Spectrum of Endovascular Embolization Techniques for the Treatment of Renal Vascular Lesions

• Abstract
• Introduction
• Clinical Features
• Imaging
• Arteriovenous Malformations and Arteriovenous Fistulas
• Aneurysms
• Traumatic Vascular Lesions
• Complications of Endovascular Management
• Conclusion
• References

Abstract

Renal vascular lesions are rare and often asymptomatic. They can be congenital or acquired. Congenital lesions include aneurysms, arteriovenous malformations (AVMs), and arteriovenous fistulas (AVFs). Acquired lesions are usually secondary to trauma or iatrogenic injury and include pseudoaneurysms, AVFs, and vessel transection. Management of renal vascular lesions depends on the location and type of the lesion. AVMs are managed by endovascular embolization of the nidus. It can be done by transarterial route when a single or a few arterial feeders are present. The transvenous route is preferred for complete obliteration of the nidus if multiple arterial feeders and a single collector vein are present. Liquid embolic agents are the preferred embolizing agents in AVMs. Congenital or acquired AVFs are managed by coil embolization. Superselective embolization using coils or n-butyl cyanoacrylate glue is the treatment of choice for aneurysms, pseudoaneurysms, and transections involving the segmental renal arteries. Aneurysms and pseudoaneurysms involving the main renal artery are treated by stent graft placement.

Introduction

Renal vascular lesions are rare, and they can be congenital or acquired. Congenital lesions include aneurysms, arteriovenous malformations (AVMs), and arteriovenous fistulas (AVFs). Acquired lesions are usually secondary to trauma or iatrogenic injury and include pseudoaneurysms, AVFs, and vessel transection. Symptomatic lesions require urgent treatment to prevent further clinical deterioration, and endovascular embolization is the preferred treatment choice for these lesions.

In this review, we aim to discuss the various techniques of endovascular embolization of vascular lesions of the kidney.

Clinical Features

The most common symptoms of congenital high-flow vascular lesions are hematuria and flank pain due to urinary tract obstruction by blood clots. They can often be asymptomatic and detected incidentally on abdominal imaging done for unrelated indications. High-output cardiac failure can rarely occur with large fistulas.[1] High-flow vascular shunts can impair renal function due to reduced perfusion of normal renal parenchyma.[2] Patients with renal artery aneurysms can present with abdominal pain or hematuria.[3] Resistant hypertension is seen in two-thirds of the patients with renal artery aneurysms, likely due to compression of renal arteries or turbulent flow within the aneurysm, resulting in renal hypoperfusion.[4] Traumatic and iatrogenic vascular lesions commonly present with hematuria and flank pain due to perirenal hematoma. Hemodynamic instability or a drop in hemoglobin following trauma to the flanks, renal surgery, or percutaneous renal interventions should raise the suspicion of renal vascular injury.

Imaging

Ultrasonography (USG) is often the initial imaging modality for evaluating patients with abdominal pain or hematuria. Although less sensitive in picking up small vascular lesions, USG helps diagnose the other more common causes of hematuria, such as renal calculi and renal masses. B-mode USG may reveal perinephric hematoma, which is seen as a hyperechoic fluid collection around the kidney. Patients with hematuria may have hyperechoic contents within the pelvicalyceal system, suggesting blood clots. Doppler examination is essential to pick up vascular lesions in patients with hematuria. Pseudoaneurysms show a typical “yin-yang” sign on color Doppler. In vascular shunts, spectral Doppler shows a low-resistance waveform in the artery and an arterialized pulsatile waveform in the draining vein.[5] Posttraumatic or iatrogenic AVFs appear as small areas of color flow aliasing in the periphery of the kidney. High-flow fistulas with significant shunting of blood flow may be associated with a dampened spectral waveform in the rest of the normal renal parenchyma.

Contrast-enhanced computed tomography (CT) is the primary imaging modality for diagnosing renal vascular lesions. Multiphasic CT angiography with arterial and venous phases acquisition and 1-mm thin-slice reconstruction is essential for arriving at a diagnosis. Early venous opacification in the arterial phase suggests a vascular shunt, and the nidus of an AVM is seen as a cluster of small vessels showing enhancement in the arterial phase. Pseudoaneurysm is seen as a contrast-filled outpouching, with the same contrast opacification as the feeding artery in all phases of acquisition. On the other hand, active contrast extravasation is seen as a pool of extravascular contrast that increases in density and size in the subsequent phases of acquisition.

