Traumatska protrahirana hematurija i pseudoaneurizma segmentalne arterije bubrega u 16-godišnjeg dječaka, liječena endovaskularnom embolizacijom

Anko Antabak, Dino Papeš, Krešimir Bulić, Ivo Sjekavica, Ivana Jurca, Dražen Perkov, Tomislav Luetić

Većina ozljeda bubrega u djece liječi se neoperativno, no protrahirana krvarenja i ozljede većih krvnih žila često zahtijevaju aktivno zaustavljanje krvarenja. Traumatske pseudoaneurizme segmentalne arterije nastaju u oko 2,5% ozljeda bubrega. Manifestiraju se protrahiranim, intermitentnim ili sekundarnim hematurijama, ali mogu biti i asimptomatske. Liječenje većinom započinje praćenjem, a oko trećine djece zahtijeva aktivni kirurški ili endovaskularni postupak. Dvije su osnovne tehnike endovaskularne embolizacije zavojnicama: „sandwich“ i „coil packing“, a moguća je okluzija uz pomoć stenta. Traumatska protrahirana hematurija, pseudoaneurizma segmentalne arterije bubrega i postupak liječenja rijetko su opisani, osobito u djece. U ovom radu prikazujemo dječaka s tupom ozljedom bubrega, protrahiranim krvarenjem i traumatskom pseudoaneurizmom segmentalne arterije bubrega, liječenog endovaskularnom embolizacijom u lokalnoj anesteziji i sedaciji pristupom kroz desnu femoralnu arteriju. Mikrokateterom 2,7 Fr selektivno je kateterizirana dominantna kranijalna bubrežna arterija i prikazana pseudoaneurizma sa zonom krvarenja interlobarnog ogranka segmentalne arterije. Zavojnicom 2 × 4 mm (Interloc 18, Boston scient) emboliziran je interlobarni ogranak segmentalne arterije s pseudoaneurizmom, bez znakova krvarenja ili značajnijeg ispada vaskularizacije parenhima bubrega na kontrolnim serijama. Endovaskularna metoda ima brojne prednosti nad klasičnom kirurgijom, no i nedostatke poput izlaganja relativno visokim dozama zračenja i kontrasta. Zadnjih godina, uporabom robota u urologiji, opisana je primjena minimalno invazivne robotske tehnike operacijskog liječenja pseudoaneurizme renalne arterije. Smanjenje broja nefrektomija i porast udjela neoperativnog liječenja i endovaskulanih zahvata danas predstavljaju trend u pristupu traumatskim ozljedama burega. KBC Zagreb ima sve specijalnosti i subspecijalnosti potrebite za kirurške i endovaksularne zahvate u djece, čime predstavlja nacionalni centar za zbrinjavanje sveobuhvatne traume bubrega u djece.

Most renal injuries in pediatric patients are treated conservatively, but prolonged hematuria and major blood vessel injuries often require active bleeding control. Traumatic pseudoaneurysms of segmental branches of the renal artery occur in 2.5% of renal injuries. They usually manifest as prolonged or intermittent secondary hematuria, but may be asymptomatic as well. Watchful waiting is the initial treatment, and around one third of patients eventually require active surgical or endovascular treatment. The two main endovascular coil embolisation methods are the “sandwich” and the “coil packing” technique, but occlusion using a stent is also possible. Traumatic prolonged hematuria caused by pseudoaneurysm of the renal segmental arterial branch, and the methods of treatment are rarely reported, especially in children. This report presents a boy in whom a blunt kidney injury lead to the formation of a pseudoaneurysm of the renal segmental arterial branch, causing prolonged hematuria. The patient was treated by endovascular embolisation through the right femoral artery, in local anesthesia and conscious sedation. A 2.7 Fr microcatheter was used to selectively enter the dominant cranial renal artery and show the pseudoaneurysm of a segmental interlobar arterial branch. A 2×4 mm coil was used to occlude the segmental interlobar arterial branch and pseudoaneurysm, with no post-procedural bleeding or
significant renal segmental ischemia. Endovascular treatment offers advantages over open surgery, but has certain drawbacks as well, such as high radiation and contrast exposure. In the last few years, a minimally invasive robotic surgical procedure has been described for the treatment of intra-renal pseudoanurysm. The current worldwide trend in pediatric renal injuries treatment is the reduction in the number of nephrectomies, and a shift to non-operative and minimally invasive treatment, including endovascular procedures. University Hospital Centre Zagreb has all the specialities and capacities required for surgical and endovascular procedures in children, making it the national referral centre for pediatric renal injuries treatment.