ACUTE RENAL ARTERY THROMBOSIS FOLLOWING BLUNT TRAUMA* LT. COL . J . W. McANINCH (MC) USA From the Department of Surgery, Urology Service, Letterman Army Medical Center, San Francisco, California

ABSTRACT - Forty-one cases of renal artery thrombosis following blunt trauma have been reported previously. Most injuries resulted from acute deceleration, and the left kidney was involved more frequently than the right kidney . An additional case, a nineteen-year-old victim of a motorcycle accident, had immediate surgery following an early diagnosis . Although the kidney was viable, arterial repair was unsuccessful, and a nephrectomy was performed . Following blunt trauma, patients with microhematuria should have an immediate excretory urogram and retrograde cystogram . With nonvisualization of the kidney, arteriography is necessary to establish the diagnosis . Prompt operation is mandatory if the kidney is to be saved .

Blunt abdominal trauma rarely causes vascular injury. In 176 patients with blunt trauma, Ross, Acherman, and Pierce' found only 4 with arterial injury . Injury to major arteries is even more uncommon because of their retroperitoneal position and strong muscular wall . Even so, in 1861 von Recklinghausen 2 reported the first case of acute renal artery thrombosis resulting from blunt trauma . His case was a thirteen-year-old patient who had been injured in a fall . The diagnosis was not established until eight days later at necropsy . Only 40 additional cases have been reported .'-'' In our age of industrialization, fast moving vehicles, and advanced methods of locomotion, we are seeing more patients in emergency rooms with severe blunt trauma . Many of these patients have findings to suggest genitourinary trauma, but only by aggressive and rapid evaluation can renal artery injury be diagnosed in time to save a kidney from complete infarction . The purpose of this contribution is to present a case of renal artery thrombosis and to review the literature regarding this injury . *The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense .


Case Report A nineteen-year-old man was injured in a motorcycle accident . When he was examined at the emergency room shortly after injury, he was alert and vital signs were normal . His blood pressure was 120/80 turn . Hg. Positive physical findings included an acute condition of the abdomen, bilateral upper extremity fractures, and contusions of the lower abdomen and pelvis . His hematocrit was 44 . His electrolytes were normal, and the serum creatinine was 1 .5 mg . per 100 ml . A catheterized urine specimen contained red blood cells (too numerous to count) . A plain roentgenogram of the abdomen showed fracture of the right pubic ramus and wing of the left ilium . A retrograde cystogram series showed no extravasation . A high dose excretory urogram showed a normal-appearing right kidney (Fig . IA) . A left renal shadow was apparent, but no visualization was noted . A transfemoral retrograde arteriogram demonstrated complete occlusion of the left renal artery 2 cm . from its origin (Fig . 1B) . Delayed films showed a faint nephrogram and faint visualization of the calyces with a left kidney of normal size (Fig . 1C) . Findings were consistent with acute thrombosis of the left renal artery .



JULY 1975



FIGURE 1 . (A) Preoperative intravenous pyelogram shows normal right kidney and nonvisualization of left kidney . (B) Art trio gram shows left renal artery with complete obstruction . (C) Delayed arteriogram shows faint left nephrogram indicating some renal perfusion .

Operation was performed through a midline incision four hours after injury . The left renal artery was found to be completely thrombosed 2 cm . from its origin (Fig . 2) . A 1-cm . segment of artery directly over the thrombosis was severely contused and dark . No retroperitoneal hematoma was present. The kidney was tense and viable . The artery with the thrombosis was transected, and the injured segment was removed . Attempt at reanastomosis was unsuccessful, and a left nephrectomy was done . His ruptured spleen was removed, and a gastrostomy tube was inserted . He had an uneventful postoperative course . Serum creatinine at time of discharge was 1 .3 mg. per 100 ml . The kidney weighed 170 Gm . Microscopic examination of the injured renal artery showed extensive hemorrhage into the adventitia, and in UROLOGY



one area the muscular and intimal layer were fragmented so that the lumen was in direct communication with the adventitia . Multiple small cysts were scattered throughout the renal medulla and cortex which prompted the diagnosis of polycystic disease (Potter's type III) . Comment This case illustrates the importance of rapid diagnosis and prompt surgery . The patient's condition was stable, and the preoperative arteriogram demonstrated the arterial occlusion . The kidney was viable at operation which gave a chance for salvage; however, tension at the arterial anastomosis was too great, and the kidney was lost. Bypass graft was not used because of intraperitoneal contamination . The right kidney 75

FIGURE 2 . Location and extent of acute thrombosis found at operation .