Magnetic resonance imaging (MRI) is less commonly used for diagnosing renal vascular shunts. It can be used as a radiation-free alternative to CT in patients with hematuria. Vascular shunts are seen as tortuous flow voids in T1- and T2-weighted images. Features of vascular shunts in contrast-enhanced MRI are similar to those seen in CT.

Digital subtraction angiography (DSA) is the gold-standard imaging technique for detecting vascular lesions but is rarely used as a stand-alone diagnostic tool. DSA scores over the cross-sectional imaging modalities due to its high temporal resolution, which is helpful for the diagnosis and characterization of high-flow shunts. Common femoral artery or radial artery access is obtained, following which the renal artery is catheterized using an appropriately curved 4 or 5F angiographic catheter such as a renal double curve, Cobra, or Simmons catheter. An angiogram is obtained by injecting up to 12 mL of iodinated contrast into the renal artery at the rate of 3 to 4 mL/s.[6] A high frame rate of 7.5 to 10 frames per second helps accurately identify the feeding arteries and draining veins in a vascular shunt to plan endovascular embolization. It is the preferred first-line imaging modality in hemodynamically unstable patients with a high index of suspicion of renal vascular injury after percutaneous renal interventions. Delayed acquisition after contrast injection is essential to identify contrast extravasation. If the nonselective renal angiogram fails to reveal any abnormality, a superselective angiogram of the culprit segmental artery identified on CT should be performed using a microcatheter. In patients with suspected vascular injury following percutaneous nephrostomy, the initial angiogram may fail to reveal any vascular injury due to the tamponade effect of the catheter. In such cases, the angiogram should be repeated after removing the nephrostomy catheter over a guidewire.[7]

Arteriovenous Malformations and Arteriovenous Fistulas

AVMs are abnormal arteriovenous communications with an intervening tangle of small abnormal vessels called the nidus. AVMs can have single or multiple feeding arteries and draining veins. Although congenital, they usually present later in life.

Yakes classification system is used to classify AVMs depending on the presence of intervening nidus and the number and morphology of the draining veins.[8]

• Type I—direct fistula between the feeding artery and the draining vein

• Type IIa—typical AVM with an intervening nidus

• Type IIb—AVM with nidus draining into an aneurysmal vein

• Type IIIa—feeding arteries drain into a single dilated collector vein

• Type IIIb—dilated collector vein with multiple outflow veins

• Type IV—infiltrative AVM with intervening normal tissue.

AVMs are managed by endovascular embolization of the nidus. The transarterial route is the most commonly used approach for embolization and is associated with a high rate of clinical success.[9] [10] Liquid embolic agent, n-butyl cyanoacrylate (NBCA) glue, is the preferred embolizing agent in AVMs ([Fig. 1]). A 20 to 25% NBCA-ethiodized oil mixture will likely penetrate the nidus adequately. A high concentration of 50 to 75% NBCA is used when there are high-flow fistulae within the lesion, and proximal flow control by balloon occlusion of the feeding artery is helpful in such cases.[5] The embolic agent is injected in such a way that the origin of the draining vein is also embolized to reduce the risk of recurrence. Ethylene vinyl alcohol (EVOH) copolymer, which is commonly used for the treatment of cerebral AVMs, can also be used in renal AVMs with the added advantage of better penetration into the nidus as compared with NBCA glue ([Fig. 2]).[11] To prevent the reflux of EVOH into the feeding artery, the pressure cooker technique is used, in which a proximal plug is formed by placing coils or injecting 50% NBCA glue using a second microcatheter. Transarterial or percutaneous injection of alcohol, with or without coils, can also be used for obliteration of AVMs.[12] It is beneficial in AVMs with fine arterial feeders that are difficult to occlude using coils or liquid embolic agents. Care should be taken not to exceed the dose beyond 0.5 to 1 mL/kg to prevent the occurrence of acute pulmonary arterial hypertension.

