Idiopathic renal arteriovenous fistula demonstrating a huge aneurysm with a high risk of rupture: report of a case

Endovascular treatment of a giant renal artery aneurysm associated with an arteriovenous fistula: Report of a case and review of the literature

Renal artery aneurysm (RAA) concomitant with a renal arteriovenous fistula (RAVF) has been infrequently reported in the literature. We report a case of a 42-year-old man suffering from a giant RAA combined with a congenital high-flow RAVF. The contrast-enhanced CTA showed a 12.7-cm RAA synchronous with an RAVF between the right renal artery and a draining vein. After a comprehensive preoperative assessment, an endovascular approach was decided. Successful embolization was performed using an Amplatzer vascular Plug, and multiple coils. Completion angiogram demonstrated no flow into the RAA. The results of longterm follow-up demonstrate that endovascular techniques are safe and effective for the management of RAAs combined with high-flow RAVF.

Endovascular Occlusion of a Renal Arteriovenous Fistula with Renal Vein Aneurysm Formation for Rupture Prevention

Purpose

To report the effectiveness of left renal artery (LRA) occlusion using Amplatzer Vascular Plug (AVP) II as treatment for a high-flow renal arteriovenous fistula (RAVF) with multiple renal vein aneurysms (RVA) to prevent aneurysm rupture and cardiac decompensation.

Case Report

A 59-year-old female suffering from a post-traumatic RAVF presented with tachycardia and increased cardiac output (CO). Doppler ultrasonography and computed tomography (CT) scan revealed a high-flow RAVF with multiple RVAs and unilateral critically reduced kidney function. Appreciating recent interventional therapeutic advances, the patient was treated with endovascular placement of AVP II into the left renal artery (LRA) resulting in complete occlusion of the RAVF to effectively reduce the risk of RVA rupture and cardiac decompensation. No anti-platelet medication was administrated after the occlusion of the LRA. The patient's physical capacity improved since right heart volume strain was normalized, and CO was reduced.

Conclusion

Transbrachial AVP II occlusion of the LRA is effective to occlude high-flow RAVFs to prevent risk of life-threatening RVA rupture. Additional follow-up is warranted to verify long-term effectiveness of this approach.

Renal arteriovenous malformation mimicking hydronephrosis-hidden danger

Renal arteriovenous malformations (AVMs) are rare, with an incidence of approximately 0.04%. Diagnosis is often challenging due to mimics of AVMs. We report a case of renal AVM mimicking hydronephrosis on ultrasound and unenhanced computed tomography (CT). A 24-year-old female with background of recurrent urinary tract infections (UTIs) presented to the Accident and Emergency department with 1 day history of bilateral flank pain, dysuria, rigors and pyrexia. Urine dipstick showed microscopic haematuria and blood tests showed mild neutrophilia. Dilated right renal pelvis was seen on ultrasound. Unenhanced CT of the urinary tract demonstrated right hydronephrosis with no evidence of calculi. Subsequent Uro-radiology meeting discussion concluded that renal pelvis might be pus-filled and recommended an urgent nephrostomy. However, ultrasound Doppler scan performed at the time of the planned nephrostomy demonstrated colour flow within dilated renal pelvis suggestive of an AVM. Nephrostomy was abandoned and subsequent CT angiogram confirmed a large congenital AVM. The patient was referred for embolization.Colour flow ultrasound imaging is a simple and quick technique to diagnose AVMs. However, as in our case, when colour flow Doppler imaging was not used at the initial ultrasound, the opportunity to obtain an accurate diagnosis was missed. If the subsequently planned nephrostomy had taken place, this may have led to potentially serious outcomes. We suggest that colour flow imaging should be used prior to nephrostomy insertion to differentiate hydronephrosis from vascular abnormalities.

[RENAL ARTERIOVENOUS FISTULA (ANEURYSMAL TYPE) TREATED BY NEPHRECTOMY UNDER BALLOON CATHETER OCCLUSION OF RENAL ARTERY: A CASE REPORT]

A 60-year-old man presented with leg edema and shortness of breath. He was being treated with medication for chronic heart failure for the past 3 years and had been in a traffic accident when he was 13 years old. Computed tomography showed a huge right renal arteriovenous fistula (AVF). The right renal artery measured 16 mm in diameter, the renal aneurysm was observed to be 60 mm, renal vein 87 mm, and the inferior vena cava 60 mm in diameter. His high-output heart failure was attributed to his right renal AVF, for which treatment was deemed necessary. Due to the risk of pulmonary embolism associated with transcatheter arterial embolization, we performed a nephrectomy with temporary interruption of renal blood flow using a balloon catheter. He was observed to be asymptomatic immediately after surgery.

En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy: A Double-institutional Analysis of Safety and Efficacy

OBJECTIVE

To explore the safety and efficacy of en bloc stapling of the renal hilum (EBSH) during laparoscopic nephrectomy (LNx) in a large double-institution cohort with an extended follow-up period.

METHODS

We performed a retrospective review of patients undergoing LNx with EBSH between 2008 and 2014 at 2 academic medical centers. Data analyzed included tumor size, tumor pathology, operative time, estimated blood loss, and perioperative or postoperative complications. Evaluation of arteriovenous fistula (AVF) formation was assessed by postoperative imaging studies, physical examination, or new-onset diastolic hypertension.

