Percutaneous rheolytic thrombectomy for treatment of acute renal-artery thrombosis

Significant Calcification of an Entire Aortic Tree with Renal Artery Subocclusion: Acute Kidney Injury, Ischemic Kidney Disease, and the Tissue Viability Question-A Case Report

BACKGROUND

Undiagnosed and untreated atherosclerotic renal artery stenosis (ARAS) can result in end-stage kidney disease (ESKD). To obtain an accurate diagnosis, it is crucial to recognize the symptoms and signs suggesting renal artery stenosis (RAS) and perform appropriate diagnostic and treatment procedures afterward.

CASE PRESENTATION

We present a case of a 60-year-old female patient with hypertensive crisis, acute heart failure (HF), and pulmonary edema as the initial signs of acute kidney injury (AKI) caused by right RAS and left renal artery occlusion in the presence of severe aortic atherosclerosis revealed on computed tomography angiography (CTA) of the abdomen. The patient's renal function recovered completely following percutaneous transluminal angioplasty (PTA) with stent implantation in the right renal artery at the site of subocclusion.

CONCLUSIONS

Even in patients with concomitant disorders like type-2 diabetes mellitus (T2DM), hypertension (HTN), or HF, the dilatation of significantly narrowed renal arteries due to severe calcifications can result in complete renal function recovery.

Vacuum-Assisted Thrombo-Aspiration for Paradoxical Embolism in Left Renal Artery: A Case Report and Literature Review

Paradoxical embolism through the foramen ovale is a rare and devastating event requiring urgent treatment. Herein, we present the case of a 23-year-old male who presented with a pulmonary embolism complicated by a left renal artery paradoxical embolism. Urgent vacuum-assisted thrombo-aspiration restored normal perfusion of the left kidney within 5 hours. The patient had a patent foramen ovale and heterozygous thrombophilia. However, a radioisotopic scan performed 2 years later revealed an unexpected decrease in left renal perfusion. Therefore, despite the angiographic success, functional evaluation using a renal scan should be performed to assess renal function.

Renal infarction in a patient with thyrotoxicosis-induced atrial fibrillation treated successfully with dabigatran, a case report and literature review

Renal infarction is an underdiagnosed condition with multiple possible causes, including atrial fibrillation. The treatment approach includes percutaneous endovascular therapy (PET) to restore blood flow, antiplatelet therapy, anticoagulation, or combination therapy, depending on the patient's status and available modalities. Warfarin is the standard anticoagulation therapy, although direct oral anticoagulation (DOAC) therapy is getting more popular. Here, we present a 60-year-old male patient with hyperthyroidism complicated by acute renal infarction, which was successfully treated with dabigatran, evident by non-recurrence and restoration of blood flow in a follow-up CT angiogram. This case report may open the door for the use of DOAC in acute renal infarction though more studies are needed to prove the efficacy.

Role of late renal revascularization in functional renal salvage

The duration that renal parenchyma will tolerate ischemia has continued to be debated. We have reported the cases of three patients who had undergone revascularization procedures with successful return of baseline renal function after prolonged renal artery occlusion of 14 days to 3 months. These cases highlight that aggressive revascularization can lead to successful renal salvage in selected patients. We examined the characteristics of these patients and those of others in the literature and reviewed the factors favoring recovery.

When Bodybuilding Goes Wrong—Bilateral Renal Artery Thrombosis in a Long-Term Misuser of Anabolic Steroids Treated with AngioJet Rheolytic Thrombectomy

Bilateral renal infarction is an extremely rare condition with only few cases reported in the literature. We present a case of bilateral renal infarction affecting an otherwise healthy 34 year old bodybuilder chronically misusing testosterone and stanozolol. The patient presented with severe flank pain mimicking renal colic and biochemical features of acute kidney injury. Diagnostic workup revealed thrombosis affecting both renal arteries. Subsequently, the patient underwent a percutaneous rheolytic thrombectomy with AngioJet catheter, along with catheter-directed thrombolysis. Right-sided retroperitoneal hematoma developed as an early complication, mandating surgical exploration and nephrectomy due to kidney rupture and the unstable condition of the patient. Intensive care and continuous renal replacement therapy were instigated until a gradual improvement of the patient status and a return of kidney function was achieved. No abnormalities were found in the cardiological and hematological evaluation. We believe this is a first report of bilateral renal infarction associated with anabolic steroid misuse in an otherwise healthy individual, and a first report of AngioJet thrombectomy in bilateral thrombosis of renal arteries. It stresses the importance of a thorough diagnostic workup of colic patients and emphasizes the need for sports medicine to reach out to amateur athletes with education on the harms of doping.

