Abstract Spontaneous renal rupture is a rare and catastrophic cause of intra-abdominal hemorrhage. While most cases arise from renal tumors, vascular malformations, or anticoagulation, rupture of a previously normal kidney is exceedingly uncommon particularly as an unexpected postoperative complication of coronary artery bypass grafting. Microembolization, transient ischemic insult, and anticoagulation following cardiac surgery may predispose susceptible renal microvasculature to parenchymal failure and abrupt hemorrhage. Because the presentation often overlaps with gastrointestinal or musculoskeletal pain syndromes, diagnosis may be delayed until profound hemodynamic instability occurs. Early imaging and rapid, coordinated multidisciplinary intervention are essential for survival. A 77 year old man with coronary artery disease, hypertension, diabetes, and hyperlipidemia, three weeks s/p CABG, presented with abrupt, severe left flank pain, nausea, and vomiting. He appeared acutely ill and diaphoretic, and rapidly developed profound hypotension, prompting immediate ICU admission for vasopressor support and massive transfusion. His hemoglobin declined sharply from his postoperative baseline. Multiphase CT angiography demonstrated complete left renal parenchymal disruption with large volume hemoperitoneum and active arterial extravasation. Despite aggressive resuscitation, anemia and shock progressed. Emergency angiography identified a lower-pole pseudoaneurysm, likely secondary to rupture of an ischemically weakened intrarenal vessel. Endovascular coil embolization achieved definitive hemostasis, allowing hemodynamic stabilization, liberation from vasopressors, and preservation of renal function. SRR accounts for 0.1% of renal emergencies. Although classically linked to angiomyolipoma and renal cell carcinoma, postoperative cardiac patients may be uniquely vulnerable due to microembolic events, transient renal ischemia-reperfusion injury, and anticoagulation-associated coagulopathy. When rupture occurs intraperitoneally, the absence of a confining retroperitoneal barrier allows rapid blood loss with early circulatory collapse. Thus, clinicians must maintain vigilance for renal hemorrhage in post CABG patients presenting with flank pain, dropping hemoglobin, or unexplained shock. Management centers on rapid hemorrhage control and resuscitation. Balanced transfusion strategies (1:1:1 red cells:plasma:platelets), avoidance of excessive crystalloid to prevent dilutional coagulopathy, and early recognition of shock physiology are paramount. Endovascular embolization now represents first-line therapy, offering hemostasis rates exceeding 90% while preserving renal tissue, supplanting historical emergency nephrectomy. This case highlights that spontaneous renal rupture, though extremely rare, may represent an under recognized complication of cardiac surgery, potentially mediated by embolic and ischemic renal injury. In high acuity postoperative cardiac patients, rapid activation of hemorrhage protocols and early endovascular intervention can decisively alter prognosis. This abstract is funded by: None
George et al. (Fri,) studied this question.