Super Selective Endovascular Embolization of Post-Biopsy Renal Vascular Injury via Transradial Route

Renal pseudoaneurysm and/or arteriovenous (AV) fistula are rare but recognized complications of percutaneous renal biopsy, with potential for life-threatening hemorrhage.¹

We report the case of a 16-year-old female patient who presented with a 1-year history of intermittent fever, productive cough, weight loss, and appetite loss. Evaluation revealed deranged renal function (Urea = 52 mmol/L, Cr = 2.36 µmol/L) and anemia (Hb = 7.5 g/L). She underwent a percutaneous renal biopsy at another center. She presented us with left flank pain. She was hemodynamically stable (BP = 120/70 mmHg) with mild tachycardia (PR = 108/min). There was tenderness in the left lumbar region. A biphasic contrast-enhanced CT of the abdomen revealed a left posterior perinephric hematoma and a renal pseudoaneurysm from the accessory renal artery located in the lower pole. Emergent endovascular coiling via a transradial approach was planned.

Under local anesthesia, radial access was taken using a 5 fr Glidesheath Slender™ Sheath and a RADIFOCUS™ Glidecath™ R.A.V.I. MG1 (Terumo Corp., Tokyo, Japan) catheter, which was advanced to the left renal artery. Angiography confirmed the presence of a focal pseudoaneurysm arising from a lower polar segmental renal artery along with an early draining vein, suggestive of a renal AV fistula [Figure 1, Video 1]. Selective microcatheterization was performed, and a single detachable 2 mm × 7 cm microcoil (Nester, Cook Medical) was deployed. Post-procedure angiography demonstrated no residual filling of the aneurysmal segment or fistulous communication.

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Figure 1:

Arterial phase contrast-enhanced CT abdomen in the axial (a) Maximum intensity projection (MIP) images, showing left posterior perinephric hematoma (white asterisk) along with contrast filled outpouching (solid white arrow in a to e) seen in left accessory renal artery; (b) Coronal MIP and (c) 3D Volume Rendering Technique demonstrating the early draining vein in the lower pole (hollow white arrows) and the pseudoaneurysm (solid white arrow); Digital subtraction angiography showing (d) catheter and (e) microcatheter runs demonstrating the pseudoaneurysm (solid white arrows) along with the early draining vein (black arrows); (f) Post coiling 5 Fr angiographic catheter run shows complete obliteration of the pseudoaneurysm as well as the early draining vein.

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Advantages of transradial access include early ambulation, faster recovery, and fewer access site complications.² Studies have shown ∼98% technical success rates for transradial access in non-coronary intervention, with an overall complication rate of ∼2%.³

Renal artery embolization remains a cornerstone technique in the management of iatrogenic vascular injuries post-biopsy. Transradial renal coiling is feasible in the management of post-biopsy renal pseudoaneurysms. With growing expertise and improved device compatibility, it is likely to become the preferred access in suitable cases.