Iatrogenic Vascular Injuries

Iatrogenic main renal artery injuries with perforation or rupture are rare and almost exclusively reported after renal artery angioplasty or stenting with an incidence of 1.6% (Morris andBonnevie 2001). One case of an iatrogenic renal artery perforation as a complication of cardiac catheterization has been reported (Bates et al. 2002). Since most iatrogenic renal artery lesions occur during endovascular procedures, there are no reports on the clinical symptoms, but only on the angio-graphic findings (Fig. 15.4.1). Arteriovenous fistulae, pseudoaneurysms, arterial dissection, or contrast extravasation are the possible radiological findings in these traumatic vascular lesions. Traditional therapy for renal perforation has been renal artery ligation followed by bypass grafting or nephrectomy, but nowadays the treatment for acute iatrogenic rupture of the main renal artery is balloon tamponade. The size of the angioplasty balloon chosen for tamponade should be 1 mm smaller in diameter than the size of the balloon or stent that caused the rupture. The balloon is fully inflated without the use of a manometer in all cases. Time of the procedure varies; a maximum of 3 min, followed by rapid deflation, and a repeat after 2 min is effective in most cases. However, in some cases inflation may need to last up to 10 min, while in other cases a single 1-min balloon inflation is enough. After the treatment of each ruptured renal artery, a selective renal digital subtraction angiogram should be performed to exclude

Fig. 15.4.1. Abdominal angiogram showing free contrast extravasation from the distal segment of the right main renal artery (arrow)

further extravasation. However, in case of failure immediate availability of a stent graft is vital.

Patients with iatrogenic operative injuries are strikingly different from those with penetrating, blunt, or catheter-related vascular trauma. Renal vessels are vulnerable during oncologic procedures. Factors that increase technical difficulty are previous operation, tumor recurrence, radiation exposure, and chronic inflammatory changes. Renal vein injuries during elective abdominal operations are a serious complication with significant morbidity. Most patients with operative venous injuries have partial lacerations that can be managed with relatively simple techniques, such as ve-norraphy and patch angioplasty with autologous vein of ePTFE graft if venorraphy is not possible because of significant vessel narrowing (Oderich et al. 2004).

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