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Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
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On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
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Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

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Dr. Anuradha
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : October | Volume : 16 | Issue : 10 | Page : PR01 - PR03 Full Version

Paradigm Shift in the Management of Pseudoaneurysm Following Nephrolithotomy-A Case Series

Published: October 1, 2022 | DOI:
Sunirmal Choudhury, MD Taquedis Noori, Dilip Kumar Pal

1. Associate Professor, Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India. 2. Postdoctoral Trainee, Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India. 3. Professor and Head, Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dilip Kumar Pal,
Professor and Head, Department of Urology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India.


Renal artery pseudoaneurysm after nephrolithotomy or pyelolithotomy is rare, but is more often following Percutaneous Nephrolithotomy (PCNL) or renal biopsy. It is a potentially life-threatening condition, with an incidence of 0.1 to 0.3% after nephrolithotomy or pyelolithotomy. Manifestation may vary, from asymptomatic to symptoms like local bloody discharge, haematuria, pain, high blood pressure, and rupture causing a life-threatening condition. A minimally invasive technique, selective or super-selective angioembolisation is the treatment of choice. This case series reports, five cases presented with either bloody wound discharge or intermittent haematuria in the Emergency Department, post nephrolithotomy. All patients were resuscitated in the Emergency Department with intravenous fluid and packed red blood cell transfusion. After resuscitation, three patients were diagnosed with renal artery pseudoaneurysm on Computed Tomography of Kidneys, Ureters and Bladder (CT KUB) and angiography, and two patients with digital subtraction angiography during the intervention. All were treated with super-selective renal artery angioembolisation, with endovascular coiling of different sizes. All patients made an uneventful recovery, and on followup no complication was evident. Now-a-days the popularity of angioembolisation for renal artery pseudoaneurysm has increased, which shows a paradigm shift from a traditional surgical intervention.


Angioembolisation, Endovascular coiling, Pyelolithotomy

Pseudoaneurysm after nephrolithotomy is very rare. Incidence of pseudoaneurysm after nephrolithotomy and pyelolithotomy is 0.1 to 0.3%, while during PCNL and percutaneous renal biopsy, it is 0.6 to 1% and 2 to 3.4% respectively (1). It may manifest as local symptoms, haematuria, hypertension, or even catastrophic rupture of the vessel resulting in life-threatening haemorrhage and shock. Selective or super-selective renal embolisation is now the treatment of choice (2). Renal artery embolisation was first introduced in 1964 and advancement in radiology resulted in the development of super-selective renal arterial embolization (3). Tissue loss after embolisation is very important in end organs like kidney (4). Currently selective or super-selective renal embolisation is a safe and effective therapeutic option for pseudoaneurysm or arteriovenous malformation (5). Surgical intervention is rarely required, because it usually results in partial or total nephrectomy. Surgical intervention is reserved for large and refractory renal artery pseudoaneurysm (6).

Case Report

Case 1

A 58-year-old male presented to Emergency Department, with a bloody discharge from the operated site after 2.5 month of open nephrolithotomy for renal stone, done at a peripheral hospital three month ago. He had a history of 18 units of packed red blood cell transfusion before presenting to our hospital. On admission, haemoglobin was 7 gm/dL. He was resuscitated with 2 units of packed red blood cells and intravenous fluid. After hemodynamic stabilisation, Computed Tomography angiography was done which shows a pseudoaneurysm of size 5.6×3.8×5 cm, arising from the segmental artery of the interpolar region of the left kidney with a large haematoma of size-13.4×11.2×24.6 cm surrounding the interpolar region, effacing the calyx and extending posteriorly in the lumbar region of the left-side of the pelvis over the psoas muscle (Table/Fig 1)a,b,(Table/Fig 2). Selective embolisation with endovascular coil (Two IMWCE 0.035?-3 mm-3 cm) was done (Table/Fig 3)a,b. After endovascular coiling, bloody discharge from the wound subsided. Follow-up was done with Ultrasonography (USG) KUB. On one month of follow-up, the patient was doing well.

