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Renal Arteries: Exclusion
Keith B. Quencer, MD; T. Gregory Walker, MD, FSIR
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KEY FACTS

  • Preprocedure

    • Procedure

      • Outcomes

        TERMINOLOGY

        • Definitions

          • Renal trauma
            • Blunt, penetrating, or iatrogenic injury
              • Renal injury present in 8-10% of blunt and penetrating abdominal injuries
              • 98% of isolated renal injuries are minor
              • Severe renal injury often associated with other organ injury (~ 80%)
              • May cause pseudoaneurysm (PSA)/arteriovenous fistula (AVF)
              • Iatrogenic causes of renovascular injury
                • Biopsy
                • Percutaneous nephrostomy/nephrolithotomy
                • Balloon angioplasty
                • Extracorporeal shock wave lithotripsy
            • Hematuria present in 95% of patients with renal trauma
          • Grading of renal trauma
            • Grade 1
              • Small parenchymal contusion
              • Stable subcapsular hematoma
                • Treatment: Conservative
            • Grade 2
              • Laceration < 1 cm in depth
              • Stable perirenal hematoma
                • Treatment: Conservative
            • Grade 3
              • Laceration > 1 cm in depth
                • No extension into collecting system
                • Treatment: Conservative if stable, angiogram ± intervention if ongoing blood loss or hemodynamically unstable
            • Grade 4
              • Laceration that extends into collecting system
              • Vascular injury of main renal artery or vein
              • Expanding subcapsular or perinephric hematomas
                • Treatment: Angiogram and embolization
            • Grade 5
              • Avulsion of renal hilum with devascularization of kidney
              • Complete laceration or thrombosis of main renal artery or vein
              • Ureteropelvic junction avulsion
              • Shattered kidney
                • Treatment: Varied, nephrectomy often performed
            • Category I (minor)
              • 75-85% of renal trauma
              • Minor cortical contusion/infarction/laceration (no collecting system/medulla involvement)
              • Small intrarenal/subcapsular hematoma
              • Managed conservatively
            • Category II (major)
              • 10% of renal trauma
              • Types of major trauma
                • Laceration extending into medulla; may involve collecting system
                • Segmental renal ischemia/infarction from stretch injury/arterial thrombosis
              • Management varies; usually endovascular
            • Category III (catastrophic)
              • 5% of renal trauma
              • Types of catastrophic trauma
                • Multiple lacerations (e.g., fractured kidney)
                • Vascular pedicle injury (e.g., transection)
              • Typically managed with nephrectomy
            • Category IV
              • Injury involving ureteropelvic junction
              • Management varies from surgical to conservative
          • Renal artery pseudoaneurysm (PSA)
            • Focal disruption/rupture of arterial wall
              • Results in contained arterialized hematoma
                • Contained by adjacent parenchymal tissue
            • Symptoms: Hypertension/flank pain/hematuria
            • Etiologies: Traumatic, spontaneous, iatrogenic, vasculitis (e.g., polyarteritis nodosa)
            • Potential for delayed rupture after clot degradation/restoration of normal hemodynamics
              • Delayed rupture has mortality rate as high as 80%
              • High risk of rupture if PSA > 2 cm
          • Renal arteriovenous fistula (AVF)
            • Abnormal connection between artery and vein
              • Causes abnormal hemodynamics (high-output heart failure, shunting away from normal kidney tissue)
            • Symptoms: Hypertension/high-output heart failure/hematuria/renal insufficiency
            • Etiologies
              • Often acquired (posttraumatic/iatrogenic)
              • Congenital
                • May have arterial/venous aneurysms
              • Idiopathic
                • Can be associated with fibromuscular dysplasia
          • Angiomyolipoma (AML)
            • Benign hamartomatous tumors
              • Variable amounts of blood vessels/muscle/fat
            • Most common benign renal tumor
              • No malignant potential; rarely locally aggressive
            • Abnormal blood vessels
              • No internal elastic lamina, disordered fibrotic smooth muscle cells
              • Prone to intratumoral aneurysm formation and rupture
            • Goal of embolization is devascularization
              • Limits/prevents growth/spontaneous rupture
                • Secondary goal: Preserve normal parenchyma
            • 80% sporadic
              • Typically unilateral; often static/slowly growing
            • 20% associated with tuberous sclerosis complex (TSC)
              • Often bilateral/large; progressive growth
          • Renal arteriovenous malformation (AVM)
            • Typically congenital
            • Multiple communications between arteries and veins
          • Renal artery aneurysm (RAA)
            • 2nd most common visceral aneurysm (15-22%) after splenic
            • Congenital causes: Fibromuscular dysplasia, phakomatoses (e.g., tuberous sclerosis, neurofibromatosis), intrinsic collagen deficiencies (e.g., Ehlers-Danlos, Marfan), vasculitides (e.g., Behcet)
            • Acquired causes: Atherosclerosis/degenerative
            • Often asymptomatic
            • Possible symptoms
              • Hypertension/renal insufficiency from microemboli
              • Hematuria/flank pain from aneurysm rupture
            • Tend to occur at bifurcation of main renal artery
          • Renal artery perforation/rupture
            • Occurs in 3.5% of renal artery interventions

