laceration of the lumbar artery during renal biopsy has been reported only in four instances .
a 58-year - old lady presented with swelling of face that progressed to involve abdomen and feet , along with oliguria , cola colored urine and breathlessness on minimal exertion . on examination , she had puffiness of eyelids and swelling of feet .
cardiovascular examination revealed left ventricular third sound and respiratory system examination revealed bilateral crackles in infrascapular areas .
investigations showed hemoglobin of 12.1 g / dl , platelet count 2.57 lakhs / cumm , random blood glucose 82 mg / dl , blood urea 88 mg / dl , serum creatinine 5.63 mg / dl , total serum proteins 7.8 g / dl , and albumin 4.0 g / dl .
urinalysis revealed albumin : + , red blood cells : 1012/hpf , and red blood cell casts .
the 24 h urine protein was 1.1 g , total cholesterol 258 mg / dl , antistreptolysin o > 400 u / l , complement 3 435 mg / l ( reference range : 10321495 mg / l ) , and complement 4 150 mg / l ( reference range : 167385 mg / l ) .
patient was subjected to a renal biopsy with a 16 gauge automated spring - loaded biopsy gun with length for sample notch being 1.6 cm and a possible penetration depth of 22 mm ( bard biopty systems , usa ) .
after second pass , the patient complained of pain from the biopsy site to the left flank and anterior abdomen .
the radiologist noticed the appearance of an echogenic band around left kidney and in the muscular planes .
a computerized tomography scan of abdomen revealed left perinephric collection of 1200 ml and heterogenous collection in left lumbar region [ supplementary figure 1 ] .
angiogram revealed a focal active contrast extravasation from arcuate or interlobular artery in lower pole of left kidney and from lumbar artery at third lumbar vertebra [ supplementary figure 2 ] .
her blood pressure fell to 80/60 mmhg from the pre - biopsy reading of 140/100 mmhg , and the hemoglobin dropped to 8.1 g / dl .
right femoral artery was cannulated with a cordis 6.0f femoral sheath , into which a judkin 's diagnostic catheter 5.0f was passed . into this catheter , floppy percutaneous transluminal coronary angioplasty guidewire , 0.014 inch in diameter and 300 cm in length
the bleeding site was approximately 10.5 cm away from the vertebral column [ figure 1 and supplementary figure 3 ] . over this guidewire , a micro catheter , 2.25f and 130 cm in length ( asahiintecc )
gelfoam was injected so as to occlude the bleeding site [ supplementary figure 5 ] .
computed tomography scan abdomen : bleeding from lumbar artery ct showing angiogram : bleeding from lumbar artery angiogram : bleeding from lumbar artery renal angiogram : no bleeding in the kidney 2.25f micro catheter introduced into lumbar artery lumbar artery embolized with gelfoam
usually , four on each side [ figure 2 ] , they arise posterolaterally from the aorta opposite the lumbar vertebrae . a fifth
, smaller pair occasionally from the median sacral artery but lumbar branches of the iliolumbar arteries usually takes their place .
the lumbar arteries posterolaterally on the four upper lumbar vertebral bodies , behind the sympathetic trunks , to intervals between the lumbar transverse processes and continue into the abdominal wall .
the right arteries pass posterior to the inferior vena cava ; the upper two right and first left are also posterior to the corresponding crus .
arteries of both sides pass under tendinous arches ( which span the lateral cavities of the vertebral bodies ) for attachment of psoas major , proceeding posterior to the muscle and the lumbar plexus .
they then cross the quadratus lumborum , the upper three posterior , the last usually anterior to it . at its lateral border
, they pierce the posterior aponeurosis of the transversus abdominis , advancing between it and the internal oblique .
they anastomose with one another and the lower posterior intercostal , subcostal , iliolumbar , deep circumflex iliac and inferior epigastric arteries . as the upper three pairs of lumbar arteries
pass behind the quadratus lumborum , they are at risk injury from the renal biopsy needle .
anatomy of lumbar arteries ( 14 ) in the two previous reports [ table 1 ] , the presence of bleeding sites and arteriovenous fistula in kidney has misled and the laceration of the lumbar artery was missed .
there was a delay of 20 h and 48 h in these two patients respectively before the laceration of the lumbar artery was recognized .
previous reports of hemorrhage from lumbar artery following percutaneous renal biopsy embolization of lumbar artery is fraught with the risk of infarction of the spinal cord .
the artery of adamkiewicz ( or great anterior radiculomedullary artery or arteria radicularis anterior magna ) is the dominant thoracolumbar segmental artery that supplies the spinal cord .
this artery has a variable origin ; but most commonly arises on the left ( ~80% ) at the level of 912 intercostal artery ( ~70% ) .
it arises from the radiculomedullary branch of the posterior branch of the intercostal or lumbar artery , which arises from the thoracic or abdominal aorta respectively .
the variations of its origin include from lumbar arteries at the level of l1 or l2 ( 10% ) , intercostal arteries at the level of t5 to t8 ( 15% ) and arises on the right ( 20% )
. the injection of gelfoam and placement of coils should be done only after considering all these variations in the origin of this artery .
the use of liquid embolization materials is also contraindicated due to higher risk of spinal cord injury .
the lumbar artery embolization has been reported to have caused infarction of paraspinal muscles in two patients .
bleeding from lumbar artery is a rare complication but can be successfully managed with prompt recognition and intervention .
 we present a 58-year - old lady who underwent ultrasound - guided renal biopsy for suspected acute glomerulonephritis . within minutes , the radiologist noticed an echogenic band around left kidney and in the muscular planes . 
 computerized tomography revealed focal active contrast extravasation from arcuate or interlobular artery in lower pole of left kidney and lumbar artery at third lumbar vertebra . 
 the bleeding vessel was occluded with gelfoam . 