Renal Subcapsular Hematoma Caused by Hydrophilic Guide Wire during Patent Ductus Arteriosus Closure.

Hydrophilic guide wire-associated renal subcapsular hematoma (RSH) during patent ductus arteriosus (PDA) closure is an extremely rare clinical condition. Herein, we present the case of a 16-year-old adolescent who suffered accidental hydrophilic 0.035-inch guide wire-related RSH during PDA closure. This RSH was diagnosed by computerized tomography and selective renal angiography. It was successfully treated by conservative treatment.

INTRODUCTION

Renal subcapsular hematoma (RSH) induced by renal angioplasty or kidney biopsy is not rare in occurrence. However, the incidence of guide wire-associated RSH during coronary angiography or cardiac intervention is unclear because it is rarely reported.[12] This clinical condition may trigger potentially fatal retroperitoneal hemorrhage or hypovolemic shock, or it may result in loss of the kidney in the full anticoagulation state.[3] Therefore, prompt recognition of RSH and urgent hemostasis with hemodynamic and intravascular volume supports are essential to prevent fatality.

CASE REPORT

A 16-year-old female patient was referred to our cardiology polyclinic with the complaint of palpitations. A continuous mechanical heart murmur located at the upper left sternal border was detected on physical examination, and transthoracic echocardiography revealed a patent ductus arteriosus (PDA). The patient's pulmonary artery pressure and left ventricular function were evaluated as usual. She was taken to the catheter hall to undergo the PDA closing procedure on the following day because she was symptomatic, as the murmur was detected in the physical examination. Angiography performed in the catheterization laboratory defined the anatomy of the ductus arteriosus. After the determination of the length and diameter of the PDA, it was successfully crossed with a 0.035-inch hydrophilic guide wire and closed with a 4 mm × 7–3 mm AMPLATZER™ Duct Occluder II device (St. Jude Medical, Plymouth, MN, USA) [Figure 1a]. The patient was taken to cardiology service without experiencing any problems in the catheter hall.

Figure 1

Angiographic image showing successful closure of patent ductus arteriosus with 4 mm × 7–3 mm AMPLATZER™ Duct Occluder II device device (a), digital subtraction angiographic image of the left renal arterial system (b), 64-cut multislice contrast-enhanced axial computerized tomography image of the left kidney being compressed by the subcapsular hematoma (c)

In the cardiology regular service, the patient had a sudden onset of left-sided blunt abdominal pain 3 h after PDA closure. Thus, she was taken back to the catheter hall for renal angiography because of the suspicion of the left renal ischemia. Renal artery angiography did not demonstrate any complications that could have occurred during PDA closure, such as dissection or perforation of the left renal artery [Figure 1b]. We decided to perform an abdominal computerized tomography (CT) to evaluate the cause of the abdominal pain. CT images demonstrated a subcapsular hematoma putting pressure on the left renal cortex, starting from the left kidney upper pole, and extending to the lower pole along the lateral neighborhood kidney, and it had a size of 77 mm × 62 mm × 30 mm [Figure 1c]. Blood samples of the patient that were taken after the abdominal pain began revealed a hemoglobin value of 9.8 g/dL, which was 13.2 g/dL before the PDA closure procedure. Three units of erythrocyte suspension transfusion were given to the patient. Intravenous hydration, prophylactic antibiotic therapy, absolute bed rest, and analgesia were given to the patient according to the recommendations of the Urology Department.

On the following day, the hemoglobin values were stable. The left-sided abdominal pain of the patient decreased slowly. In the succeeding abdominopelvic ultrasound and CT controls, significant decreases were observed in the size of the subcapsular hematoma. Control CT performed before discharge of the patient revealed that the hematoma decreased to approximately 4 cm at the widest point and that it was partially organized [Figure 2]. Renal artery venous engorgement was normal. The patient was discharged from hospital 7 days after the PDA closure. The 1st-month control of the patient did not indicate any clinical problems.

Figure 2

64-cut multislice contrast-enhanced computerized tomography scan axial and sagittal images of the patient 1 week (a and b) and 1 month (c and d) after discharge. Note the reduced amount of the hematoma by the time

DISCUSSION

The use of hydrophilic wires can result in distal renal artery perforation. The symptoms include ipsilateral flank pain, hematuria, hypotension, and shock, which may all result in death.[4] Our RSH case occurred because of the use of a hydrophilic guide wire during PDA closure. RSH can be fatal, and therefore, the early recognition of this unusual clinical condition is important. A suspicion based on the operating steps of PDA closure and rapidly performed imaging modalities are essential for the early detection of RSH.

The most important diagnostic modalities are CT and selective renal angiography. Careful visualization of the segmental artery vasculature can identify free vessel perforation and perinephric hematoma. Selective renal angiography demonstrates the site and amount of bleeding and provides the chance for interventional hemostasis simultaneously.[4] Balloon tamponade, stent grafts, or embolized coils can be used according to the vessel size or location.[5] However, in the case of an end-artery perforation such as in the present case, emergency surgery should be generally considered as the primary treatment. By contrast, conservative treatment, which includes the reversal of the full anticoagulant state, replacement of the lost intra-arterial volume by blood transfusions, and serial ultrasonography monitoring, remains the best choice if salvaging the kidney is considered.

The use of a hydrophilic guide wire has a potential risk for unexpected piercing or entering into arterial branches even under the proper fluoroscopic navigation.[2] We need to perform guide wire passage carefully from the beginning of the procedure under full visual monitoring to avoid rare complications such as renal artery dissection, renal artery perforation, and RSH.

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Conflicts of interest

There are no conflicts of interest.