Guide wire perforation leading to fatal perirenal hemorrhage from transcortical collaterals after renal artery stent placement.

After successful renal artery angioplasty and stent placement, a patient in a fully anticoagulated state developed hypotension and flank pain. Review of the intraprocedural angiogram demonstrated transcortical position of the guide wire. Computed tomography of the abdomen revealed a large perinephric hematoma. Although only a single renal artery branch was accessed with the guide wire during stent placement, subsequent emergent angiography revealed extravasation from multiple capsular branches. Renal artery embolization failed to control the hemorrhage. The patient's course rapidly deteriorated and he ultimately died. The unique angiographic finding and proposed mechanism of this fatal complication are described and discussed.