Renal Arterial Injuries: A Single Center
Analysis of Management Strategies and Outcomes
Sean P. Elliott, Ephrem O. Olweny and Jack W. McAninch*
From the Department of Urologic Surgery, University of Minnesota, Minneapolis, Minnesota, and Department of
Urology, University of
California-San Francisco and San Francisco General Hospital (EOO, JWM), San Francisco, California
Vol. 178, 2451-2455, December 2007
THE JOURNAL OF UROLOGY.
DOI:10.1016/j.juro.2007.08.002
Purpose
• Renal injury occurs in up to 1.2% of trauma cases in the United States.
• Only 2.5% to 4% of these cases involves the renal vasculature
• Renovascular injuries are associated with multiple non-renal organ injuries
and with a high mortality rate of 19% to 44%
• Management of main and segmental renal artery injury following external
trauma is controversial
• After main renal artery injury the controversy surrounds
nephrectomy vs revascularization
• whereas after segmental renal artery injury the debate involves
operative vs nonoperative management
Materials and Methods
•
•
•
•
Data on a total of 82 renal artery injuries in 81 patients
collected between 1978 and 2006
They were retrospectively reviewed
Patient demographics, length of stay, transfusion requirements and injury
characteristics (artery subtype, grade, mechanism, and associated
parenchymal, venous and nonrenal injuries) were recorded.
• Management strategies and outcomes for each renal artery injury subtype
were compared.
TABLE 1.
No. pts (%)
Median age (range)
No. males (%)
No. females (%)
No. trauma (%):
Penetrating
Blunt
No. Parenchymal
laceration (%)
No. associated injuries (%)
No. shock (%)
No. hematuria/total
No. (%):
Gross
Microscopic
Absent
Unknown
No. RAIs (%):
Isolated arterial injury
Combined arterial
venous injury
No. injury grade/total
No. (%):
4
5
Patient and injury characteristics
MAI
36 (43)
29 (15–74)
30 (41)
6 (14)
SRAI
45 (57)
27 (4–68)
43 (59)
2 (5)
Totals
81
28 (4–74)
73 (90)
8 (10)
20 (49)
16 (40)
21 (45)
21 (51)
24 (60)
26 (55)
41 (51)
40 (49)
47 (58)
34 (47)
26 (57)
30/33 (91)
38 (53)
20 (43)
30/34 (88)
72 (89)
46 (57)
60/67 (90)
18/30 (60)
12/30 (40)
3/33 (9)
3/36 (8)
36
16 (29)
20 (74)
15/30 (50)
15/30 (50)
4/34 (12)
11/45 (24)
46
39 (71)
7 (26)
33/60 (55)
27/60 (45)
7/67 (10)
14/81 (17)
82
55 (67)
27 (33)
4/48 (8)
32/34 (94
44/48 (92)
) 2/34 (6)
48/82 (59)
34/82 (41)
• For main renal artery injury the respective outcomes of nephrectomy vs
vascular repair were a mean transfusion of 10,275 vs 6,125 ml (p 0.39)
• Length of stay 18 days for each, mortality rate 26% vs 13%, renal
• Failure rate 8% vs 25%
• Renal insufficiency/impaired selective function by renal scintigraphy
4% vs 13% (each p not significant).
TABLE 2.
Outcomes of nephrectomy vs vessel repair for MRAI
Nephrectomy
No. pts
23
Mean SD transfusion requirement (ml)
10,275 12,871
Mean SD LOS (days)
17.9 22
No. death during hospitalization (%)
6 (26)
No. renal failure (%)
2* (8)
No. hypertension
1*
No. renal insufficiency (Cr mg/dl 1.5 or greater) or impaired renal function
1 (4)
40% or less by renal scan (%)
No. other renal related complications during hospitalization (%)†
1 (4)
No. nonrenal nonfatal complications during hospitalization (%)
4 (17)
No. uneventful hospitalization, lost to followup (%)
6 (26)
No. no sequelae, Cr 1.5 mg/dl or less at followup
3 (13)
Vessel Repair
8
6,125 5,393
18.3 21
1 (12.5)
2 (25)
0
1 (12.5)
p Value
0
0
2 (25)
2 (25)
0.57
0.28
1
0.59
•The patient who underwent bilateral renovascular surgery had hypertension associated with renal failure.
•†Eg infection
0.39
0.97
0.4
0.29
0.57
0.47
• For segmental renal artery injury operative vs nonoperative management
was associated with a mean transfusionof 4,994 vs 820 ml (p 0.01)
• Length of stay 29 vs 11 days (p 0.23) and mortality rate 8% vs 6% (p 1.0).
• Renal failure and impaired selective renal function on scintigraphy were
similar between the groups.
TABLE 3.
Outcomes of operative vs nonoperative SRAD management
Operative
No. pts 24 18
Mean SD transfusion requirement (ml)
Mean SD LOS (days)
No. death during hospitalization (%)
No. renal failure (%)
No. hypertension (%)
No. renal insufficiency or impaired renal
function 40% or less by renal scan (%)
4,994 6,016
29.3 59
2 (8)
2* (8)
1*
2 (8)
No. persistent urinoma requiring intervention (%)
No. renal related complications during hospitalization (%)†
No. nonrenal nonfatal complications during hospitalization (%)
No. uneventful hospitalization, lost to followup (%)
No. no sequelae, Cr 1.5 mg/dl or less at followup (%)
0
1 (4)
4 (17)
6 (25)
7 (29)
Nonoperative
820 903
11.3 12
1 (6)
0
1 (6)
3 (16)
1 (6)
0
0
9 (50)
3 (16)
p Value
0.01
0.23
1
0.5
1
0.65
0.46
1
0.12
0.11
0.46
* The patient who underwent bilateral renovascular surgery had hypertension associated with renal failure.
† Excluding urinoma.
Conclusion
• Nephrectomy for main renal artery injury has outcomes
similar to those of vascular repair and it does not worsen
posttreatment renal function in the short term
• Nonoperative management for segmental renal artery injury
results in excellent outcomes.
THANK YOU