The transvenous route is preferred for complete obliteration of the nidus if multiple arterial feeders are present. Lesions with a solitary draining vein are ideal for transvenous embolization ([Fig. 3]). After obtaining access into the draining vein, a microcatheter is advanced close to the nidus. Coils or vascular plugs are deployed downstream to the microcatheter tip using a second catheter or microcatheter to reduce the venous outflow (reverse pressure cooker technique). Subsequently, NBCA glue–Lipiodol mixture or low-viscosity EVOH copolymer is injected into the nidus through the microcatheter. The concentration of the NBCA glue–Lipiodol mixture depends on the rate of flow in the vein. Inducing hypotension also facilitates better penetration of the nidus. The high technical success rate, low recurrence rate, and reduced risk of ischemia to the normal renal parenchyma favor the use of the transvenous route over the transarterial route in lesions with suitable anatomy.[13]

AVFs can be congenital or acquired. They are primarily treated by embolization using coils or vascular plugs ([Fig. 4]). The use of detachable coils helps in better control during the deployment. Vascular plugs are used when the fistula is large or associated with very high flow. They are oversized by at least 30 to 50% of the target vessel size. AVF embolization can also be done using a highly concentrated (75%) NBCA glue–Lipiodol mixture with the help of pharmacologically induced hypotension that reduces the forward flow across the fistula and prevents glue migration ([Fig. 5]). The catheter or microcatheter used in such cases must have a tip that is shaped in such a way that it touches the vessel wall. This ensures that the NBCA glue cast adheres to the vessel wall during injection, reducing the risk of distal migration. AVFs involving the main renal artery and those with a short length of feeding artery can be treated by stent graft placement.[5]

Aneurysms

Renal artery aneurysms are rare and most commonly detected incidentally on imaging done for unrelated indications. They can develop secondary to atherosclerosis, vasculitis, fibromuscular dysplasia, and inherited connective tissue diseases such as Ehlers–Danlos' syndrome.[4]

Treatment is indicated in symptomatic aneurysms and asymptomatic ones >3 cm in diameter. Due to the high risk of rupture during pregnancy, treatment is indicated in all women of the childbearing age group, irrespective of the size of the aneurysm. Resistant hypertension is seen in a fraction of patients with renal artery aneurysms and is an indication for treatment.[4] Aneurysms of the segmental renal arteries are best treated by embolization of the parent artery by coils or liquid embolic agents. Management of aneurysms involving the hilar vessels distal to the main renal artery bifurcation is challenging. Narrow-neck saccular aneurysms can be treated by coil embolization of the sac. Wide-neck aneurysms, defined as a neck >4 mm in width or dome-to-neck ratio <2, require balloon or stent-assisted coiling. If the aneurysm involves the origins of multiple segmental arteries, preservation of these branches may not be possible, and total occlusion of the aneurysm along with the branches can be done if the contralateral kidney is normal ([Fig. 6]). Fusiform and wide-neck saccular aneurysms of the main renal artery are treated by stent graft placement, provided that there is an adequate landing zone proximal and distal to the aneurysm. Aneurysms involving the ostium or the distal bifurcation of the main renal artery are poor candidates for stent graft placement and are best treated by surgical repair.[14] Flow diverters used for treating intracranial aneurysms have also been employed for treating renal artery aneurysms. They offer the advantage of preserving flow into the renal artery branches arising from the treated segment while the aneurysm gets occluded.[15]

Traumatic Vascular Lesions

Renal vascular injuries can occur secondary to trauma or can be iatrogenic. Traumatic vascular injury has been incorporated into the American Association for the Surgery of Trauma Kidney Injury Scale in its 2018 revision. Vascular injury is visualized as active contrast extravasation, pseudoaneurysm, or AVF on imaging.[16] Endovascular embolization is the primary treatment option for renal trauma patients with vascular injury, active bleeding, or non-self-limiting hematuria who are hemodynamically stable and do not respond to fluid resuscitation.[17] Shattered kidneys without avulsion of the renal hilum can also be treated by superselective embolization of the bleeders.[18] Although operative management is preferred for hemodynamically unstable patients with renal vascular injury, embolization can also be performed in such cases unless there is a compelling indication for open surgery, such as penetrating trauma or bowel perforation.[19] [20]

