Endovascular management of an unsual case of spontaneous Retroperitoneal Haemorrhage due to Fibromuscular Dysplasia

Abstract

Background: Fibromuscular dysplasia (FMD) is an uncommon vascular disease that results in stenosis, dissection or aneurysmal degeneration. However, it can sometimes manifest atypically, as we show in this case.

Case presentation: A 24-year old patient with no relevant medical history with severe left hypochondrium pain. The physical examination showed blood pressure levels of 160/90 mmHg. An abdominopelvic CT evidenced left retroperitoneal haematoma associated with active bleeding and left renal artery stenosis. Given these findings, it was decided to perform an endovascular treatment. Significant stenosis was seen during the arteriography in both renal arteries, suggesting fibromuscular dysplasia and development of a collateral neovascular network responsible for the retroperitoneal haematoma. It was embolised in association with angioplasty of the left renal artery. The patient had a favourable outcome; however, high blood pressure levels persisted. A new bilateral renal angioplasty was performed, which returned blood pressure values to normal. The patient was discharged without needing antihypertensives.

Conclusions: FMD is a rare disease that can show multiple clinical presentations and need individualized treatment options. Endovascular techniques are in the first therapeutic line regarding fibromuscular dysplasia.

Keywords: Angioplasty; Embolization; Fibromuscular dysplasia; Retroperitoneal haematoma.

Fig. 1

a Angio-CT, coronal plane. Left retroperitoneal haematoma (white arrowheads), with active bleeding inside (black asterisk). b Selective arteriography of the left renal artery, with contrast extravasation (black arrowhead) dependent on vascular network, and stenosis of the renal artery (white arrow). c Embolisation material in the vascular network (white arrow), new contrast extravasation point dependent on adrenal aortic branch (black arrowhead). d Control after embolisation and angioplasty, without identifying contrast extravasation points and with partial recovery of the stenosis (white arrow)

Fig. 2

a Stenosis of the right renal artery (black arrowhead) with string of beads appearance (white arrow). b Pre-treatment aortogram with stenosis of both renal arteries (white arrowhead). c Aortogram after bilateral angioplasty, with resolution of the stenosis