218 Bratisl Lek Listy 2005; 106 (67): 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 Republic.firstname.lastname@example.org Abstract 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 patients 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 patients 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. Discussion 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 (67): 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: 27262730. 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: 129134. speed, decrease of resistant index (Mutz, 1997). Angiographic examination remains to be the golden standard and a way for a Horèièka V, Krejèí K, Zadrail J. Arteriovenózní pitìl jako kompli- kace biopsie ledvin. Vnitø Lék 2002: 5: 432437. 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: 898902. 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: 934935. Received April 13, 2005. Accepted May 10, 2005.