Iatrogenic injury can occur following percutaneous interventions such as biopsy, nephrostomy, nephrolithotomy, and open renal surgery.[5] Hematuria persisting even after 48 hours, a significant drop in hemoglobin, or hemodynamic instability indicates arterial injury.[7] Endovascular embolization is an effective treatment option for iatrogenic renal artery injuries with high clinical success rates and low complication rates.[21] [22]

Superselective embolization using coils or NBCA glue is the treatment of choice for traumatic pseudoaneurysms and transections involving the segmental renal arteries ([Figs. 7] and [8]). Injury to the main renal artery is treated by stent-graft placement ([Fig. 9]). Main renal vein avulsion is, however, an indication for operative management.[17] Small pseudoaneurysms located along the periphery of the kidney can be embolized by ultrasound-guided percutaneous injection of thrombin or NBCA glue. Rarely, bleeding from multiple capsular arteries may occur secondary to the renal capsule getting stripped off from the cortex by subcapsular hemorrhage ([Fig. 10]). This phenomenon, termed the “weeping sponge kidney,” can occur following percutaneous interventions or wire perforation of the renal artery during endovascular interventions and can be treated by superselective endovascular embolization.[23] Injury to the intercostal or lumbar arteries can occur following percutaneous renal interventions ([Fig. 11]). A high index of suspicion should be kept for such injuries in patients who continue to remain hemodynamically unstable after embolization of the renal artery bleeder or in whom renal angiography fails to reveal any vascular injury.[22]

Complications of Endovascular Management

Various complications can rarely arise during endovascular embolization. Access site complications include hematoma and pseudoaneurysm formation. Catheterization-related complications include arterial dissection and wire perforation of the artery, and meticulous technique is essential in reducing the incidence of such complications. Iatrogenic dissection of the feeding artery can result in obliteration of the vascular lesion. However, as the dissection can spontaneously resolve and the feeding artery can get recanalized, follow-up imaging is necessary to document the complete obliteration of the lesion ([Fig. 12]). Embolization of the arteries supplying the normal parenchyma leads to renal infarcts and subsequent reduction in renal function ([Fig. 7C]). It can be prevented by superselective embolization of the target artery, sparing the branches supplying the normal parenchyma whenever possible.[1] The infarcted tissue can rarely get infected, leading to abscess formation. Migration of the embolizing agent into the pulmonary circulation is a concern in high-flow vascular shunts, and it can be prevented by inducing hypotension during embolization.

Conclusion

A multitude of endovascular treatment options is available for the management of renal vascular lesions. An approach to endovascular management of various renal vascular lesions is depicted in [Fig. 13]. Selection of the appropriate route and agent for embolization is necessary for optimum treatment of the lesion.

Conflict of Interest

None declared.

Note

This study has been presented as a poster at the annual conference of the Indian Society of Vascular and Interventional Radiology (ISVIR) held in Jaipur on January 11–14, 2024.

Authors' Contributions

M.C. worked as guarantor for the integrity of the entire study. V.P.P. and S.P. conceptualized and designed the study. V.P.P. also performed literature research. V.P.P., N.S.H., S.A.B., and S.U.R. prepared the manuscript. S.P., P.M., and M.C. edited the manuscript.

Ethical Approval

Ethical approval is not required as the article does not involve research on animal/human subjects.

