Rare complication of active renal arterial hemorrhage after extracorporeal shockwave lithotripsy (ESWL) in a low-risk patient: A case report

Renal calculi commonly present with flank pain or hematuria. Extracorporeal shockwave lithotripsy (ESWL) is a noninvasive treatment for kidney or proximal ureteral stones ≤10 mm, except in cases of obesity, pregnancy, coagulopathy, high stone attenuation on computerized tomography (CT), or abnormal renal anatomy. Rare complications include ureteral obstruction, urinary tract infection, and hemorrhage. This case report reviews a rare complication of active renal arterial hemorrhage after outpatient ESWL, requiring resuscitation and interventional radiology (IR). A 44-year-old Caucasian male presented to the emergency department (ED) with mild tachycardia, pallor, and significant right flank pain following an outpatient ESWL hours earlier. A point-of-care ultrasound demonstrated free fluid in the hepatorenal space. The initial non-contrast CT scan of the abdomen and pelvis revealed a large perinephric hematoma but possible extravasation. The CT of the abdomen and pelvis with contrast revealed active intrarenal arterial extravasation with extensive retroperitoneal hemorrhage and perinephric hematoma; his hemoglobin was 8.1 g/dL. The patient underwent emergent IR embolization and received five units of packed red blood cells during his stay at the intensive care unit (ICU). He was discharged on hospital day three. Less than 1% of cases report major vascular bleeding following an ESWL. Early recognition by the emergency medicine physician can help significantly decrease morbidity and mortality by initiating early multidisciplinary response through urology, IR, and intensive care.