Large spontaneous perirenal haematoma following percutaneous transluminal coronary angioplasty

Abstract

Perirenal haematoma is a rare and life-threatening condition in view of severe and ongoing blood loss. Most common causes are renal cancer, angiomyolipoma and vasculitis. Spontaneous causes of this rare entity may occur with use of anticoagulants and antiplatelets. We report a 61-year-old male patient diagnosed with large perirenal haematoma following percutaneous transluminal coronary angioplasty for myocardial infarction under heparin cover that was managed conservatively.

Background

Spontaneous perirenal haematoma is the dissection of blood into the subcapsular or perinephric space. Most common causes are renal cancer, angiomyolipoma, vasculitis, infection, coagulation disorders and so on, with malignancy being most common entity.¹ Perinephric bleed following cardiac intervention is rarely reported in literature.² We present a case of large perinephric haematoma after coronary artery reperfusion therapy (CART) in a patient with myocardial infarction.

Case presentation

A 61-year-old male patient was diagnosed with myocardial infarction following an episode of acute chest pain. There was no significant medical history or family history contributing to present illness. The patient was admitted under cardiology emergency services and investigated. Routine blood test revealed haemoglobin—12.5 g/L, platelets—240×10⁹/L, serum creatinine—1.0 mg/dL, international normalised ratio (INR)—1.0, serum Creatine kinase -MB was 45 IU/L, and ECG showed tall peaked T waves and ST segment elevation. Chest X-ray was normal. Vitals were monitored on hourly basis. Two-dimensional echocardiogram showed 45% ejection fraction, left ventricular hypertrophy and mild pericardial effusion. Coronary angiography showed near complete blockage of left anterior descending branch of left coronary artery. The rest of the major cardiac vessels were normal. The patient underwent coronary artery reperfusion therapy, and drug eluting stent was placed across left anterior descending branch of coronary artery via percutaneous approach. Unfractionated heparin of 5000 IU loading dose was given immediately after the procedure and continued later by at the rate of 18 IU/kg/hour. The patient was monitored at regular intervals, the and activated plasma thromboplastin time was measured every 6 hours. The same day, the patient complained of acute onset severe left flank pain associated with one episode of vomiting. There was no fever, bowel, bladder complaints or haematuria. On systemic examination, there was mild tenderness in left flank region.

Investigations

Ultrasound abdomen reported a subcapsular collection of 8×12 cm along the surface of left kidney. Renal parenchyma was pushed upwards and medially by the collection. Contrast-enhanced CT of the abdomen confirmed the above findings and was suggestive of perirenal haematoma with Hounsfield unit of 50 (figure 1). There was no solid component or abnormal enhancement in the haematoma. Bilateral kidneys were enhancing well and showed prompt excretion on delayed images. There was a drop of haemoglobin by 2 g/L on day 1 after CART, and urine culture was sterile. Vasculitis workup in form of antineutrophil cytoplasmic antibody, erythrocyte sedimentation rate, C-reactive protein were within normal limits.

Figure 1.

Contrast-enhanced CT axial (A) and coronal (B) images showing left large perirenal haematoma (white arrow) with Hounsfield unit 50 pushing the kidney medially and upwards.

Differential diagnosis

• Vasculitis.

• Coagulation disease.

• Coincidental renal tumour.

Treatment

The patient was managed conservatively with adequate bed rest and vitals monitoring. Serial ultrasound was done to monitor the size of perirenal haematoma. There was no further drop in haemoglobin, and pain was managed by oral analgesics. The patient was started on oral antiplatelets and heparin tapered gradually. The patient remained stable with no transfusion requirement and discharged on day 6 of hospital admission.

Outcome and follow-up

The patient was followed up at 3 months with non-contrast CT scan which showed complete resolution of perirenal haematoma (figure 2). The patient is currently on dual antiplatelet and under regular follow-up.

Figure 2.

Non-contrast CT axial (A) and coronal (B) images showing complete resolution of perirenal haematoma (white arrow) at 3 months follow-up.

Discussion

Spontaneous perirenal haemorrhage or haematoma also known as Wunderlich syndrome is a rare life-threatening entity reported with renal tumours, vascular diseases, coagulation disorders and so on. Zhang et al reported in his meta-analysis of 165 patients that renal tumour was the most common cause of perinephric haematoma followed by angiomyolipoma.¹ Vascular causes such as polyarteritis nodosa, Wegener’s disease, arteriovenous malformation constitutes the other causes. Similar predisposing causes had been noted by Daskalopoulos et al in his case series.² Search for renal tumour should be made in every patient presenting with perinephric haematoma based on the above studies. Coronary angiography is a relatively safe diagnostic procedure in patients with myocardial infarction. Angioplasty and placement of stent via percutaneous approach is minimally invasive option for coronary artery disease. As an anticoagulant, heparin is commonly used to prevent thrombosis. Heparin inhibits natural homeostasis by creating a complex with antithrombin III and enhancing its effect. However, heparin is not without limitations and may increase the possibility of vascular and haemorrhagic complication such as haematoma at the site of catheterisation after initial haemostasis, retroperitoneal haemorrhage and pseudoaneurysm at the site of femoral artery puncture, all of which might necessitate diagnosis and management.³ The index case complained of acute onset severe flank pain and was diagnosed with perirenal haematoma following coronary intervention. Whether single bolus dose of intravenous heparin following coronary intervention can lead to perinephric haematoma is difficult to ascertain, though it has been reported in literature in one case report. Goel et al reported a case of spontaneous perirenal haematoma during coronary angiography which was assumed to be due to heparin use during the procedure.⁴ Kwon et al reported a very unique case of right renal infarction and subcapsular haematoma after cardiac angiography.⁵ However, a randomised controlled trial studying the effect of heparin administration during coronary angiography by Gharakhani et al reported no adverse effect on clot formation or haemorrhagic and vascular complication.⁶ Clinical presentation of such patients varies widely. Sudden onset flank pain is often present in such patients, which was present in index case as well. Fever, vomiting and occasionally haematuria may be present. All patients require contrast CT for evaluating extent of haematoma, active bleed and underlying cause of bleed. With the better imaging techniques, the correct diagnosis can be ascertained, and follow-up imaging in cases of non-demonstrable pathology is essential. Management approach for spontaneous perinephric haematoma has become more conservative in recent years with advancement of imaging techniques that reliably lead to correct diagnosis of underlying predisposing cause. Management has changed from nephrectomy to more conservative approaches in such cases.^{7 8} In clinical stable patients with no active bleed and non-expansile haematoma, conservative management should be undertaken. Close monitoring of vitals, serial haemoglobin levels and imaging in the form of ultrasound can be done to assess expansion of haematoma. Patients with active bleeding, expansile haematoma or requiring multiple blood transfusions often need selective renal artery embolisation or surgery. Our patient was symptomatic for perirenal haematoma; however, his vitals were stable and there was no further haemoglobin drop on serial follow-up. Follow-up of with contrast imaging has been suggested to rule out any renal or vascular pathology which might be uncovered after the resolution of haematoma. We believe that the single bolus dose of heparin was the cause of perinephric bleed in our patient, and such patient can be managed conservatively if remains stable.

Patient’s perspective.

​I am very thankful to whole team of doctors and support staff for managing my case extremely well.

Learning points.

• Spontaneous perirenal haematoma is rare.

• Most common cause is renal tumour.

• Anticoagulants like heparin used for coronary angioplasty can cause perirenal haematoma.

• Management is usually conservative.

• Serial follow-up and close monitoring is advised.