• References

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  Search in Google Scholar
• 9 Eom HJ, Shin JH, Cho YJ, Nam DH, Ko GY, Yoon HK. Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up. Clin Radiol 2015; 70 (11) 1177-1184
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• 10 Murata S, Onozawa S, Nakazawa K. et al. Endovascular embolization strategy for renal arteriovenous malformations. Acta Radiol 2014; 55 (01) 71-77
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  PubMedSearch in Google Scholar
• 12 Hwang JH, Do YS, Park KB, Chung HH, Park HS, Hyun D. Embolization of congenital renal arteriovenous malformations using ethanol and coil depending on angiographic types. J Vasc Interv Radiol 2017; 28 (01) 64-70
  PubMedSearch in Google Scholar
• 13 Lee SY, Do YS, Kim CW, Park KB, Kim YH, Cho YJ. Efficacy and safety of transvenous embolization of type II renal arteriovenous malformations with coils. J Vasc Interv Radiol 2019; 30 (06) 807-812
  PubMedSearch in Google Scholar
• 14 Ghosh S, Dutta SK. Endovascular interventions in management of renal artery aneurysm. Br J Radiol 2021; 94 (1124): 20201151
  PubMedSearch in Google Scholar
• 15 Eldem G, Erdoğan E, Peynircioğlu B, Arat A, Balkancı F. Endovascular treatment of true renal artery aneurysms: a single center experience. Diagn Interv Radiol 2019; 25 (01) 62-70
  PubMedSearch in Google Scholar
• 16 Kozar RA, Crandall M, Shanmuganathan K. et al; AAST Patient Assessment Committee. Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg 2018; 85 (06) 1119-1122
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• 18 Kwon H, Bae M, Jeon CH, Hwangbo L, Lee CM, Kim CW. Volume preservation of a shattered kidney after blunt trauma by superselective renal artery embolization. Diagn Interv Radiol 2022; 28 (01) 72-78
  PubMedSearch in Google Scholar
• 19 Desai D, Ong M, Lah K, Clouston J, Pearch B, Gianduzzo T. Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals. ANZ J Surg 2020; 90 (09) 1705-1709
  PubMedSearch in Google Scholar
• 20 Brewer Jr ME, Strnad BT, Daley BJ. et al. Percutaneous embolization for the management of grade 5 renal trauma in hemodynamically unstable patients: initial experience. J Urol 2009; 181 (04) 1737-1741
  PubMedSearch in Google Scholar
• 21 Contegiacomo A, Amodeo EM, Cina A. et al. Renal artery embolization for iatrogenic renal vascular injuries management: 5 years' experience. Br J Radiol 2020; 93 (1106): 20190256
  PubMedSearch in Google Scholar
• 22 Haochen W, Jian W, Li S, Tianshi L, Xiaoqiang T, Yinghua Z. Superselective renal artery embolization for bleeding complications after percutaneous renal biopsy: a single-center experience. J Int Med Res 2019; 47 (04) 1649-1659
  PubMedSearch in Google Scholar
• 23 Hawthorn B, Kawa B, Cavenagh T. et al. Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage. Clin Radiol 2023; 78 (12) e1010-e1016
  PubMedSearch in Google Scholar

Address for correspondence

Publication History

Article published online:
04 June 2025

© 2025. Indian Radiological Association. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/)

