A 53-year-old woman presented with hematuria and elevated creatinine after a percutaneous biopsy of her renal transplant. Sonography with Doppler was performed (figures 1A, 1B). This was followed by arteriography (figures 2A, 2B) and intervention (figure 2C). What is the most likely diagnosis?
Prepared by Charles Ariz, MD; Jade Wong-You Cheong, MD; and
Geoffrey Hastings, MD, Department of Radiology, University of
Maryland, Baltimore, MD.
A 53-year-old woman presented with hematuria and elevated
creatinine after a percutaneous biopsy of her renal transplant.
Sonography with Doppler was performed (figures 1A, 1B). This was
followed by arteriography (figures 2A, 2B) and intervention (figure
2C). What is the most likely diagnosis?
Post-biopsy arteriovenous fistula (AVF) in a renal transplant
It is not uncommon for traumatic arteriovenous fistulae to
develop after percutaneous biopsy of renal transplants. As a result
of the cutting needle, a direct communication is formed between an
intrarenal artery and vein. Patients are most commonly asymptomatic
but may present with new onset hematuria, pain, or elevation in
creatinine. Most small AVFs resolve spontaneously without
intervention. Less commonly, AVF may cause renal hypertension or
high output cardiac failure.
Gray-scale sonography typically demonstrates no abnormalities.
Color and duplex Doppler are invaluable in making this diagnosis,
demonstrating a characteristic pattern of findings. Increased
arterial diastolic velocities occur as a result of the abnormal
arteriovenous communication and the low resistance to arterial
flow. Increased velocities are also observed within the draining
vein, as is a pulsatile waveform resulting in an arterialized
appearance. Localized turbulent venous flow often is present at the
site of the AVF, causing vibration of the perivascular soft tissue.
This causes random assignment of color Doppler in the soft tissue
in the immediate vicinity of the AVF, known as a perivascular bruit
Selective renal arteriography is effective in demonstrating
direct AV communication within the post-biopsy renal allograft.
Most asymptomatic patients are managed conservatively, and the
majority of these patients will have AVFs that close spontaneously.
When patients are symptomatic, super-selective embolization, done
as part of the arteriography procedure, is the preferred treatment
option and enjoys a high rate of success. A variety of embolization
materials have been employed, including micro-coils and gelfoam, as
used in this case. The goal of treatment is permanent cessation of
flow within the AVF with minimal sacrifice of renal parenchyma.
1. Castaneda-Zuniga WR, Tadavarthy SM, Young AT, et
Interventional Radiology, vol 1, pp 45-46. Baltimore, Williams
& Wilkins, 1992.
2. Kurtz AB, Middleton WD:
Ultrasound: The Requisites, pp 482-483. St Louis, Mosby, 1995.
3. Matsell DG, Jones DP, Boulden TF, et al:
Arteriovenous fistula after biopsy of renal transplant kidney:
Diagnosis and treatment. Pediatr Nephrol 6:562-564, 1992.
4. Middleton WD, Kellman GM, Melson GL, Madrazo
Postbiopsy renal transplant arteriovenous fistulas: Color Doppler
and US characteristics. Radiology 171:253-257, 1989.