Renal artery avulsion from blunt abdominal trauma in a horseshoe kidney: endovascular management and an unexpected complication.

A 21-year-old man sustained a blunt abdominal trauma in a motor vehicle collision. The patient was tachycardic and hypotensive at presentation and reported abdominal pain and left lower extremity pain. Chest and pelvic radio graphs showed no anomaly, but a plain radiograph of the left lower extremity showed an open left tibial plateau fracture. The patient was sent for computed tomography (CT) scanning. Findings on CT included a retroperitoneal hematoma adjacent to a horseshoe kidney. The right side of the kidney was found at the midline, and it was partially devascularized. There was active extravasation of the intravenous contrast at the right common iliac artery, just below the aortic bifurcation, close to the right pole of the horseshoe kidney (Fig. 1). We decided to proceed with a diagnostic angiography for the suspected iliac artery injury. The angiogram showed that the kidney was vascularized by a renal artery originating from the aorta on each side, a single artery originating from the aorta supplied the isthmus, and an additional right polar artery was avulsed from the right common iliac artery and actively bleeding (Fig. 1). The injury was treated by placement of a covered stent (10-mm diameter, 6-cm length, Fluency Plus, selfexpandable) through a right femoral access (Fig. 2). The patient’s hemodynamics improved and he was transferred to the intensive care unit (ICU). He received a total of 8 L of crystalloids, 8 units of packed red blood cells and 500 mL of fresh frozen plasma. The patient received daily acetylsalicylic acid afterwards. Internal fixation of the tibia fracture occurred the same day. Over the course of the next 5 days in the ICU, a transient elevation in serum creatinine without oliguria de veloped and resolved within 3 days, with return to a normal creatinine level. The patient showed no signs of hemorrhage and was discharged to the ward. From days 8 to 11 post injury, he experienced progressive abdominal pain, ileus, shortness of breath, fever and oliguria. Sepsis was excluded with repeated cultures, including CT-guided aspiration of the hematoma. Additional CT imaging showed increasing volume of the retroperitoneal hematoma from liquefaction and swelling in the retroperitoneum, without additional signs of active bleeding (Fig. 3). His hemoglobin level remained stable. Anuria developed on day 11, which could not be explained by sepsis, systemic inflammatory response syndrome (SIRS), nephrotoxicity or shock. A large palpable mass that appeared tensed, corresponding to the retroperitoneal hematoma, could be easily felt and was painful on physical examination. Serum creatinine peaked to 631 μmol/L. The patient was brought to the operating room for laparotomy. Vincent Trottier, MD* Marie-Andree Lortie, MD† Emilie Gouin, MD† Francois Trottier, MD‡

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