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• References

• 1 Chimpiri AR, Natarajan B. Renal vascular lesions: diagnosis and endovascular management. Semin Intervent Radiol 2009; 26 (03) 253-261
  PubMedSearch in Google Scholar
• 2 Riedlinger WFJ, Kissane JM, Gibfried M, Liapis H. Congenital bilateral renal arteriovenous malformation: an unrecognized cause of renal failure. Pediatr Dev Pathol 2004; 7 (03) 285-289
  PubMedSearch in Google Scholar
• 3 Henke PK, Cardneau JD, Welling III TH. et al. Renal artery aneurysms: a 35-year clinical experience with 252 aneurysms in 168 patients. Ann Surg 2001; 234 (04) 454-462 , discussion 462–463
  PubMedSearch in Google Scholar
• 4 Chaer RA, Abularrage CJ, Coleman DM. et al. The Society for Vascular Surgery clinical practice guidelines on the management of visceral aneurysms. J Vasc Surg 2020; 72 (1S): 3S-39S
  CrossrefPubMedSearch in Google Scholar
• 5 Maruno M, Kiyosue H, Tanoue S. et al. Renal arteriovenous shunts: clinical features, imaging appearance, and transcatheter embolization based on angioarchitecture. Radiographics 2016; 36 (02) 580-595
  PubMedSearch in Google Scholar
• 6 Hatzidakis A, Rossi M, Mamoulakis C. et al. Management of renal arteriovenous malformations: a pictorial review. Insights Imaging 2014; 5 (04) 523-530
  CrossrefPubMedSearch in Google Scholar
• 7 Lessne ML, Holly B, Huang SY, Kim CY. Diagnosis and management of hemorrhagic complications of interventional radiology procedures. Semin Intervent Radiol 2015; 32 (02) 89-97
  PubMedSearch in Google Scholar
• 8 Yakes W., Baumgartner I. Interventional treatment of arterio-venous malformations. Gefässchirurgie 2014; 19: 325-330
  Search in Google Scholar
• 9 Eom HJ, Shin JH, Cho YJ, Nam DH, Ko GY, Yoon HK. Transarterial embolisation of renal arteriovenous malformation: safety and efficacy in 24 patients with follow-up. Clin Radiol 2015; 70 (11) 1177-1184
  PubMedSearch in Google Scholar
• 10 Murata S, Onozawa S, Nakazawa K. et al. Endovascular embolization strategy for renal arteriovenous malformations. Acta Radiol 2014; 55 (01) 71-77
  PubMedSearch in Google Scholar
• 11 Wetter A, Schlunz-Hendann M, Meila D, Rohde D, Brassel F. Endovascular treatment of a renal arteriovenous malformation with Onyx. Cardiovasc Intervent Radiol 2012; 35 (01) 211-214
  PubMedSearch in Google Scholar
• 12 Hwang JH, Do YS, Park KB, Chung HH, Park HS, Hyun D. Embolization of congenital renal arteriovenous malformations using ethanol and coil depending on angiographic types. J Vasc Interv Radiol 2017; 28 (01) 64-70
  PubMedSearch in Google Scholar
• 13 Lee SY, Do YS, Kim CW, Park KB, Kim YH, Cho YJ. Efficacy and safety of transvenous embolization of type II renal arteriovenous malformations with coils. J Vasc Interv Radiol 2019; 30 (06) 807-812
  PubMedSearch in Google Scholar
• 14 Ghosh S, Dutta SK. Endovascular interventions in management of renal artery aneurysm. Br J Radiol 2021; 94 (1124): 20201151
  PubMedSearch in Google Scholar
• 15 Eldem G, Erdoğan E, Peynircioğlu B, Arat A, Balkancı F. Endovascular treatment of true renal artery aneurysms: a single center experience. Diagn Interv Radiol 2019; 25 (01) 62-70
  PubMedSearch in Google Scholar
• 16 Kozar RA, Crandall M, Shanmuganathan K. et al; AAST Patient Assessment Committee. Organ injury scaling 2018 update: spleen, liver, and kidney. J Trauma Acute Care Surg 2018; 85 (06) 1119-1122
  CrossrefPubMedSearch in Google Scholar
• 17 Coccolini F, Moore EE, Kluger Y. et al; WSES-AAST Expert Panel. Kidney and uro-trauma: WSES-AAST guidelines. World J Emerg Surg 2019; 14: 54
  CrossrefPubMedSearch in Google Scholar
• 18 Kwon H, Bae M, Jeon CH, Hwangbo L, Lee CM, Kim CW. Volume preservation of a shattered kidney after blunt trauma by superselective renal artery embolization. Diagn Interv Radiol 2022; 28 (01) 72-78
  PubMedSearch in Google Scholar
• 19 Desai D, Ong M, Lah K, Clouston J, Pearch B, Gianduzzo T. Outcome of angioembolization for blunt renal trauma in haemodynamically unstable patients: 10-year analysis of Queensland public hospitals. ANZ J Surg 2020; 90 (09) 1705-1709
  PubMedSearch in Google Scholar
• 20 Brewer Jr ME, Strnad BT, Daley BJ. et al. Percutaneous embolization for the management of grade 5 renal trauma in hemodynamically unstable patients: initial experience. J Urol 2009; 181 (04) 1737-1741
  PubMedSearch in Google Scholar
• 21 Contegiacomo A, Amodeo EM, Cina A. et al. Renal artery embolization for iatrogenic renal vascular injuries management: 5 years' experience. Br J Radiol 2020; 93 (1106): 20190256
  PubMedSearch in Google Scholar
• 22 Haochen W, Jian W, Li S, Tianshi L, Xiaoqiang T, Yinghua Z. Superselective renal artery embolization for bleeding complications after percutaneous renal biopsy: a single-center experience. J Int Med Res 2019; 47 (04) 1649-1659
  PubMedSearch in Google Scholar
• 23 Hawthorn B, Kawa B, Cavenagh T. et al. Weeping sponge kidney: an unusual phenomenon that should be considered in cases of severe renal haemorrhage. Clin Radiol 2023; 78 (12) e1010-e1016
  PubMedSearch in Google Scholar