PMC4360528_01
a Abdominal contrast-enhanced computer-tomography image. A large tumor was observed in the left renal upper pole with fat attenuation suggesting AML. A massive intratumoral hemorrhage was visualized as an enhanced area (arrow). b Left renal angiography (early phase). The tumor-feeding branch of the left renal artery contained several aneurysms. The outermost aneurysm had ruptured and contrast agent was extravasated into the hematoma (arrow). c Left renal angiography (parenchymal phase). The hematoma was immediately filled with contrast agent that flowed counter-clockwise (arrows) and rapidly exited the hematoma via the left renal vein (arrowheads). d Left renal angiography after embolization. After embolization, angiography showed no evidence of arterial bleeding, hematoma, or early venous return. The normal renal parenchyma was preserved.
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F1
AML (fig. 1a). An intratumoral hematoma measuring 7 cm in diameter was equally enhanced with the artery during the arterial phase of a dynamic study. The outermost aneurysm had ruptured into the tumor, causing an intratumoral hematoma to form (fig. 1b). The blood flowed counter-clockwise within the intratumoral hematoma and moved from the hematoma to the left renal vein and inferior vena cava in a manner that hemodynamically resembled a high-flow renal AV fistula (fig. 1c). Left renal arteriography after embolization showed only minor leakage into the hematoma and no embolization of the normal renal parenchyma (fig. 1d).
PMC4360528_02
a Abdominal three-dimensional CT angiography image. The tumor-feeding branch of the left renal artery with the aneurysm (white arrow). The aneurysm had ruptured both into the right side of the tumor, resulting in the formation of an intratumoral hematoma (gray arrow), and into the left side of a peritumoral vein, resulting in early venous return (white arrowheads). b Left renal angiography (early phase). An aneurysm of the tumor-feeding artery (white arrow) had ruptured both into the right side of the tumor, resulting in the formation of an intratumoral hematoma (black arrowheads), and into the left side of a peritumoral vein, resulting in early venous return (white arrowheads). c Left renal angiography after embolization. After embolization, the tumor, tumor-feeding artery, aneurysm, and AV fistula were not observed. The normal renal parenchyma was preserved.
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F2
Abdominal three-dimensional CT angiography image showed a large left renal AML (12 x 11 x 9 cm) containing a ruptured intratumoral aneurysm that was producing both an intratumoral hematoma (fig. 2a) and an AV fistula with early venous return. Left renal angiography confirmed the presence of a ruptured intratumoral aneurysm creating the AV fistula (fig. 2b). Left renal angiography after embolization showed that the ruptured aneurysm and AV fistula had been successfully embolized without embolization of the normal renal parenchyma (fig. 2c).