        PREPROCEDURE

        • Indications

          • Preprocedure Imaging

            • Getting Started

              PROCEDURE

              • Patient Position/Location

                • Procedure Steps

                  • Alternative Procedures/Therapies

                    OUTCOMES

                    • Complications

                      • Expected Outcomes

                        Selected References

                        1. Chong ST et al: Renal trauma: imaging evaluation and implications for clinical management. Abdom Radiol (NY). 41(8):1565-79, 2016
                        2. Hellmund A et al: Rupture of renal artery aneurysm during late pregnancy: clinical features and diagnosis. Arch Gynecol Obstet. 293(3):505-8, 2016
                        3. Ramaswamy RS et al: Arterial embolization for the treatment of renal masses and traumatic renal injuries. Tech Vasc Interv Radiol. 19(3):203-10, 2016
                        4. Andersen PE et al: Interventional treatment of renal angiomyolipoma: immediate results and clinical and radiological follow-up of 4.5 years. Acta Radiol Open. 4(7):2058460115592442, 2015
                        5. Coleman DM et al: Renal artery aneurysms. J Vasc Surg. 62(3):779-85, 2015
                        6. Duan XH et al: Urgent transcatheter arterial embolization for the treatment of ruptured renal angiomyolipoma with spontaneous hemorrhage. Acta Radiol. ePub, 2015
                        7. Eom HJ et al: Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up. Clin Radiol. 70(11):1177-84, 2015
                        8. Flum AS et al: Update on the Diagnosis and Management of Renal Angiomyolipoma. J Urol. 195(4P1):834-46, 2015
                        9. Frey GT et al: Image-Guided Renal Intervention. Radiol Clin North Am. 53(5):1005-19, 2015
                        10. Gross JA et al: Imaging of Urinary System Trauma. Radiol Clin North Am. 53(4):773-88, ix, 2015
                        11. Kautza B et al: "Management of blunt renal injury: what is new?". Eur J Trauma Emerg Surg. 41(3):251-8, 2015
                        12. Minocha J et al: Transcatheter renal interventions: a review of established and emerging procedures. J Clin Imaging Sci. 5:5, 2015
                        13. Muller A et al: Renal artery embolization-indications, technical approaches and outcomes. Nat Rev Nephrol. 11(5):288-301, 2015
                        14. Murray TE et al: Transarterial Embolization of Angiomyolipoma: A Systematic Review. J Urol. 194(3):635-9, 2015
                        15. Rankin T et al: Wunderlich syndrome: the role of the general surgeon. Am Surg. 81(3):E113-4, 2015
                        16. Sasongko TH et al: Rapamycin and its analogues (rapalogs) for Tuberous Sclerosis Complex-associated tumors: a systematic review on non-randomized studies using meta-analysis. Orphanet J Rare Dis. 10:95, 2015
                        17. Schieda N et al: Ten uncommon and unusual variants of renal angiomyolipoma (AML): radiologic-pathologic correlation. Clin Radiol. 70(2):206-20, 2015
                        18. Serafetinides E et al: Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 67(5):930-6, 2015
