杨宁介入医学网

肾血管性病变：肾血管病变可以继发于肾的钝性创伤、穿透伤；或各种操作导致的肾医源性损伤；或自发性有或没有潜在的疾病[1]。
 

1. 先天性肾动静脉血管畸形；或获得性动静脉瘘；

       获得性动静脉瘘多继发于肾活检、外科手术、创伤、肿瘤和炎性疾病。由于肾活检例数的增加，肾获得性动静脉瘘也增加[4]。
 

2. 肾脏外伤：钝性伤、穿透伤和医源性损伤[1]

        医源性损伤包括外科手术或经皮手术导致肾严重出血。医源性损伤是最常见的肾血管损伤原因（＞50%），表现为动静脉瘘[33]、动脉肾盂瘘（arteriocalyceal fistula ）、假性动脉瘤和肾周血肿[2，3]。

        Percutaneous Nephrolithotomy（经皮肾镜取石术）：分标准通道和微通道。文献报道标准通道严重出血的发生率为1.06~4.4%[26,29]，微通道为0.3%[27]。Martin 等[28] 8 例PCNL术后出血患者采用超选择动脉栓塞治疗除1例孤立肾外7例患者栓塞前后血肌酐无明显变化,此后1~3年随访中仅1例出现高血压,余无异常。

        腹腔镜肾部分切除：640例延迟出血（术后7~30天，肉眼血尿持续＞24小时），13例（2%）严重出血需要栓塞[7]。

        多数是动脉瘤出血（77%）[7]。没有肾盂积水被认为是严重肾出血的危险因素[37]，因为肾实质厚，肾造瘘通道出血可能性大[38]。另一个危险因素是穿刺的次数。
 

         经皮肾活检出血危险因素：高危因素包括高血压、凝血机制障碍；新的出现的危险因素包括年龄、性别以及最近报告的淀粉样变[5，6]。多数表现为动静脉瘘，相比外伤，活检导致的动静脉瘘可以自愈[34]。
 

3. 肾脏真性或假性动脉瘤出血（renal artery pseudoaneurysm，RAP）；动脉瘤形成的机制以前文献有报告[13]。
 

        结节性多动脉炎[39]是影响多器官的小动脉或中动脉的坏死性血管炎。特点是局灶性、血管壁，特别是分叉部位的非特异性炎症。血管闭塞导致器官梗死以及微动脉瘤破裂可以导致肾周围血肿是本病的两大特征。孤立性的结节性多动脉炎发生自发性肾周围血肿是不常见的并发症，可导致危及生命。
 

4. 肾脏外伤破裂出血；非医源性的穿透伤（stab wound）是不常见的，穿刺伤表现为肾动静脉瘘已经报告超过20例[35]。
 

5. 肾肿瘤破裂：包括肾癌破裂、肾血管平滑肌脂肪瘤和肾转移癌破裂（滋养叶细胞肿瘤）[24]。
 

        血管平滑肌脂肪瘤（angiomyolipoma）是肾脏最常见的间质肿瘤（mesenchymal tumor），包含程度不同的成熟脂肪组织、平滑肌和厚壁血管。人群中发病0.3%，所有肾实质肿瘤3%[23]。如果肿瘤≥4cm，80%~90%的肿瘤是症状性的，其中50%~60%的肿瘤会自发破裂出血[30，31]。Moorhead 等人[32]在1977年首次报告了超选择栓塞肾血管平滑肌脂肪瘤。
 

6. 抗凝治疗：透析病人自发性出血[25]。
 

7. 不明原因出血

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6. Eiro M, Katoh T,Watanabe T: Risk factors for bleeding complications in percutaneous renal biopsy. Clin Exp Nephrol 9:40-45, 2005

7. Montag S, Rais-Bahrami S, Seideman CA, Rastinehad AR, Vira MA, Kavoussi LR, Richstone L. Delayed haemorrhage after laparoscopic partial nephrectomy: frequency and angiographic findings. BJU Int. 2011 May;107(9):1460-6

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13. Cohenpour M, Strauss S, Gottlieb P et al. Pseudoaneurysm of the renal artery following partial nephrectomy: imaging findings and coil embolization. Clin Radiol 2007; 62: 1104–9
14. Negro H, Kawakita M, Koda Y. Renal artery pseudoaneurysm after laparoscopic partial nephrectomy for renal cell carcinoma in a solitary kidney. Int J Urol 2005; 12: 683–5
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21. Richstone L, Reggio E, Ost MC et al. Hemorrhage following percutaneous renal surgery: characterization of angiographic findings. J Endourol 2008; 22: 1129–35

23. Hadju SI, Foote FWJr. Angiomyolipoma of the kidney: report of 27 cases and review of the literature. J Urol 1969; 102:
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24. Vijay RK, Kaduthodil MJ, Bottomley JR, Abdi S. Metastatic gestational trophoblastic tumour presenting as spontaneous subcapsular renal haematoma. Br J Radiol. 2008 Sep;81(969):e234-7.

25. Kawahara T, Kawahara K, Ito H, Yamaguchi S, Mitsuhashi H, Makiyama K, Uemura H, Sakai M, Kubota Y. Spontaneous renal hemorrhage in hemodialysis patients. Case Rep Nephrol Urol. 2011 Jul;1(1):1-6.

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27. 何永忠, 刘建河, 曾国华, 等. 微创经皮肾镜取石术后迟发出血原因及介入治疗. 中华泌尿外科杂志, 2006, 27(6): 371-3.

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32. Moorhead JD, Fritzsche P, Hadley HL. Management of hemorrhage secondary to renal angiomyolipoma with selective arterial embolization. J Urol 1977;117:122–3.

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34. Heyns CF, van Vollenhoven P. Increasing role of angiography and segmental artery embolization in the management of renal stab wounds. J Urol. 1992;147:1231-4.

35. Benson DA, Stockinger ZT, McSwain NE Jr. Embolization of an acute renal arteriovenous fistula following a stab wound: case report and review of the literature. Am Surg. 2005;71:62-5.

36. Hadi Rokni Yazdi, Yashar Moharramzadeh Endovascular Treatment of Renal Arteriovenous Fistula Following a Stab Wound Urol J. 2008;5:129-31.

37. Yanbo Wang（王艳波）, Fengming Jiang（姜凤鸣）, Yan Wang（汪岩）, Yuchuan, Hou（侯宇川）, Haifeng Zhang（张海峰） Qihui Chen（陈岐辉）, Ning Xu（许宁）, Zhihua Lu（芦志华）, Jinghai Hu, Ji Lu, Xiaoqing Wang ,Yuanyuan Hao, Chunxi Wang  Post-Percutaneous Nephrolithotomy Septic Shock and Severe Hemorrhage: A Study of Risk Factors. Urol Int 2012;88:307–310

38. Srivastava A, Singh KJ, Suri A, et al: Vascular complications after percutaneous nephrolithotomy: are there any predictive factors? Urology 2005; 66: 38–40.

39. Selman Unverdi, MD, Mustafa Altay, MD, Murat Duranay, MD, Ismail Kırbas, MD, Selim Demirci, MD, and Enver Yuksel, MD Polyarteritis Nodosa Presenting with Splenic Infarction, Bilateral Renal Infarction, and Hematoma Southern Medical Journal • Volume 102, Number 9, September 2009 972-973