医源性肾动脉损伤的肾动脉造影表现及栓塞治疗

Renal arterial angiography and embolization in patients with iatrogenic renal artery injury

目的探讨医源性肾动脉损伤的肾动脉造影表现及栓塞治疗效果。方法收集2005年8月至2008年11月间我院于肾脏手术后出现持续性或间断性肉眼血尿患者共14例。均经肾动脉造影证实为医源性肾动脉损伤,其中继发于经皮肾镜取石术11例,继发于肾穿刺活检术、肾贯穿伤缝合修补术、输尿管镜检查并双J管置放术各1例。血尿出现距手术操作时间为3～346d(中位时间8d)。肾动脉造影检查后均行经导管肾动脉节段性栓塞治疗。栓塞材料为弹簧圈、正丁基-2-氰基丙烯酸酯(NBCA)、聚乙烯醇(PVA)颗粒、无水乙醇。术后随访10～49个月。结果病变位于肾脏上极4例,下极10例。肾动脉造影表现为肾假性动脉瘤1例,肾动静脉瘘6例,肾假性动脉瘤合并动静脉瘘7例。栓塞后肾动脉造影显示病变均达到完全性栓塞,术后2～12d肉眼血尿消失。随访期间,1例右肾下极动静脉瘘栓塞后13个月因术侧肾区钝性外伤再次出现血尿,经造影证实原动静脉瘘未见复发,但右肾下极发现由另一叶间动脉供血形成的假性动脉瘤,再次使用弹簧圈栓塞,随访14个月未见血尿复发。其余13例随访10～49个月未见血尿复发。本组术后均无严重并发症。结论肾动静脉瘘、假性动脉瘤是医源性肾动脉损伤的主要类型,应用弹簧圈行肾动脉节段性栓塞治疗是一种安全、有效的治疗方法。

Objetctive To study the finding of renal arterial angiography and the effect of segmental renal arterial embolization （SRAE） in patients with iatrogenic renal artery injury. Methods Between Augest 2005 and November 2008, 14 patients with persistent or intermittent gross hematuria after renal operations in our hospita! were collected. Renal artery injuries were confirmed by renal artery angiography in all patients, of which 11 cases were secondary to percutaneous nephrolithotomy （PCNL）, and 3 cases were secondary to renal biopsy, renal suture of penetrating wound, ureteroscopy combined with double-J tube implantation respectively. The gross hematuria emerged in 3 to 346 days after renal operations （Median time, 8 days）. All patients underwent SARE after renal artery angiography. The embolic agents included coils, PVA, NBCA, ethanol. Fourteen patients were followed up for 10 to 49 months after SRAE. Results In 14 patients, the lesions were located in lower pole of the kidney in 10 cases, and in upper pole of kidney in 4 cases. The findings of angiography showed that renal pseudoaneurysm （RAP） in 1 case, renal arteriovenous fistula （RAVF） in 6 cases, and RAVF combined with RAP in 7 cases. Total occlusions were accomplished and hematuria ceased in 2-12 days after SRAE in all cases. During the follow-up periods, hematuria emerged again in one patient with RAVF in the lower pole of the right kidney caused by blunt trauma in the same kidney after 13 months. Renal arterial angiography demonstrated that the former lesion had no recurred. But a pseudoaneurysm feed by another interlobar artery was found in the lower pole of the right kidney. The patient was treated with SRAE by using coils again, and no hematuria recurred within 14 months. None of 14 patients had severe complications after SRAE. Conclusions RAVF and RAP are dominating forms in iatrogenic renal artery injury. Segmental renal arterial embolization by using coils is safe and effective for iatrogenic renal artery injury.