                        19. Tonolini M et al: Multidetector CT imaging of complications after laparoscopic nephron-sparing surgery. Insights Imaging. 6(4):465-78, 2015
                        20. Takeuchi N et al: Ruptured renal arteriovenous malformation successfully treated by catheter embolization: a case report. BMC Res Notes. 7:19, 2014
                        21. Tuna IS et al: Contrast-enhanced CT and MR imaging of renal vessels. Abdom Imaging. 39(4):875-91, 2014
                        22. Zhu MS et al: Factors that can minimize bleeding complications after renal biopsy. Int Urol Nephrol. 46(10):1969-75, 2014
                        23. Szmigielski W et al: Renal trauma imaging: Diagnosis and management. A pictorial review. Pol J Radiol. 78(4):27-35, 2013
                        24. Olin JW, Sealove BA: Diagnosis, management, and future developments offibromuscular dysplasia. J Vasc Surg 2011;53(3):826-836.e1.
                        25. Sam K et al: Percutaneous embolization of iatrogenic arterial kidney injuries: safety, efficacy, and impact on blood pressure and renal function. J Vasc Interv Radiol. 22(11):1563-8, 2011
                        26. Cura M et al: Vascular malformations and arteriovenous fistulas of the kidney. Acta Radiol. 51(2):144-9, 2010
                        27. Ginat DT et al: Transcatheter renal artery embolization: clinical applications and techniques. Tech Vasc Interv Radiol. 12(4):224-39, 2009
                        28. Lee SY et al: Embolization of renal angiomyolipomas: short-term and long-term outcomes, complications, and tumor shrinkage. Cardiovasc Intervent Radiol. 32(6):1171-8, 2009
                        29. Lenton J et al: Embolization of renal angiomyolipoma: immediate complications and long-term outcomes. Clin Radiol. 63(8):864-70, 2008
                        30. Kubota Y et al: Transcatheter arterial embolization with N-butyl-2-cyanoacrylate (Hystoacryl) in two treatments for huge renal arteriovenous malformation. Hinyokika Kiyo. 53(5):307-10, 2007
                        31. Poulakis V et al: Treatment of renal-vascular injury by transcatheter embolization: immediate and long-term effects on renal function. J Endourol. 20(6):405-9, 2006
                        32. Chatziioannou A et al: Endovascular treatment of renal arteriovenous malformations. Urol Int. 74(1):89-91, 2005
                        33. Dinkel HP et al: Blunt renal trauma: minimally invasive management with microcatheter embolization experience in nine patients. Radiology. 223(3):723-30, 2002
                        34. Yamakado K et al: Renal angiomyolipoma: relationships between tumor size, aneurysm formation, and rupture. Radiology. 225(1):78-82, 2002
                        35. Kawashima A et al: Imaging of renal trauma: a comprehensive review. Radiographics. 21(3):557-74, 2001
                        36. Defreyne L et al: Cirsoid renal arteriovenous malformation treated by endovascular embolization with n-butyl 2-cyanoacrylate. Eur Radiol. 10(5):772-5, 2000
                        Related Anatomy
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                        Related Differential Diagnoses
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                        References
                        Tables

