図１３と図１４で尿管が描出されておりかなり晩期相の造影CTである．図４〜図１４の↑が腎実質で，3個以上に分離し深在性粉砕型の損傷 IIIcである．周囲の液貯留はややdensityが高く，不均一で血腫または血腫と尿の混合液であろう．腎実質に重ならない△はextravasation（出血）か腎外に漏出した尿か，尿管と大動脈が同等に造影されているので鑑別は容易ではない．尿管が造影されないearly phaseで認められればextravasation（出血）と診断できる．図８と図９で血腫がGerota筋膜外（傍腎腔）からIVCまで広がっており（※）H3と分類され，手術になる場合が多い．輸血と輸液にもかかわらず血圧が低下したので手術となり，左腎摘出術を施行した（図A）．

文献考察：AAST grade４と５で，Gerota筋膜を超える，または対側腎周囲腔まで広がる血腫例は血管造影の適応であり，TAEが有効な治療となる．
J Trauma. 2001 Sep;51(3):526-31.
The role of interventional radiology in the management of blunt renal injury: a practical protocol.
Hagiwara A, Sakaki S, Goto H, Takenega K, Fukushima H, Matuda H, Shimazaki S.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of a protocol designed to minimize the need for surgery in the management of severe blunt renal injury. METHODS: Forty-six of 752 trauma patients had evidence of renal injury on computed tomographic (CT) scan. Two patients required emergency laparotomy, and the remaining 44 patients were classified by CT scan grade using the American Association for the Surgery of Trauma classification system. Patients with CT scan grade 3 or over underwent renal angiography. RESULTS: Twenty-one patients had a high-grade injury on CT scan (> or =3). Eight had angiographic evidence of extravasation from renal arterial branches and underwent transarterial embolization. One patient with a grade 5 injury had extravasation from a main renal vein and underwent immediate laparotomy. This was the only patient who required surgery for renal injury. CONCLUSION: Surgery can be avoided in most cases of blunt renal injury. Hemodynamic instability and injury to main renal veins remain indications for surgical exploration.PMID: 11535904