經導管動脈栓塞治療腎臟動靜脈畸形-案例報告及文獻回顧
黃詩孟,林才揚,黃冠華
奇美醫學中心 外科部 泌尿科
Shih-Meng Huang,Chye-Yang Lim, Steven K. Huang
Division of Urology,Department of Surgery,Chi Mei Medical Center,Tainan,Taiwan
Background:
Renal arteriovenous malformations (AVMs) are abnormal communications between the intrarenal arterial and venous systems which cause hematuria and are associated with hypertension. They may be either congenital or acquired which is often iatrogenic. Percutaneous treatment with selective endovascular techniques offers a minimally invasive and nephron-sparing option.
Case presentation:
This 44-yearold female without systemic disease,operation history or trauma history suffered from gross hematuria with lower abdominal distension for 3 days. She went to emergent department where gross hematuria with anemia was noted and the computed tomography revealed much blood clot in right renal pelvis,ureter and urinary bladder. The renal function was in the normal range. After manual Foley irrigation and blood transfusion,bladder temponade was still noted,so evacuation of blood clot with coagulation and right diagnostic ureterorenoscopy were done. Erythematous mucosa with much blood clot over right renal pelvis but no active bleeding was noted. The computed tomography angiography(CTA) showed no obvious bleeding lesion. Gross hematuria improved gradually after continuous Foley irrigation. However,repeated gross hematuria with acute urine retension happened after remving Foley. The 2nd CTA revealed complex renal AVMs with multiple feeding arteries,so transarterial embolization(TAE) with coils was done. Gross hematuria improved without impaired renal function. The computed tomography 6 months later showed focal atrophy of right kidney and the dynamic renal function study showed diminished right renal split glomerular filtration rate about 33%.
Discussion:
Our patient without trauma or operation history was diagnosed as renal AVMs which is congenital or
idiopathic. Congenital renal AVMs are rare,with reported incidence of 0.04%. The clinical presentation
was gross hematuria which happened in 75% cases in previous study. Some cases have hypertension
which is related to altered flow dynamics within the renal artery. The operation was arranged for
evacuation of blood clot and coagulation due to bladder temponade,but no obvious active bleeding was
noted. Renal AVMs were suspected,but first CTA showed no obvious lesion which may be masked by
much blood clot. Due to repeated gross hematuria, renal AVMs was diagnosed by the 2nd
CTA and TAE was performed. Surgical options including total or partial nephrectomy are \
alternatives if malignant cause or symptomatic hematuria refractory to embolization,which
are more invasive. During follow-up period,impaired right renal function with focal renal
atrophy was noted ,which may caused by TAE.
Conclusion:
Renal arteriovenous malformations usually presented with macro- or microhematuria which may become life threatening. Digital subtraction angiography is the gold standard for diagnosis and percutaneous embolisation techniques offered a safe and minimally invasive treatment.