                        Tables

                        KEY FACTS

                        • Preprocedure

                          • Procedure

                            • Outcomes

                              TERMINOLOGY

                              • Definitions

                                • Renal trauma
                                  • Blunt, penetrating, or iatrogenic injury
                                    • Renal injury present in 8-10% of blunt and penetrating abdominal injuries
                                    • 98% of isolated renal injuries are minor
                                    • Severe renal injury often associated with other organ injury (~ 80%)
                                    • May cause pseudoaneurysm (PSA)/arteriovenous fistula (AVF)
                                    • Iatrogenic causes of renovascular injury
                                      • Biopsy
                                      • Percutaneous nephrostomy/nephrolithotomy
                                      • Balloon angioplasty
                                      • Extracorporeal shock wave lithotripsy
                                  • Hematuria present in 95% of patients with renal trauma
                                • Grading of renal trauma
                                  • Grade 1
                                    • Small parenchymal contusion
                                    • Stable subcapsular hematoma
                                      • Treatment: Conservative
                                  • Grade 2
                                    • Laceration < 1 cm in depth
                                    • Stable perirenal hematoma
                                      • Treatment: Conservative
                                  • Grade 3
                                    • Laceration > 1 cm in depth
                                      • No extension into collecting system
                                      • Treatment: Conservative if stable, angiogram ± intervention if ongoing blood loss or hemodynamically unstable
                                  • Grade 4
                                    • Laceration that extends into collecting system
                                    • Vascular injury of main renal artery or vein
                                    • Expanding subcapsular or perinephric hematomas
                                      • Treatment: Angiogram and embolization
                                  • Grade 5
                                    • Avulsion of renal hilum with devascularization of kidney
                                    • Complete laceration or thrombosis of main renal artery or vein
                                    • Ureteropelvic junction avulsion
                                    • Shattered kidney
                                      • Treatment: Varied, nephrectomy often performed
                                  • Category I (minor)
                                    • 75-85% of renal trauma
                                    • Minor cortical contusion/infarction/laceration (no collecting system/medulla involvement)
                                    • Small intrarenal/subcapsular hematoma
                                    • Managed conservatively
                                  • Category II (major)
                                    • 10% of renal trauma
                                    • Types of major trauma
                                      • Laceration extending into medulla; may involve collecting system
                                      • Segmental renal ischemia/infarction from stretch injury/arterial thrombosis
                                    • Management varies; usually endovascular
                                  • Category III (catastrophic)
                                    • 5% of renal trauma
                                    • Types of catastrophic trauma
                                      • Multiple lacerations (e.g., fractured kidney)
                                      • Vascular pedicle injury (e.g., transection)
                                    • Typically managed with nephrectomy
                                  • Category IV
                                    • Injury involving ureteropelvic junction
                                    • Management varies from surgical to conservative
                                • Renal artery pseudoaneurysm (PSA)
                                  • Focal disruption/rupture of arterial wall
                                    • Results in contained arterialized hematoma
                                      • Contained by adjacent parenchymal tissue
                                  • Symptoms: Hypertension/flank pain/hematuria
                                  • Etiologies: Traumatic, spontaneous, iatrogenic, vasculitis (e.g., polyarteritis nodosa)
                                  • Potential for delayed rupture after clot degradation/restoration of normal hemodynamics
                                    • Delayed rupture has mortality rate as high as 80%
                                    • High risk of rupture if PSA > 2 cm
                                • Renal arteriovenous fistula (AVF)
                                  • Abnormal connection between artery and vein
                                    • Causes abnormal hemodynamics (high-output heart failure, shunting away from normal kidney tissue)
                                  • Symptoms: Hypertension/high-output heart failure/hematuria/renal insufficiency
                                  • Etiologies
                                    • Often acquired (posttraumatic/iatrogenic)
                                    • Congenital
                                      • May have arterial/venous aneurysms
                                    • Idiopathic
                                      • Can be associated with fibromuscular dysplasia
                                • Angiomyolipoma (AML)
                                  • Benign hamartomatous tumors
                                    • Variable amounts of blood vessels/muscle/fat
                                  • Most common benign renal tumor
                                    • No malignant potential; rarely locally aggressive
                                  • Abnormal blood vessels
                                    • No internal elastic lamina, disordered fibrotic smooth muscle cells
                                    • Prone to intratumoral aneurysm formation and rupture
                                  • Goal of embolization is devascularization
                                    • Limits/prevents growth/spontaneous rupture
                                      • Secondary goal: Preserve normal parenchyma
                                  • 80% sporadic
                                    • Typically unilateral; often static/slowly growing
                                  • 20% associated with tuberous sclerosis complex (TSC)
                                    • Often bilateral/large; progressive growth
                                • Renal arteriovenous malformation (AVM)
                                  • Typically congenital
                                  • Multiple communications between arteries and veins
                                • Renal artery aneurysm (RAA)
                                  • 2nd most common visceral aneurysm (15-22%) after splenic
                                  • Congenital causes: Fibromuscular dysplasia, phakomatoses (e.g., tuberous sclerosis, neurofibromatosis), intrinsic collagen deficiencies (e.g., Ehlers-Danlos, Marfan), vasculitides (e.g., Behcet)
                                  • Acquired causes: Atherosclerosis/degenerative
                                  • Often asymptomatic
                                  • Possible symptoms
                                    • Hypertension/renal insufficiency from microemboli
                                    • Hematuria/flank pain from aneurysm rupture
                                  • Tend to occur at bifurcation of main renal artery
                                • Renal artery perforation/rupture
                                  • Occurs in 3.5% of renal artery interventions

