Embolization of post-traumatic renal arteriovenous fistula

Traumatic penetrating arteriovenous fistulas: a collective review

INTRODUCTION

Traumatic penetrating arteriovenous fistulas (AVFs) are very rare. The majority of these injuries occur secondary to penetrating trauma. Objectives of this study: review their incidence, clinical presentation, radiologic identification, management, complications and outcomes.

METHODS

A literature search was performed on MEDLINE Complete-Pubmed from 1829-2019. PRISMA guidelines were utilized. Of 305 potentially eligible articles, 201 articles were selected.

INCLUSION CRITERIA

patients age ≥ 18, articles with title and abstract in English, AVFs secondary to penetrating trauma, articles which specified vessels involved in AVFs, and those reporting complete information on patient presentation, diagnosis, imaging, surgical and/or endovascular surgical management, and outcomes of penetrating AVF's.

EXCLUSION CRITERIA

articles reporting blunt or iatrogenic AVFs, pediatric patients, fistulas used for dialysis and their complications, articles lacking complete information, cranial/spinal AVFs or cardiac AVFs, and duplicate articles. Mechanism of injury (MOI), diagnosis, involved vessels, management and outcomes of patients with AVFs secondary to penetrating trauma were recorded.

RESULTS

There were a total of 291 patients with AVFs secondary to penetrating injuries. Mechanism of injury (MOI): stab wounds (SW)-126 (43.3%), Gunshot wounds (GSW)-94 (32.3%), miscellaneous-35 (12%), mechanism unspecified-36 (12.4%). Anatomic area: neck-69 (23.7%) patients, thorax-46 (15.8%), abdomen-87 (30%), upper and lower extremities-89 (30.6%). Most commonly involved vessels-vertebral artery-38 (13%), popliteal vein-32 (11.7%). Angiography was diagnostic-265 patients (91.1%).

INTERVENTIONS

Surgical- 202 (59.6%), Endovascular-118 (34.8%). Associated: aneurysms/pseudoaneurysms-129 (44.3%).

CONCLUSION

Most AVFs occur secondary to penetrating injuries. Stab wounds account for the majority of these injuries. Most frequently injured vessels are vertebral artery and superficial femoral vein. Surgical interventions are the most common mode of management followed by endovascular surgical techniques.

Complications of Renal Trauma

Renal trauma is rare, and significant complications from renal trauma are generally rarer still occurring in less than 5% in modern series. Close follow-up of injured patients and scrupulous use of imaging, including computed tomography scan, arteriogram, or retro-grade pyelogram when appropriate, increase detection rates and establish the diagnosis in most patients. Treatment varies by etiology and may range from watchful waiting to percutaneous drainage to, in rare cases, nephrectomy.

The Literature Increasingly Supports Expectant (Conservative) Management of Renal Trauma — A Systematic Review

BACKGROUND

The perfect degree of operative intervention in renal trauma is unknown. However, expectant management for most blunt renal trauma is the standard of care, and nonoperative management is increasingly accepted for stab wounds. The best treatment of gunshot wounds and vascular injuries is still unclear; however, recent data indicates that a trial of nonoperative therapy may be warranted in those not exsanguinating from the kidney. Conservative management has many benefits, the greatest of which is decreasing the rate of iatrogenic nephrectomy. We have reviewed the world's literature to determine the level of support for expectant management of renal injury.

METHODS

The English language literature concerning renal trauma was identified with the assistance of Medline, and additional cited works not picked up in the initial search were obtained. One hundred and ten citations were ultimately reviewed dating back to 1947.

RESULTS

Most modern citations support at least a trial of expectant management for renal trauma patients not exsanguinating from the kidney, and without ureteral or renal pelvis injuries. The treatment of renovascular injuries has less consensus, but it appears that 'conservative' management by the application of nephrectomy is often the best approach, although renovascular repair may be attempted in rare cases.

CONCLUSION

Dozens of papers going back as far as 50 years seem to support the wider use of nonoperative therapy of renal injuries, although for unclear reasons, this approach is not yet universally accepted.

Embolization of an Acute Renal Arteriovenous Fistula following a Stab Wound: Case Report and Review of the Literature

Surgery has traditionally been the definitive form of invasive management for renal vascular injuries. There is a growing trend in the use of endovascular techniques as an alternative to surgery in the trauma setting. We present the case of a 24-year-old woman with an acute renal arteriovenous fistula caused by a stab wound in the left flank, which was successfully managed with selective arterial embolization. This represents only the second reported case of such an approach in the acute setting.

Renal artery to inferior vena cava fistula following gunshot wound to the abdomen

Traumatic fistula involving the renal artery and IVC is a rare event, and typically is a result of penetrating injury. A case of right renal artery to IVC fistula following a gunshot wound to the abdomen is reported, and illustrates the significant hemodynamic changes that accompany these fistulae. We also emphasize the importance of thorough initial exploration of retroperitoneal hematomas following penetrating trauma, and review management options in the treatment of renal arteriovenous fistulae.

Management of traumatic hematuria by selective renal artery embolization

Angiography and selective renal arterial embolization were performed in 17 patients with traumatic lesions of the kidney and hematuria. Of the patients 8 had retroperitoneal extravasation of contrast medium owing to rupture, 6 had traumatic arteriovenous fistulas and 5 had pseudoaneurysms. Immediate control of hemorrhage was achieved in 16 patients (94.1 per cent), while delayed control was obtained in 1. Hematuria recurred in 4 of the 17 patients (23.5 per cent) and resulted in total nephrectomy in 3 (17.6 per cent) despite repeated embolization in 2. Embolization alone was successful in 14 patients (82.4 per cent). According to the followup preservation of renal function and viable parenchyma was excellent in all embolized patients. Our results indicate that transcatheter embolization should be performed in patients with renal trauma and uncontrollable hematuria before any surgical attempt is made.