appeared normal on angiogram although pathologic evidence of early polycystic disease was found in the left kidney . The left renal artery is more commonly thrombosed by blunt trauma than the right . Of the 41 cases reported 27 had only left artery involvement, 12 had only right artery involvement, 2 had bilateral involvement . The difference is statistically significant at the p = 0 .001 confidence level by the Fisher exact method . The right renal artery, even though it is longer, is relatively fixed as it passes behind the vena cava and has additional fixation by the overlying duodenum and right lobe of the liver . These anatomic conditions apparently offer protection to the right side . Several authors believe the mechanism of injury has been a rapid deceleration of the body . 1 .3.4 .6 The more mobile left kidney is forcibly set in motion which results in overstretching and angulation of the main renal artery. Collins and Jacobs 3 postulated a superiorinferior type of motion as a cause for the injury . However, it would appear an anteroposterior motion is more likely in deceleration injuries that are due to vehicle accidents (Fig . 3) . The arterial intima is the least elastic tissue of the vessel wall ; and when it is ruptured, subintimal dissection and occlusion occur ." The present case had intima and muscularis ruptured, and probably an aneurysm or "blow-out" of the vessel wall would have developed. An aneurysm from blunt trauma has been described by Jevtich and Montero . s No symptoms are characteristic of renal artery injury . Nearly half of the 41 patients had no clinical evidence of major abdominal injury . 6 All patients have had microscopic or gross hematuria . Accurate and early diagnosis can be 76

made only by prompt evaluation including a cystogram, urogram, and arteriogram . In a stable patient with hematuria, a retrograde cystogram should be done to rule out bladder injury . A high dose excretory urogram is mandatory to determine kidney status, With nonvisualization of the kidney arteriography should be performed to establish vessel injury . Many patients are in shock, and immediate surgery may preclude preoperative arteriography . In these cases hemorrhage should be controlled at surgery and an intraoperative arteriogram performed .' Mere palpation to determine the extent of vessel injury is notoriously inaccurate .' Early diagnosis with emergency surgery offers the only opportunity to salvage a kidney with acute arterial thrombosis . Retrograde pyelograms may be helpful if one suspects congenital renal absence or renal loss from other causes . Skinner' reported the only successful early treatment with thrombectomy and revascularization of the renal artery ; the patient remained normotensive and had restoration of renal function. Fay et al . 10 successfully autotransplanted the right kidney . The other reported cases have had renal loss from acute necrosis within seven days of injury or later as hypertensive complications occurred . 1-'•1-9 The present case was diagnosed and had surgical exploration within four hours of injury . The kidney was visable but reanastomosis could not be achieved after segmental resection of the artery. Exact time for development of ischemia in these patients is unknown, but surgery should be performed within twelve hours .° •'• 3 0 The faint nephrogram and calyceal filling, seen in the case presented, proved that some arterial perfusion existed . This

FIGURE 3 . Postulated mechanism of vascular injury in acute thrombosis .



condition may be present in any case, and no delay in surgery should occur after a diagnosis is made, even though several hours may have passed . Simple thrombectomy would he the recommended treatment if muscularis and adventitia were not injured . Other considerations include segmental resection and end to end anastomosis of the artery, synthetic or venous bypass grafts, splenic artery graft, and autotransplantation . The risk of these procedures must be weighed against the associated complications and conditions that exist in each patient . The patient with bowel perforations and a contaminated abdomen runs a higher incidence of complications . Hypertension has been commonly reported in this injury when a latent diagnosis was made .2 •s '9 All of these cases subsequently required nephrectomy . Patients with hypertension and a history of abdominal trauma should have an excretory urogram to establish any possible renal abnormalities . Letterman Army Medical Center Presidio of San Francisco, California 94129 (DR . McANINCH)


References 1 . Ross, R ., ACHERMAN, E ., and PIERCE, J . M . : Traumatic subintimal hemorrhage of renal artery, J . Urol . 104: 11 (1970) . 2 . voN RECKLINCHAUSEN, F . : Hemorrhagische Niereninfarkte, Virchows Arch . IPathol. Anat .] 20 : 205 (1861) . 3 . COLLINS, H . A., and JACOBS, J . K . : Acute arterial injuries due to blunt trauma, J . Bone joint Surg. 43-A : 195 (1961) . 4 . EVANS, A,, and MoCc, R, : Renal artery thrombosis due to closed trauma, J . Urol . 105 : 330 (1971) . 5 . CAPONEGRO, P . J ., and LEADBETTER, G . W . : Traumatic renal artery thrombosis, ibid. 109 : 769 (1973) . 6 . SKINNER, D . C . : Traumatic renal artery thrombosis, Ann . Surg . 177: 264 (1973) . 7 . GRABLOWSKY, O. M ., WEICHERT, R . F ., GOFF, J . B ., and SCHLEGEL, U . : Renal artery thrombosis following blunt trauma : report of four cases, Surgery 67 : 895 (1969) . 8 . JEVTICII, M . J ., and NIoNTERO, C . G . : Injuries to renal vessels by blunt trauma in children, J . Urol . 102 : 493 (1969) . 9 . CORNELL, S ., REASA . D . A., and CULP, D . A . : Occlusion of the renal artery secondary to acute or remote trauma, J,A .M .A . 219 : 1755 (1972) . 10 . FAY, R ., BROSMAN, S ., LINDSTROME, R, and COHEN, A . : Renal artery thrombosis : a successful revascularization by autotransplantation, J . Urol. 111 ; 572 (1974) .


Acute renal artery thrombosis following blunt trauma.

Forty-one cases of renal artery thrombosis following blunt trauma have been reported previously. Most injuries resulted from acute deceleration, and t...
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