                              PREPROCEDURE

                              • Indications

                                • Preprocedure Imaging

                                  • Getting Started

                                    PROCEDURE

                                    • Patient Position/Location

                                      • Procedure Steps

                                        • Alternative Procedures/Therapies

                                          OUTCOMES

                                          • Complications

                                            • Expected Outcomes

                                              Selected References

                                              1. Chong ST et al: Renal trauma: imaging evaluation and implications for clinical management. Abdom Radiol (NY). 41(8):1565-79, 2016
                                              2. Hellmund A et al: Rupture of renal artery aneurysm during late pregnancy: clinical features and diagnosis. Arch Gynecol Obstet. 293(3):505-8, 2016
                                              3. Ramaswamy RS et al: Arterial embolization for the treatment of renal masses and traumatic renal injuries. Tech Vasc Interv Radiol. 19(3):203-10, 2016
                                              4. Andersen PE et al: Interventional treatment of renal angiomyolipoma: immediate results and clinical and radiological follow-up of 4.5 years. Acta Radiol Open. 4(7):2058460115592442, 2015
                                              5. Coleman DM et al: Renal artery aneurysms. J Vasc Surg. 62(3):779-85, 2015
                                              6. Duan XH et al: Urgent transcatheter arterial embolization for the treatment of ruptured renal angiomyolipoma with spontaneous hemorrhage. Acta Radiol. ePub, 2015
                                              7. Eom HJ et al: Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up. Clin Radiol. 70(11):1177-84, 2015
                                              8. Flum AS et al: Update on the Diagnosis and Management of Renal Angiomyolipoma. J Urol. 195(4P1):834-46, 2015
                                              9. Frey GT et al: Image-Guided Renal Intervention. Radiol Clin North Am. 53(5):1005-19, 2015
                                              10. Gross JA et al: Imaging of Urinary System Trauma. Radiol Clin North Am. 53(4):773-88, ix, 2015
                                              11. Kautza B et al: "Management of blunt renal injury: what is new?". Eur J Trauma Emerg Surg. 41(3):251-8, 2015
                                              12. Minocha J et al: Transcatheter renal interventions: a review of established and emerging procedures. J Clin Imaging Sci. 5:5, 2015
                                              13. Muller A et al: Renal artery embolization-indications, technical approaches and outcomes. Nat Rev Nephrol. 11(5):288-301, 2015
                                              14. Murray TE et al: Transarterial Embolization of Angiomyolipoma: A Systematic Review. J Urol. 194(3):635-9, 2015
                                              15. Rankin T et al: Wunderlich syndrome: the role of the general surgeon. Am Surg. 81(3):E113-4, 2015
                                              16. Sasongko TH et al: Rapamycin and its analogues (rapalogs) for Tuberous Sclerosis Complex-associated tumors: a systematic review on non-randomized studies using meta-analysis. Orphanet J Rare Dis. 10:95, 2015
                                              17. Schieda N et al: Ten uncommon and unusual variants of renal angiomyolipoma (AML): radiologic-pathologic correlation. Clin Radiol. 70(2):206-20, 2015
