by the spread of ultrasonography and by          clinical examination. Consequently, renal angiography was car-
introduction of modern automatic bioptic sets. RB is carried out       ried out, which demonstrated a hypertrophic aberrant artery in
in adult as well as in paediatric patients under ultrasonography       the region of the lower pole of the left kidney, from which blood
control using an automated spring-loaded biopsy device. This ex-       was instantaneously flowing through a high-flow arteriovenous
amination method is highly efficient for diagnoses; occasionally it    fistula (AVF) with a minute aneurysm to the corresponding seg-
may be accompanied by complications, which may even lead to            mental vein and massively filling up the left renal artery as well
loss of the kidney or patient’s death (Horèièka, 2002; Bilge, 1999).   as the vena cava inferior.
                                                                            The arteficial AVF was high-flow with the AVF flow velo-
Material and methods                                                   city at 150 cm/s (Fig. 1).

    A 10-year-old boy was treated for a primary nephrotic syn-         Results
drome. Standard corticoid therapy did not result in remission.
Therefore RB was indicated before introducing further treatment.           Due to the fact that the microscopic haematuria attacks oc-
The biopsy of the left kidney was carried out using a bioptic set      curred repeatedly and also taking into account the patient’s clini-
Temno Biopsy Device with a 14 G syringe, 15 cm length, under           cal condition and the renal angiography finding, it was decided
usual conditions, i.e. after prior administration of analgesic and
sedative and local anesthesia in recumbence.                           1st Department of Paediatrics, Faculty of Medicine, Masarykiensis Uni-
                                                                       versity, Brno, and Department of Paediatric Radiology Faculty of Medi-
    Immediately after RB was undertaken, microscopic haemat-
                                                                       cine, Masarykiensis University Brno, Czech Republic
uria was observed, within 48 hours after RB macroscopic haemat-
                                                                       Address for correspondence: L. Kopecna, MD, PhD, 1st Dept of Pae-
uria attacks occurred. Life-threatening haematuria lead to haemor-     diatrics, Faculty of Medicine, Masarykiensis University, Cernopolni 9,
rhagic shock development necessitating blood transfusion with-         CZ-613 00 Brno, Czech Republic.
out delay. Ultrasonography and CT examinations performed               Phone: +420.5.32234237, Fax: +420.532234238
                                  Kopecna L et al. Arteriovenous fistula as a complication…                                        219

Fig. 1. Intraarterial angiography shows pseudoaneurysm and arte-    Fig. 3. Occlusion of the pseudoaneurysm and arteriovenous fistula
riovenous fistula.                                                  after embolization.


                                                                        Renal biopsy is a routine examination method in nephrol-
                                                                    ogy. Its development was enabled by an increased usage of ultra-
                                                                    sonography and by introducing automated biopsy sets. Based on
                                                                    written information available, the number of all complications
                                                                    accompanying kidney biopsy falls within the range of 5 to 10 %
                                                                    (Preda, 2002). Among the most frequent complications we may
                                                                    find microscopic haematuria (up to 25 %) and perirenal haema-
                                                                    toma (up to 42 %). Usually the complications are clinically in-
                                                                    significant, as the complications require any treatment or even
                                                                    blood transfusion in less than 4 % of the cases. In rare cases RB
                                                                    complications are caused by infections (0.9 %), intestine perfo-
                                                                    rations (0.8 %), surgery is necessary in 0.3 % of cases. There are
                                                                    less than 0.2 % cases where performing RB leads to death.
                                                                        Arteriovenous fistula in connection with performing RB is
                                                                    observed in 1.5 to 16 % cases, more often it afflicts a transplanted
                                                                    kidney (Dorffner, 1998). The development of AVF is as follows:
                                                                    around 70 % are spontaneously cured within 3.5 to 20 months.
                                                                    For the remaining 30 % AVF does not spontaneously recover
Fig. 2. Embolization of the feeding artery was performed with       and gradual remodeling of the vessel bed within the AVF drain-
microcoils.                                                         age region lead to complications, including haemorrhage, hy-
                                                                    pertension or alterations in kidney function. These complicated
to perform a complete endovasal embolization. Embolization was      AVF occurrences may be divided from time perspective into two
carried out using small platinum spirals (MWCE-18S-3/2,-18S-        groups. In the first group the symptoms (mainly macroscopic
4/2,-18S-5/2-TORNADO Embolization Microcoil) and the tis-           haematuria) occur immediately after biopsy. In the second group
sue adhesive Histoacryl (Figs 2 and 3).                             the symptoms develop after months or years after biopsy and AVF
    Further course of the treatment was then entirely free of any   may be manifested as microscopic or macroscopic haematuria,
complications. Currently the boy has been for over a year in a      anaemia, hypertension or gradual alterations of kidney functions.
clinical and laboratory remission of the nephrotic syndrome, the        Diagnostic demonstration of AVF may be provided using
blood pressure values are normal.                                   physical examination, when auscultation in the kidney region
220                                       Bratisl Lek Listy 2005; 106 (6–7): 218 – 220

will show murmur or thrill. This examination though has a low        Reference
sensitivity of demonstration. When measuring blood pressure,
pathological values may be found, both hypertension as well as       Bilge I, Roznes I, Acunas B et al. Endovascular treatment of arterio-
                                                                     venous fistulas complicating percutaneous renal biopsy in three pae-
hypotension. An easily accessible and efficient method, not be-
                                                                     diatric cases. Nephrol Dial Transplant 1999: 14: 2726—2730.
ing burdensome on the patient, of detecting a fistula is duplex or
triplex ultrasonography. Dopplerometric measurement in the           Dorffner R, Thurnher S, Prokesch R et al. Embolization of iatroge-
                                                                     nic vascular injuries of renal transplants immediate and follow up re-
anastomosis region proves an increase in systolic and diastolic
                                                                     sults. Cardiovasc Intervent Radiol: 1998: 21: 129—134.
speed, decrease of resistant index (Mutz, 1997). Angiographic
examination remains to be the golden standard and a way for a        Horèièka V, Krejèí K, Zadražil J. Arteriovenózní pištìl jako kompli-
                                                                     kace biopsie ledvin. Vnitø Lék 2002: 5: 432—437.
therapeutic solution of the condition. Only symptomatic AVF
without spontaneous recovery are accepted for treatment (Bilge,      Mutz S, Türk I, Schönberger B et al. Colour-codex duplex sonogra-
1999).                                                               phy in the diagnostic assessment of vascular complications after kidney
                                                                     transplantation in children. Pediatr Radiol 1997: 27: 898—902.
    Transarterial superselective embolization has become the
most frequent medical procedure.                                     Preda A, Van Dijk LC, Van Oostaijen JA et al. Complication rate
    A range of materials is used: steel and platinum spirals,        and diagnostic yield of 515 consecutive ultrasound-guided biopsies of
bucrylate, lipiodol a contrast substance bolus (Sharma, 2002,        renal allografts and native kidneys using a 14-gauge Biopty gun. Euro-
                                                                     pean Radiology 2002.
Dorffner 1998). In rare cases an operation is necessary (blood
vessel ligation, nephrectomy).                                       Sharma AK, Sunil S, Rowlands P et al. Pseudoaneurysm with severe
                                                                     hematuria in renal allograft after renal biopsy treated by percutaneous
                                                                     embolization. Nephrol Dial Transplant 2002: 17: 934—935.

                                                                                                                  Received April 13, 2005.
                                                                                                                  Accepted May 10, 2005.