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Intraoperative Superselective Embolization of a Biopsy-Related Arteriocalyceal Fistula During a Kidney Transplantation

2012; Wolters Kluwer; Volume: 94; Issue: 2 Linguagem: Inglês

10.1097/tp.0b013e31825ace84

1534-6080

Andrea Bosio, F. Lasaponara, Ettore Dalmasso, Andrea Doriguzzi Breatta, Giovanni Di Pasquale, O. Sedigh, A Verri, Carlo Negro, E. Alessandria, Dorico Righi, Giuseppe Segoloni, Dario Fontana,

Renal Diseases and Glomerulopathies

Although macroscopic hematuria occurs in 3.4% to 10% of patients after renal transplant biopsies, major complications requiring invasive procedures are rare (1%). An arteriocalyceal fistula associated with severe gross hematuria has been reported in less than 0.1% of graft biopsies (1, 2). In such cases, an angiographic evaluation is indicated, and a superselective arterial embolization should be considered to save the kidney (3–5). In the literature, some case reports describe the successful selective arterial embolization in arteriocalyceal fistulas caused by diagnostic biopsies performed for renal function impairment in transplanted kidneys (4, 6). To our knowledge, the case that we present is the first intraoperative treatment by superselective arterial embolization during a kidney transplantation of an arteriocalyceal fistula caused by a scoring biopsy on the graft performed at the moment of organ recovery. CASE REPORT A 73-year-old man with end-stage renal disease secondary to IgA nephropathy was proposed as a renal transplant candidate. The graft consisted of a right kidney recovered from a deceased donor. A renal core needle biopsy was performed at the moment of organ recovery to assess the graft score, following our transplant center guidelines. After a cold ischemia time of 25 hr 15 min, the graft was transplanted into the right iliac fossa.The intervention proceeded routinely until the moment of clamp removal from the graft vessels, when a massive hematuria occurred with an arterial bleeding pattern coming out from the ureter. An attempt to stop the bleeding by holding selective digital pressure on the likely track of graft biopsy and keeping the ureter clamped for 20 min did not obtain any positive result. An arteriocalyceal fistula was suspected, indicating the evaluation core needle biopsy as the possible cause of the injury. Blood pressure and coagulation were kept under control. The graft blood perfusion was satisfactory. An intraoperative arterial fistula embolization was attempted to save the graft and preserve renal function as much as possible. The interventional radiologist was called. He performed a renal allograft selective angiography through a percutaneous transfemoral access. The angiography confirmed the diagnosis of an arteriocalyceal fistula at the site of the previous scoring biopsy, between an upper pole branch of the renal artery and a superior calyx. An intraoperative superselective embolization of the arterial vessel afferent to the fistula with a 3-mm amagnetic microcoil was performed (Fig. 1). The gross hematuria immediately disappeared. No other sources of bleeding were identified. The postembolization angiography confirmed the success of the procedure.FIGURE 1: Embolization was performed with a 3-mm amagnetic microcoil (arrow); residual contrast medium is still present in the previous communicating calyx.The renal transplantation was routinely completed with a ureterovesical extravesical implantation at the anterior surface of the bladder dome according to the antirefluxive Lich-Gregoire technique. A 4.8F 12-cm double-J ureteral stent with antirefluxive valve was placed to protect the anastomosis. The patient was kept in the intensive care unit for 24 hr and then readmitted to the renal transplantation unit where two blood units were transfused to correct postoperative anemia. The graft function showed a prompt response with immediate diuresis. The serum creatinine level decreased down to 1.2 mg/dL, and the patient did not need for any dialytic treatment in the postoperative period. Nuclear scanning performed 3 weeks and 8 months after renal transplantation demonstrated good blood perfusion of the graft. One year after the transplantation, renal function is still satisfactory and stable with a serum creatinine level of 1.5 mg/dL. DISCUSSION Arteriocalyceal fistula represents a rare but serious complication of renal graft core needle biopsy. Core needle biopsy and wedge biopsy differ in diagnostic accuracy and complications: core needle biopsy is more reproducible but results in more hemorrhagic complications, and wedge biopsy provides more tissue but is generally limited to the subcapsular cortical area. The use of marginal donor kidneys results in a higher number of graft evaluation biopsies to optimize allograft assessment. The decision to perform a biopsy should be carefully weighted against the risk of complications. An optimized technique should be used to minimize the risk of damage and obtain an informative result (7). In case of serious intraoperative bleeding caused by arteriocalyceal fistula, a first attempt should be made with direct digital pressure and keeping coagulation and blood pressure under control. In case of failure, superselective embolization should be considered as the last maneuver to try to save the kidney. The execution of the transplantation in a center with all suitable facilities allowing a multidisciplinary approach and a quick decision-making process are essential prerequisites for the success of the procedure. Andrea Bosio 1,5 Fedele Lasaponara1 Ettore Dalmasso1 Andrea Doriguzzi Breatta2 Giovanni Pasquale1 Omidreza Sedigh1 Aldo Verri3 Carlo L.A. Negro1 Eugenio Alessandria1 Dorico Righi2 Giuseppe P. Segoloni4 Dario Fontana1 1 Division of Urology, San Giovanni Battista Molinette Hospital Turin, Italy 2 Division of Radiology, San Giovanni Battista Molinette Hospital Turin, Italy 3 Division of Vascular Surgery, San Giovanni Battista Molinette Hospital Turin, Italy 4 Division of Nephrology, Dialysis and Kidney Transplantation, San Giovanni Battista Molinette Hospital Turin, Italy