                                              18. Serafetinides E et al: Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol. 67(5):930-6, 2015
                                              19. Tonolini M et al: Multidetector CT imaging of complications after laparoscopic nephron-sparing surgery. Insights Imaging. 6(4):465-78, 2015
                                              20. Takeuchi N et al: Ruptured renal arteriovenous malformation successfully treated by catheter embolization: a case report. BMC Res Notes. 7:19, 2014
                                              21. Tuna IS et al: Contrast-enhanced CT and MR imaging of renal vessels. Abdom Imaging. 39(4):875-91, 2014
                                              22. Zhu MS et al: Factors that can minimize bleeding complications after renal biopsy. Int Urol Nephrol. 46(10):1969-75, 2014
                                              23. Szmigielski W et al: Renal trauma imaging: Diagnosis and management. A pictorial review. Pol J Radiol. 78(4):27-35, 2013
                                              24. Olin JW, Sealove BA: Diagnosis, management, and future developments offibromuscular dysplasia. J Vasc Surg 2011;53(3):826-836.e1.
                                              25. Sam K et al: Percutaneous embolization of iatrogenic arterial kidney injuries: safety, efficacy, and impact on blood pressure and renal function. J Vasc Interv Radiol. 22(11):1563-8, 2011
                                              26. Cura M et al: Vascular malformations and arteriovenous fistulas of the kidney. Acta Radiol. 51(2):144-9, 2010
                                              27. Ginat DT et al: Transcatheter renal artery embolization: clinical applications and techniques. Tech Vasc Interv Radiol. 12(4):224-39, 2009
                                              28. Lee SY et al: Embolization of renal angiomyolipomas: short-term and long-term outcomes, complications, and tumor shrinkage. Cardiovasc Intervent Radiol. 32(6):1171-8, 2009
                                              29. Lenton J et al: Embolization of renal angiomyolipoma: immediate complications and long-term outcomes. Clin Radiol. 63(8):864-70, 2008
                                              30. Kubota Y et al: Transcatheter arterial embolization with N-butyl-2-cyanoacrylate (Hystoacryl) in two treatments for huge renal arteriovenous malformation. Hinyokika Kiyo. 53(5):307-10, 2007
                                              31. Poulakis V et al: Treatment of renal-vascular injury by transcatheter embolization: immediate and long-term effects on renal function. J Endourol. 20(6):405-9, 2006
                                              32. Chatziioannou A et al: Endovascular treatment of renal arteriovenous malformations. Urol Int. 74(1):89-91, 2005
                                              33. Dinkel HP et al: Blunt renal trauma: minimally invasive management with microcatheter embolization experience in nine patients. Radiology. 223(3):723-30, 2002
                                              34. Yamakado K et al: Renal angiomyolipoma: relationships between tumor size, aneurysm formation, and rupture. Radiology. 225(1):78-82, 2002
                                              35. Kawashima A et al: Imaging of renal trauma: a comprehensive review. Radiographics. 21(3):557-74, 2001
                                              36. Defreyne L et al: Cirsoid renal arteriovenous malformation treated by endovascular embolization with n-butyl 2-cyanoacrylate. Eur Radiol. 10(5):772-5, 2000