We report a case of a 54-year-old male patient with large polycystic kidneys who was admitted to our hospital for scheduled pretransplant open nephrectomy. The surgery was complex due to increased renal size, perinephric fibrosis and inflammation.
During the 5th postoperative day, a progressive drop of haemoglobin concentration down to 7.5 g/dl, requiring infusion of two units of packed red cells, was observed and the patient complained of strong flank pain. The fall in the haemoglobin level persisted despite transfusion.
A contrast-enhanced CT scan was performed and showed in the surgical site a right retroperitoneal haematoma measuring 12x9 cm and around collection of high-density extravascular contrast suggestive of pseudoaneurysm with contrast extravasation associated from right middle adrenal artery (Fig. 1-3).
The patient was referred to interventional radiology unit for diagnostic and therapeutic procedure. Non-selective abdominal angiography through a right femoral approach showed the pseudoaneurysm from right middle adrenal artery located in the right upper quadrant (Fig. 4). Then a selective catheterization of the middle adrenal artery (that comes directly from the aorta) was performed with a Simmons 1 catheter (Fig. 5).
The middle adrenal artery was catheterized distally with a microcatheter and occluded with 3 and 4mm fibered microcoils (Fig. 6). Control angiogram revealed permanent occlusion of the pseudoaneurysm and the middle adrenal artery (Fig. 7). After embolization, the hemodynamic status of the patient improved.
The successful outcome of adrenal embolization requires first of all the proper knowledge and interpretation of adrenal arteries anatomy. Arterial supply of the adrenal glands is usually supported by three arterial sources :
Because of this complex arterial supply, it is important to investigate all the potential sources of bleeding or vascular injury.
A pre-operative contrast-enhanced computed tomography with thin slice (0,65mm) and post-processing reconstructions is very important to acquire in order to make a final therapeutic decision and to planify the endovascular treatment, in our case we use the post-processing reconstructions to planify the therapeutic procedure, optimizing the interventional procedure and fluoroscopy time/radiation dose .
Embolising agent is adopted according to the type of vessel lesion and operator preference. We decided to embolize the middle adrenal artery with fibered microcoils in order to achieve a permanent proximal vessel occlusion with preservation of the distal and parenchymal circulation.
Knowledge of the arterial supply of the adrenal gland is mandatory for proper management of adrenal gland arteries injuries (pseudaneurysm, active bleeding, aneurysm, etc): Aortogram, identification of the differents adrenal arteries, check renal and phrenic arteries .
Compared to surgery, transarterial embolization of adrenal gland arteries is considered the less invasive method that has already proven to be safe and effective in managing adrenal haemorrhages.
Written informed patient consent for publication has been obtained.
 Fowler AM, Burda JF, Kim SK. Adrenal artery embolization: anatomy, indications, and technical considerations. American Journal of Roentgenology. 2013 201:1, 190-201. (PMID: 23789675).
 Giurazza F, Corvino F, Silvestre M, Cangiano G, Cavaglià E, Amodio F, De Magistris G, Frauenfelder G, Niola R. Adrenal glands hemorrhages: embolization in acute setting. Gland Surg. 2019 Apr;8(2):115-122. (PMID: 31183321).
 Ierardi AM, Petrillo M, Patella F, Biondetti P, Fumarola EM, Angileri SA, Pesapane F, Pinto A, Dionigi G, Carrafiello G. Interventional radiology of the adrenal glands: current status. Gland Surg. 2018 Apr;7(2):147-165. (PMID: 29770310).