RESULTS

A total of 428 patients (mean age: 63 years) underwent LNx, of which there were a total of 433 renal units with EBSH (226 left renal units, 207 right renal units). Mean operative time was 169 minutes (range: 51-489 minutes). Mean estimated blood loss was 155 mL (range: 5 mL-2000 mL). Mean tumor size was 5.6 cm (range: 0.9-14.5 cm). EBSH was performed on 69 patients with chronic infectious and inflammatory benign conditions. Three hundred (70%) patients received post-procedural imaging. No patients developed clinical or radiographic evidence of AVF at a mean follow-up of 51 months.

CONCLUSION

EBSH during LNx is efficient, effective, and safe. This large series lends further support that EBSH during LNx may not be associated with any significant risk of AVF formation at extended follow-up. We advocate that this technique is a safe alternative to ligating the renal artery and vein during LNx.

Giant idiopathic renal arteriovenous fistula managed by coils and amplatzer device: Case report and literature review

An idiopathic renal arteriovenous (AV) fistula is a rare malformation of the kidney that may present insidiously with heart failure or hematuria. The treatment may be challenging due to large fistula size that may limit endovascular management. The authors report a case of an 85-year-old Caucasian woman who presented with acute heart failure and was found to have a right renal AV fistula. Since she had no prior history of renal intervention or trauma, a diagnosis of idiopathic renal AV fistula was made. She was managed by endoluminal occlusion using multiple stainless steel coils and Amplatzer vascular plug II device. The follow-up computed tomography showed complete occlusion of the fistula. This report highlights the late presentation of this rare disease and presents the utility of the combination of coils and Amplatzer device for management of a large fistula. It also reiterates that even if large, these fistulas can be managed by endovascular occlusion.

Successful Intervention for High-Output Cardiac Failure Caused by Massive Renal Arteriovenous Fistula

Renal arteriovenous fistula is a rare clinical entity that may produce high-output cardiac failure. This report describes the case of an 81-year-old woman in whom recurrent episodes of congestive heart failure developed over a relatively short time. A massive renal arteriovenous fistula was visualized by CT scan and arteriography. Successful embolization was performed under hemodynamic monitoring with complete resolution of the patient’s symptoms.

Heart failure caused by renal arteriovenous fistula with giant renal artery aneurysms

We encountered an extremely rare case of a renal arteriovenous fistula (AVF) with 2 giant renal artery aneurysms (RAAs) in a 75-year-old woman who presented with congestive heart failure and pulmonary hypertension. A chest x-ray revealed cardiomegaly with a cardiothoracic ratio (CTR) of 65%. Computed tomography showed 2 giant left RAAs (diameter, 45 × 40 mm(2) and 75 × 60 mm(2)) associated with an AVF, dilated inferior vena cava, and dilated pulmonary arteries. A radical nephrectomy was performed through a transverse laparotomy after the left renal vein, and arteries were dissected from the inferior vena cava and aorta, respectively. The patient's postoperative course was uneventful, and her condition improved. Her cardiomegaly was ameliorated, as manifested by a decrease in CTR to 57% and the absence of volume overload.

Management of renal arteriovenous malformations: A pictorial review

Background

Arteriovenous malformations (AVMs) are communications between an artery and a vein outside the capillary level. This pathologic communication may be either a fistula, a simple communication between a single artery and a dilated vein, or a more complex communication, a nidus of tortuous channels between one or more arteries/arterioles and one or more draining veins. The latter type of lesion is most frequently seen in the extremities; in the kidney they tend to appear more rarely. The most common clinical presentation of renal arteriovenous malformations (RAVMs) is haematuria. Percutaneous treatment with selective endovascular techniques offers a minimally invasive, nephron-sparing option in comparison to the more invasive surgical approaches. The purpose of this pictorial review is to highlight the general lines of management and to show the range of imaging findings of the percutaneous treatment of RAVMs.

Methods

The imaging characteristics of a selection of cases of percutaneously managed congenital RAVMs are presented and the most common lines of approach are discussed.

Conclusion

The imaging spectrum of diagnosis and percutaneous treatment of RAVMs is presented in order to aid interpretation and endovascular management.

Teaching points

• Renal arteriovenous malformations are very rare lesions.

• Clinical expression is usually haematuria.

• Diagnosis is made with CT or MRI but the gold standard is digital subtraction angiography.

• Catheter-directed treatment with the use of coils or liquid embolics is minimally invasive, safe and effective.

Renal cell carcinoma associated with incidental presentation of renal artery aneurysm: surgical management

The Renal Artery Aneurysm (RAA) is a relatively uncommon vascular lesion. A renal artery disease coexisting in patients with Renal Cell Carcinoma (RCC) is an even more infrequent clinical presentation. We reported on the treatment of a rare case of incidentally intraoperative renal artery aneurysm discovered during a nephron-sparing surgery for RCC. After the surgery the patient did not need hypertension therapy any longer. This event is well-known, in fact a number of possible contributions to a renin-mediated hypertension management has been postulated.

Therapeutic embolization of idiopathic renal arteriovenous fistula using the "stop-flow" technique

PURPOSE

To present a case of massive idiopathic arteriovenous fistula (AVF) successfully treated with an endovascular procedure.

CASE REPORT

A 42-year-old woman with microscopic hematuria was found to have a massive idiopathic renal AVF. Percutaneous embolization was undertaken using a dual approach to deliver an occluding balloon through the draining vein and an arterial access to selectively catheterize the aneurysmal afferent artery. With the balloon inflated to interrupt flow ("stop-flow" technique), acrylic glue was delivered precisely to occlude the lesion. Duplex scans at 12 months have documented continued complete occlusion of the anomalous communication.

CONCLUSIONS

The dual arterial and venous approach with the "stop-flow" technique makes it possible to successfully treat idiopathic AVFs that have constant high-flow connections.