Bilateral Acute Renal Infarction Due to Paradoxical Embolism in a Patient with Eisenmenger Syndrome and a Ventricular Septal Defect

A 52-year-old man who was diagnosed with Eisenmenger syndrome due to a muscular-type ventricular septal defect 30 years previously, visited our emergency room after experiencing six hours of severe left flank pain and vomiting. On laboratory examination, azotemia and microscopic haematuria were identified. Contrast-enhanced computed tomography also revealed pulmonary embolism (PE) and bilateral acute renal infarction. The flank pain resolved after heparin was administered for anti-coagulation and aspiration thrombectomy was performed. The patient was discharged on warfarin as anticoagulant therapy. In this case, a paradoxical embolism was considered to have been the cause of PE and bilateral acute renal infarction in a patient with Eisenmenger syndrome.

Percutaneous Catheter Thrombus Aspiration of Right Renal Infarction Caused by Left Ventricular Thrombi due to Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is a temporal dysfunction of the left ventricle (LV) due to psychological or physiological stress; however, it rarely causes LV thrombus. We report a case of a 49-year-old woman who developed LV thrombi due to TC despite anticoagulation therapy. The thrombi caused acute systemic infarction, with the most severe occlusion being in the right renal artery. The patient underwent percutaneous catheter aspiration thrombectomy of the right renal artery and her renal function recovered shortly after. The results of this case suggest that catheter aspiration thrombectomy is effective in the treatment of thromboembolism in TC.

Rheolytic Thrombectomy with AngioJet® Is Safe and Effective in Revascularization of Renal Arteries' Acute Occlusion on Previous Complex Aortic Endovascular Repair

Acute occlusion of the visceral arteries is a threatening complication following branched endovascular aortic repair (EVAR). Its prompt diagnosis and treatment are mandatory to restore renal function. Several techniques have been used to manage this complication. We report 2 clinical cases of patients, previously treated with implantation of an off-the-shelf thoracoabdominal aortic endograft, with acute bilateral occlusion of the renal arteries. Both patients were successfully treated with AngioJet rheolytic thrombectomy. Acute occlusion of the renal arteries can dramatically complicate the outcome of patients treated with branched EVAR. Prompt diagnosis and treatment are required. Rheolytic thrombectomy rapidly removes intra-arterial thrombus through Bernoulli effect, preventing the risk of distal embolization and rapidly restoring the renal function.

Initial Experience With the 6-F and 8-F Indigo Thrombectomy System for Acute Renovisceral Occlusive Events

PURPOSE

To examine the safety and effectiveness of the new large-bore Indigo thrombectomy catheters to treat patients with acute renovisceral occlusion without the need of thrombolytic agents.

METHODS

Between November 2015 and 2016, 7 consecutive patients (mean age 65±5 years; 5 men) with acute renovisceral artery occlusion were treated with the new large-bore (6-F and 8-F) vacuum-assisted thrombectomy catheters. The occluded vessels were 6 renal arteries and 3 superior mesenteric arteries (SMAs); 5 of the 9 thromboses were in bridging stent-grafts associated with branched endografts. Mean lesion length was 63±36 mm. For the SMA and all bridging stent-grafts, 8-F catheters are routinely used through a brachial access, whereas 6-F aspiration catheters were used in native renal arteries. Technical success was defined as restoration of antegrade blood flow without the need of lysis or alternative thrombectomy/revascularization strategies. Safety endpoints were any in-hospital major adverse events. Pre- and postoperative hemoglobin and hematocrit levels were compared.

