Direct Ultrasound-guided Percutaneous Thrombin Injection as a Nephron-sparing and Contrast-sparing Treatment for Delayed Post-biopsy Intrarenal Pseudoaneurysm

Abstract

Background: Bleeding complications following percutaneous renal biopsy are generally uncommon and most often self-limited. Superselective transarterial embolization is usually considered the standard treatment for active bleeding or post-biopsy renal pseudoaneurysm. However, this approach may be technically challenging or associated with significant parenchymal loss and additional iodinated contrast exposure, particularly in patients with advanced chronic kidney disease.

Case Presentation: We report the case of a 77-year-old man with atrial fibrillation receiving direct oral anticoagulant therapy and ANCA-associated vasculitis with chronic kidney disease, who underwent ultrasound-guided percutaneous renal biopsy for significant proteinuria and persistent microscopic hematuria. The procedure was initially uneventful, with stable hemoglobin and no immediate imaging evidence of bleeding. Approximately six weeks later, the patient was readmitted for severe symptomatic anemia without gross hematuria or externalized bleeding. Contrast-enhanced CT demonstrated a large left subcapsular renal hematoma associated with a small enhancing focus within its anterior portion, consistent with an intrarenal pseudoaneurysm. Given the impaired renal function, recent iodinated contrast exposure and risk of parenchymal sacrifice, a direct ultrasound-guided percutaneous approach was selected as the primary treatment strategy. The pseudoaneurysm was punctured under ultrasound guidance using a 20G Chiba needle, followed by slow injection of thrombin-containing fibrin sealant (Tisseel®, Baxter – Illinois, USA). Immediate thrombosis of the pseudoaneurysmal cavity was achieved, with complete disappearance of the abnormal Color Doppler signal and preservation of perfusion of the remaining renal parenchyma. Follow-up CT confirmed exclusion of the pseudoaneurysm without residual bleeding. The clinical course was favorable, with no recurrent hemorrhage.

Conclusion: Direct ultrasound-guided percutaneous thrombin injection may represent a valuable nephron-sparing and contrast-sparing alternative in selected patients with post-biopsy intrarenal pseudoaneurysm, particularly when the lesion is clearly visible and safely accessible on ultrasound and when endovascular treatment may increase the risk of renal injury.

Keywords: Renal Biopsy; Oral Anticoagulant Therapy; Pseudoaneurysm; Bleeding; Kidney Disease