ARTERIOCALYCEAL FISTULA AFTER

GRAFTED KIDNEY BIOPSY

Successful Management by Selective Catheter Embolization

G. BENOIT, M .D.

J. BELLAMY, M .D.B. CHARPENTIER, M .D .

D. MOHAMEDI, M .D .A . ROCHE, M .D.

D. FRIES, M.D .

From the Nephrology Service, Unite de TransplantationRenale, Hopital Paul Brousse, Villejuif ; and the Radiologyand Urology Services, Hopital Bicetre, Kremlin-Bicetre, France

ABSTRACT-A case is reported of arteriocalyceal fistula occurring after biopsy of a grafted kidney.Hematuria and anuria were relieved by therapeutic embolic occlusion .

Arteriovenous fistulas or arteriocalyceal fistulasin grafted kidney are not an infrequent compli-cation of needle biopsy, '-4 but very few caseswith adequate treatment have been reported .We report herein 1 case of arteriocalyceal fis-tula after needle biopsy in a transplant recipientand its successful management by selective arte-rial embolization .

Case ReportA twenty-six-year-old patient with

pyelonephritis and reflux was undergoing he-modialysis in 1977 . A cadaver kidney allografttransplant was done in August, 1978 . The surgi-cal procedure consisted of implantation of thegrafted kidney in the right iliac fossa with end-to-end anastomosis of renal-hypogastric ar-teries . A lateral reimplantation of the iliac veininto the vena cava was performed . The donorureter was reimplanted in the bladder withantireflux technique according to the methoddescribed by Politano and Leadbetter .4a Thegraft functioned immediately with productionof urine in the operating room .

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Immunosuppressive therapy consisted ofazathioprine 125 nig/QD and prednisone 2 mg/QD/day tapered down from 10 mg every fourdays. His serum creatinine was down to 1 .4 mg/100 ml at day 4, but a rejection episode at day12 was treated with antilymphocyte globulin(15 ml/day) and increased dose of prednisone (5mg/day) . At day 20, the serum creatinine was1 .1 mg/l00 ml .Two months later, a percutaneous kidney

biopsy was done because of an increase inserum creatinine, which was thought to be anew rejection episode . This biopsy was donewith a Vim-Silverman needle, tangentially tothe skin without any difficulty . The biopsy wasfollowed by gross hematuria and anuria . Thehemoglobin level fell to 2 Gm, and the patientwas transfused with 2 units of red blood cells .Clinical examination showed a tender graftwith a systolic bruit in the right iliac fossa butwithout a distinctive thrill and no change inblood pressure . The same day the serumcreatinine rose to 40 mg/100 ml . Selective renalarteriography was done twenty-four hours later

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FIGURE 1 . Selective re-nal arteriography beforeembolization . (A) Earlyphase shows arteriocaly-ceal fistula from distalbranch of prepyelic arte-rial trunk. (B) Interme-diate phase demon-strates early filling ofrenal vein from arte-riovenous fistula in samearea .

and revealed a large arteriocalyceal fistula (Fig .1) . The leak was at the level of a prepyelicbranch, and therapeutic embolic occlusion wasdeemed appropriate . The catheter was ad-vanced into the trunk supplying the fistula (Fig .2), and a mixing bolus of Gel-foam was in-jected . Repeat contrast medium injection re-vealed occlusion of the fistula (Fig . 3) . Hematu-ria abruptly ceased .

Two days later the patient had normal diure-sis, and the serum creatinine fell slowly (3 .6mg/100 ml after 10 days) . A renal scintigramdone ten days later using DMSA technetium-99m and iodine-125 Hippuran showed an avas-cular zone consistent with infarction of approxi-mately 30 per cent of the whole parenchyma . Asecond scintigram done two weeks later showeda marked diminution of the avascular zone .

One month later, a urinary tract infection de-veloped, and the excretory urogram showed aureterocalyceal stasis . The surgical explorationconfirmed the diagnosis of urinary obstructionat the ureterovesical junction . A diversionpyelostomy was performed, but because of per-sistent urinary tract infection, the graft was re-moved fifteen days later.

Macroscopically the graft appeared to benormal . Microscopic examination of the embo-lized area showed a coagulative type of infarctwith fibrosis at the site of the earlier fistula . In-

FIGURE 2 . Subselective catheterization shows ar- terstitial mononuclear cells were few with mildtery distally occluded; fistula located below tip of fibrosis of the interstitium . Renal arteriescatheter.

showed moderate hypertrophy.

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Ap E

CommentThe reported incidence of clinically manifest

complications of renal percutaneous needlebiopsy vary from 0 to 15 per cent .5s Seriouscomplications are seen in patients with hyper-tension, coagulation abnormalities, and inthose with solitary kidney, as in transplant re-cipients .' Most of the lesions are arteriovenousfistulas. Arteriocalyceal fistulas are less fre-quently reported .

The majority of these lesions are small,asymptomatic, and regress or disappear withtime; very few require surgical intervention .The most frequent complications were : (1)gross hematuria, immediately after biopsy, and(2) blood loss or signs of hemorrhage leading tomultiple transfusions . Successful surgical treat-ment has been by vascular reconstruction, 9-1partial nephrectomy, 12 and embolization, 13, ' 4depending on the size, location, and accessibil-ity of the lesion. Embolization has been usedfrequently in the treatment of arteriovenous fis-tulas of the kidney, but only in few patientswith transplanted kidney. Various materialssuch as metallic pellets, Silastic pellets, fat, fas-cia, and muscle have been used for percuta-neous embolization .

There are, however, complications to selec-tive arterioembolization . There was a 5 to 10-per cent risk of producing infarction 1 J in onekidney. In our patient the infarction area was

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FIGURE 3 . Controls af-er embolization . (A)Immediate controlshows selective and dis-tal occlusion of artery,and (B) on thirtieth dayshows permanent occlu-sion and permeability ofother branches .

30 per cent. But continuous scintigram showedan appreciable regression of the lesions, al-though microscopic examination six weeks afterembolization showed evidence of infarction .

Another complication is generalized arterialspasm, leading to cortical damage, as observedby Rizk, Attalah, and Bridi ." This was not ob-served in our patient . Lastly, with larger fistu-lous tracts, the potential complications ofpulmonary emboli limit the application of em-bolization. In such situations, the use of Fo-garty balloon-type catheter, cyanoacrylate, andstainless steel coils 1e has been recommended .

Some investigators believe that percutaneousrenal biopsy should not be done in patients withsolitary kidney, while others have suggestedopen needle biopsy to permit direct visualiza-tion and selection of biopsy area .

In conclusion, we wish to stress the usefulnessof selective arteriography in the diagnosis of ar-teriovenous or arteriocalyceal fistula, especiallyin those with grafted kidney.

18 Avenue du General Leclerc94270 Le Kremlin Bicetre, France

(DR. BENOIT)

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