Case 2

A 27-year-old female presented to the Emergency Department with intermittent haematuria, after one month of open right nephrolithotomy for large calyceal stone, done at a peripheral hospital two months back. On admission the patient was pale, and her haemoglobin was 6 gm/dL. The patient was resuscitated with 4 units of packed red blood cells with intravenous fluid. After stabilization of the patient, renal angiography was done which showed a lobulated pseudoaneurysm of size 18.9×13.6 mm at the right interpolar region arising from a segmental branch of the interpolar region (Table/Fig 4). CT-guided angioembolisation with endocoil (IMWCE 0.035?-3 mm-3 cm) was done. After angioembolisation haematuria subsided, and the patient made an uneventful recovery. At one month of follow-up, she was doing well.

Case 3

A 23-year-old male presented to the Emergency Department, with haematuria, with the passage of clots after 15 days of open right nephrolithotomy done at another hospital for renal stone, one month back. On admission, patient was resuscitated with 2 units of packed red blood cells and intravenous fluid. After stabilisation of the patient, digital subtraction angiography was done, which showed a renal segmental artery aneurysm (Table/Fig 5)a,b. Selective angioembolisation with the endovascular coil (Two MWCE 0.018?-3 mm-3 cm-HILAL) was done. After angioembolisation haematuria subsided. At one month of follow-up, he was doing well.

Case 4

A 42-year-old male came to the Outdoor patient Department with a complaint of haematuria after 25 days of right nephrolithotomy for large calyceal diverticular stone, done two months back at peripheral hospital. After resuscitation of patient, digital subtraction angiography was done which shows segmental artery aneurysm and treated with selective arterial embolisation (Table/Fig 6)a,b. Postoperative recovery was uneventful. On follow-up, he was doing well.

Case 5

A 29-year-old female presented in the Emergency Department with complaints of pain at the operative site, and haematuria for 18 days after left nephrolithotomy, which was done two months ago at peripheral hospital. On admission, the patient was pale, and her haemoglobin was 5 gm/dL. The patient was resuscitated with 5 units of packed red blood cells with intravenous fluid. After stabilisation of patient, CT KUB and angiography were done, which showed a renal segmental artery aneurysm of size 22 mm×16 mm in the left interpolar region, which was treated with angioembolisation. The patient became asymptomatic afterward. At one month follow-up, patient was doing well. Basic details of all cases are given in (Table/Fig 7).


There are variety of options exist for the treatment of renal stone, including Extracorporeal Shock Wave Lithotripsy (ESWL), PCNL, laparoscopic/ open pyelolithotomy, and nephrolithotomy. Nowadays, most renal stones are managed with ESWL or PCNL. Pyelolithotomy/nephrolithotomy is still performed occasionally if the stone size is large, lack of endourology facilities, or lack of experience in PCNL (1).

Pseudoaneurysm is an unusual condition, associated with nephrolithotomy or PCNL. The most common symptom associated with renal artery pseudoaneurysm is hematuria (7). CT angiography is a valuable non invasive diagnostic modality of choice for the diagnosis of renal artery aneurysm and also for the follow-up. Pseudoaneurysm is best seen in the arterial phase of CT angiography. It also demonstrates the entire urinary tract, along with focal lesions at the same time. Digital Subtraction Angiography (DSA) remains the gold standard for the diagnosis of renal artery pseudoaneurysm. So, it is used both as a diagnostic as well as therapeutic method (8). In this case series, three patients were diagnosed with CECT KUB with CT angiography, and the remaining two patients were diagnosed with DSA, which was both diagnostic and therapeutic.

Treatment options for renal artery pseudoaneurysm are conservative, nephrectomy, open vascular surgery, or angioembolisation, depending on the patient’s clinical condition (6). But now-a-days, angiographic embolisation is the treatment of choice due to its selective and minimal invasive nature, and the maximal preservation of renal parenchyma. Small-sized (<2cm) pseudoaneurysm may be managed conservatively, but if symptomatic in terms of bleeding, pain, and hypertension then selective/super-selective embolisation is the best treatment (1). Embolisation is well-tolerated, relatively safe, and allows maximal preservation of functioning renal tissue (4). Angioembolisation has the disadvantage of arterial injury, infection, haemorrhage requiring nephrectomy, contrast-induced nephropathy, and radiation exposure (4). A large pseudoaneurysm/AV malformation (>2cm), renovascular hypertension, expansion of the aneurysm, and evidence of renal damage, may need nephrectomy or partial nephrectomy (6). Currently, total or partial nephrectomy is reserved for the patient with renal infarction, severe ischaemic renal atrophy, or particularly complex intrarenal aneurysm (1).3

The procedure of angioembolisation starts from renal angiogram through a transfemoral approach. Selective embolisation of renal artery branches can be achieved by using microcatheters, inserted co-axially in a guidewire, minimising loss of viable tissue. Different embolic agents are available to treat pseudoaneurysm like endocoils, particulate agents, and liquid agents. Embolic agents can be used either alone or in combination (9). The choice should be based on the patient’s vascular anatomy and the pathologic process. We have used endocoils agents, because of their availability in our institution.

