Contrast-enhanced ultrasonography as an adjunct to angiography for renal arterial bleeding: a four-case series

BACKGROUND: Renal artery bleeding is an uncommon but clinically important complication of surgery, percutaneous procedures, and trauma. Computed tomography (CT) is commonly used; however, indeterminate findings or concerns regarding iodinated contrast can delay hemostasis in some cases. Bedside contrast-enhanced ultrasonography (CEUS) may provide real-time information to support triage to angiography and embolization. CASE PRESENTATION: We describe four hemodynamically stable patients: post-nephrectomy, post-percutaneous nephrolithotomy, post-biopsy, and blunt trauma. CT was indeterminate in two cases and deliberately omitted in two cases to avoid delay or contrast exposure. CEUS demonstrated focal contrast pooling, pooling with associated leakage, or jet-like extravasation, helping to localize the suspected culprit branch and supporting subsequent digital subtraction angiography. Superselective coil embolization achieved angiographic stasis in all patients, with no rebleeding during the index admission. Follow-up CEUS at 48 h demonstrated findings consistent with hemostasis, and interval CT showed expected hematoma evolution without residual pseudoaneurysm. CONCLUSION: CEUS served as a bedside adjunct decision-support tool across diverse etiologies when CT results were equivocal or deferred, facilitating angiography referral and potentially contributing to timely hemostasis while preserving uninvolved renal parenchyma. This case series demonstrates concordant findings between CEUS and angiography and supports the potential role of CEUS-guided triage for acute renal arterial bleeding.