Intra-renal Pseudo-aneurysm as a complication of DJS insertion: case report & literature review

摘要

Ureteric double J stenting is one of the important urologic procedures which is not free of complications. We report a case of a 55-year- old male patient who presented with macroscopic hematuria after DJS insertion. Angiography confirmed the presence of an intra-renal pseudo-aneurysm . Selective arterial embolization was performed successfully. Because of the rarity of the case, we decided to report it and review the literature on the subject Introduction Renal artery aneurysms constitute 22% of all visceral aneurysms, and their prevalence in the population varies from 0.01% to 1.0% [6]. Intrarenal aneurysms constitute 17% of all renal artery aneurysms [7];The incidence of iatrogenic renovascular lesions has increased significantly, with the increase in the performance of minimally invasive urological procedures.[14] Intra renal pseudo-aneurysms are more commonly described as a complication of percutaneous procedures[15,16],and there are few reports of this complication following endourological surgeries[17] .The objective of this paper is to report an intra-renal pseudo-aneurysm following DJS insertion. To our knowledge, there is no documented report for such a case. Case Report A 55year old male patient , known ischemic heart disease ,diabetic, hypertensive & hypercholesterimic ,had a history of ureteric injury ,at the junction between the middle & the lower third , secondary to a complicated left ureteroscopy & laser stone fragmentation . That was managed by DJS insertion. Six weeks latter, the patient underwent removal of the DJS & retrograde pyelography which showed stricture at the lower third of the ureter, at the crossing of the iliac vessels, corresponding to the previous area of perforation. A Guide wire was introduced ,then ureteroscopy was performed which confirmed the stricture . Balloon dilatation was then done. Over the guide wire , ureteric dilatation using the balloon Ureteral dilator size 7F (4cm length balloon ) was done under fluoroscopy guidance. 1.5 ml of dye was used to inflate the balloon .The balloon was kept inflated for 3 minutes.During dilatation , the balloon ruptured & fluoroscopy showed dye leaking ,at the stricture area, into the retroperitoneal space surrounding the left iliac vessels course signifying ureteric perforation.Intra operatively , the patient was vitally stable & no bleeding could be identified. Next, the balloon was withdrawn & size 6F DJS was inserted smoothly over the guide wire to bridge the site of perforation. Post operatively, the patient was vitally stable with minimal hematuria.At the second day post operative, the patient developed acute coronary syndrome with chest pain . Cardiac enzymes & ECG where all with in normal. .He was managed by Tridil (Nitroglycerin) infusion (from 10meq/min tapered to 2meq/min till discontinued)& Isordil (Isosorbide dinitrate) 5mg sublingually TID for 5days after which the patient was discharged in a good general condition, stable vitals, clear urine & hemoglobin of 12g/dl. Five days latter , the patient presented to the Emergency department with frank hematuria with clots. There was no history of direct kidney trauma nor dysuria. The patient was conscious, oriented with Bp 150/80, pulse 105 .Abdominal examination was within normal. His lab investigations : CBC: wbcs 9.95 , Hb 7.6 , Plt 424, Coagulation profile was normal.Creatinine 126 The patient was admitted to the surgical ward. Intravenous fluids were started & Foley's catheter (3 way with irrigation) was inserted. Two units of PRBCs were transfused , Fortum (Ceftazidime) 1gram I.V Q12 h was started .Because of the recent ureteric perforation near the crossing of the iliac vessels, the patient was presumed to have uretero- iliac fistula C.T angio was done which showed left perinephric collection. The crossing point of the left ureter over the left iliac vessels , with DJS at normal position and the iliac vessels were clearly visualized. This ruled out uretero- iliac fistula.( Figure 1).Th