According to Rami A et al., and Ansari MS et al., successful management of a case of the renal artery pseudoaneurysm was done by angioembolisation (1),(9). Similarly, we managed all the cases of renal artery pseudoaneurysm by angioembolisation with very minimal complications. Angioembolisation is a paradigm shift in the management of renal artery pseudoaneurysm because it is a minimally invasive technique, less time-consuming, nephron sparing procedure, and has less complication. But the limitation of this procedure is, it needs an expert intervention specialist and the high cost of endo coils.


Pseudoaneurysm following nephrolithotomy though rare, can be life-threatening. In the modern era, such cases can be managed by minimal invasion technique, in the form of embolisation of specific branches of the renal artery and thus, kidneys can be saved. Angioembolisation can be regarded as a game changer in the modern era to manage these cases in a minimally invasive way.


Ansari MS, Dodamani D, Aron M, Seth A, Gulati M, Seith A, et al. Iatrogenic Renal pseudoaneurysm after pyelolithotomy: A case report. Annals of Saudi medicine. 2003;23(5):301-303. [crossref] [PubMed]
Vijay MK, Vijay P, Das RK, Kundu AK. Renal artery pseudoaneurysm following percutaneous nephrolithotomy. Saudi Journal of Kidney Diseases and Transplantation. 2011;22(2):347.
Alwarraky MS, Abdallah MM, Elgharbawy MS. Clinical outcome and safety of selective renal artery embolization using permanent occlusive agents for acute renal bleeding. Egyptian Journal of Radiology and Nuclear Medicine. 2020;51(1):1-0. [crossref]
Ozturk H. Intrarenal pseudoaneurysm after percutaneous nephrolithotomy at solitary kidney. Nephrourol Mon. 2014;6(5):e19037. Doi: 10.5812/ numonthly.19037. PMID: 25695029; PMCID: PMC4318009. [crossref] [PubMed]
Ferreira AI, Gomes FV, Bilhim T, Coimbra É. Embolization with Onyx® of an arterial pseudoaneurysm with an arteriovenous fistula complicating a percutaneous nephrolithotomy: A case report and review of literature. Urology Annals. 2018;10(2):225. [crossref] [PubMed]
Yang HK, Koh ES, Shin SJ, Chung S. Incidental renal artery pseudoaneurysm after percutaneous native renal biopsy. Case Reports. 2013;2013:bcr2012006537. [crossref] [PubMed]
Venkateswarlu J, Kumar S, Babu RP, Abkari A. Endovascular management of iatrogenic renal vascular injuries complicating percutaneous nephrolithotomy: Role of renal angiography and embolization; an analysis of 159 cases. Indian Journal of Radiology and Imaging. 2017;27(03):293-97. [crossref] [PubMed]
Kervancioglu S, Gelebek Yilmaz F, Erturhan S. Endovascular management of vascular complications after percutaneous nephrolithotomy. Vasa. 2014;43(6):459-64. [crossref] [PubMed]
Rami A, Kassimi M, Habi J, Guerroum H, Sabah MS, Belhaj K, et al. Renal artery pseudoaneurysms post percutaneous nephrolithotomy: A case report. Radiology Case Reports. 2022;17(3):891-93. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2022/57828.17067

Date of Submission: May 19, 2022
Date of Peer Review: Jun 25, 2022
Date of Acceptance: Aug 22, 2022
Date of Publishing: Oct 01, 2022

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? No
• For any images presented appropriate consent has been obtained from the subjects. No

• Plagiarism X-checker: May 21, 2022
• Manual Googling: Aug 18, 2022
• iThenticate Software: Aug 20, 2022 (15%)

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