RESULTS

Technical success was 100% with no major adverse events or fatal bleeding. The mean amount of aspirated blood was 219±97 mL. The mean hemoglobin and hematocrit values were 13.1±2.1 g/dL and 39%±6% prior to and 11.6±2.2 g/dL (p=0.001) and 34%±6% (p<0.0001) directly after the intervention, respectively.

CONCLUSION

The first assessment of the new large-bore Indigo thrombectomy catheters showed them to be an effective and safe lysis-free frontline therapy for acute renovisceral artery occlusion in a small cohort of patients. New users should be fully aware of the potential blood loss during aspiration.

Acute renal infarction presenting with acute abdominal pain secondary to newly discovered atrial fibrillation: a case report and literature review

We report an 85-year-old female with known history of recurrent diverticulitis presented with abdominal pain. It was believed that the patient again needed to be treated for another diverticulitis and was started on the routine treatment. The initial CT scan of abdomen showed renal infarcts bilaterally that were confirmed by a CT with and without intravenous contrast secondary to unknown cause. An ECG found accidentally that the patient was in atrial fibrillation, which was the attributed factor to the renal infarctions. Subsequently, the patient was started on the appropriate anticoagulation and discharged.

Thromboembolism as a cause of renal artery occlusion and acute kidney injury: the recovery of kidney function after two weeks

Thromboembolic occlusion is a rare cause of acute kidney injury (AKI). It may lead to permanent loss of renal function. Our patient, who had dilated cardiomyopathy and prosthetic aortic valve, presented with AKI due to thromboembolic arterial occlusion of a solitary functioning kidney. After 2 weeks delay, local intra-arterial thrombolytic treatment with recombinant tissue plasminogen activator was performed without sufficient effect. However, a subsequent percutaneous transluminal angioplasty with stenting was successful. Diuresis began immediately, and renal function was fully recovered after 2 weeks. Although there had been no evident arterial circulation in the kidney, we think that minor flow through subtotal occlusion of the main renal artery made the hibernation of kidney tissue possible and contributed to the recovery. Thus, even after prolonged ischemia, revascularization can be useful.

"Primary" percutaneous transluminal renal angioplasty for late stent thrombosis

Renal artery thrombosis is a rare, but serious and often misdiagnosed, condition, with poor prognosis and renal functional impairment. As for the rarity of the occurrence, data about real incidence of renal stent thrombosis are lacking, ranging from 0 to 1 % depending on the study evaluated. We report the case of a 43-year-old man with nephrovascular hypertension, previously treated with renal stent implantation, with a late stent thrombosis. The diagnostic and subsequent therapeutic management was analyzed and discussed.

Percutaneous mechanical thrombectomy and pharmacologic thrombolysis for renal artery embolism: case report and review of endovascular treatment

Renal artery embolism (RAE) is an uncommon event that is associated with a high rate of renal loss. We present a case of RAE to a solitary kidney that was treated with combined percutaneous rheolytic thrombectomy, intra-arterial thrombolysis, and supplemental renal artery stent placement.

Resolution of anuric acute kidney injury after left renal angioplasty and stenting for a totally occlusive in-stent restenosis of a solitary kidney

The authors report a case of unilateral renal artery in-stent occlusion leading to anuric acute kidney injury in a patient with solitary functional kidney. To their knowledge, this is the first reported case of anuric acute kidney injury, which was successfully treated with percutaneous stenting leading to return of renal function to baseline and a prompt resolution of anuria. This case demonstrates that percutaneous revascularization is a safe and feasible treatment option for in-stent occlusion of renal artery supplying a solitary functional kidney and underscores the importance of early recognition and treatment.

Renal infarction in patients presenting with suspected renal colic

Acute renal infarction is a serious medical emergency. The diagnosis is often delayed or missed as it is not common. Hence, the exact incidence of acute renal infarction is not known. Failure to consider renal infarction in the initial differential diagnosis results in a delay in diagnosis and treatment, which in turn leads to permanent loss of renal function. We present two cases of acute kidney infarction that were initially treated as renal colic. In addition, we present a third case when a kidney was saved with reperfusion therapy.