Arteriovenous fistula of a segmental renal artery branch as a complication of percutaneous angioplasty

Complications after Percutaneous Transluminal Angioplasty of Peripheral and Renal Arteries

This review deals with complications after percutaneous transluminal angioplasty (PTA). First some methodologic points are discussed. It seems important to standardize the way in which complications are reported. Our own complications in peripheral and renal PTA are summarized and taken as a basis for an analysis of various types of complications. Principally these may occur at different levels: at the puncture site, at the dilatation site as well as distant and general complications. To make comparisons with surgical series relevant it is suggested that all complications and mortality within 30 days are reported.

Gross hematuria caused by a congenital intrarenal arteriovenous malformation: a case report

Introduction

We report the case of a woman who presented with gross hematuria and was treated with a percutaneous embolization.

Case presentation

A 48-year-old Caucasian woman presented with gross hematuria, left flank pain, and clot retention. The patient had no history of renal trauma, hypertension, urolithiasis, or recent medical intervention with percutaneous instrumentation. The patient did not report any bleeding disorder and was not taking any medication. Her systolic and diastolic blood pressure values were normal at presentation. The patient had anemia (8 mg/dL) and tachycardia (110 bpm). She underwent color and spectral Doppler sonography, multi-slice computed tomography, and angiography of the kidneys, which showed a renal arteriovenous malformation pole on top of the left kidney.

Conclusions

The feeding artery of the arteriovenous malformation was selectively embolized with a microcatheter introduced using a right transfemoral approach. By using this technique, we stopped the bleeding, preserved renal parenchymal function, and relieved the patient's symptoms. The hemodynamic effects associated with the abnormality were also corrected.

Surgery for giant high-flow renal arteriovenous fistula: experience in one institution

OBJECTIVE

To present five cases of renal arteriovenous fistula (RAVF) seen at our institution, with an emphasis on surgical treatment.

PATIENTS AND METHODS

We assessed five patients with giant high-flow RAVF. The affected kidney was evaluated functionally using (99m)Tc-diethylenetriamine pentaacetic acid renal scintigraphy. The size, location, involvement of branched arteries, and renal function dictated the choice of operative method. Four patients were treated with in situ ligation of the feeding artery for extrarenal RAVF, and the remaining patient had a nephrectomy of the nonfunctioning kidney. The clinical outcome was analysed by renal function, blood pressure control, radiographic cardiothoracic ratio (CTR), occlusion of RAVF, and renal artery patency.

RESULTS

Of two patients with hypertension, the blood pressure was normalized in one. The renal function of the affected side was preserved in four patients. CTR was normalized or improved in all four patients with preoperative cardiomegaly. There was no recurrence of RAVF in any of the five patients and there was no major morbidity after surgery.

CONCLUSIONS

Surgery for giant high-flow RAVF is safe and feasible from the perspective of complications and recurrence, even though transarterial embolization has become the first line of therapy for RAVF.

Renal arteriovenous aneurysm in a 4-year-old patient

We report a case of a symptomatic renal arteriovenous aneurysm in a 4-year-old pediatric patient. We were able to diagnose the lesion by means of a Doppler renal sonogram with color duplex interrogation. The diagnosis was confirmed by digital subtraction angiography. On the basis of the angiographic findings, the aneurysm was resected, and the renal arteriovenous fistula was repaired.

Giant high-flow renal arteriovenous fistula treated by percutaneous embolization

We report the case of a giant renal arteriovenous fistula after renal biopsy in a 30-year-old man with hematuria and hypertension. We performed percutaneous endovascular embolization using macrocoils to exclude the fistula. The patient made an uneventful recovery with no further hematuria and progressive reduction of blood pressure. Follow-up by digital subtraction angiography (DSA) at 6 months showed complete occlusion of the fistula with no evidence of renal parenchymal infarction. Although giant renal arteriovenous fistulas are generally treated by nephrectomy, this case shows that embolization is a reasonable alternative to surgery.

High-output heart failure due to a renal arteriovenous fistula in a pregnant woman with suspected preeclampsia

A 29-year-old nulliparous woman had development of hypertension, proteinuria, and congestive heart failure during the third trimester of her pregnancy. Her symptoms and cardiovascular changes were consistent with congestive heart failure and severe preeclampsia. The underlying pathophysiology was believed to be caused by the high-output state of pregnancy and by the increased peripheral vascular resistance of preeclampsia. The patient underwent an elective cesarean section, but her cardiovascular symptoms did not resolve. Soon after delivery, the patient was found to have an arteriovenous fistula of the right renal artery that caused the high-output cardiac state. Embolization and surgical removal of the arteriovenous fistula resulted in complete resolution of the patient's high-output heart failure. All previously reported cases of renal arteriovenous fistulas and malformations that have occurred during pregnancy are reviewed.

Recent advances in the diagnosis and treatment of renal arteriovenous malformations and fistulas

Arteriovenous malformations remain relatively rare clinical lesions. However, with an increasing number of percutaneous renal procedures being performed, their overall incidence can be expected to increase. Congenital arteriovenous malformations usually present with hematuria, while acquired fistulas are more likely to present with hemodynamic changes, such as hypertension, cardiomegaly and congestive heart failure. Arteriography remains the principal method of diagnosis. However, newer imaging modalities such as CT, MRI and color duplex ultrasound may make significant contributions in the evaluation of these abnormalities (fig. 1). Surgery, whether nephrectomy or ligation of feeding vessels, has long been the standard treatment for symptomatic arteriovenous malformations or fistulas. The loss of normal renal parenchyma, migration of occluding agents or recanalization of abnormal vessels has limited the use of embolization as a method of treatment in the past. Recently, newer techniques and agents, such as pharmacoangiography and alcohol, have increased the efficacy of embolization therapy, either as an adjuvant to surgery, definitive therapy or palliation. Although to our knowledge there have been no controlled studies comparing surgical treatment versus embolization, certain recommendations can be made. Because of the decreasing morbidity and increasing efficacy, embolization should be attempted at the time of arteriography as a means of treatment for most arteriovenous malformations and fistulas. However, the choice of surgery, embolization or a combination must be individualized for each patient with regard to overall health, symptoms and manifestations of the fistula or malformation (fig. 2).

Treatment of neurofibromatosis associated renal artery stenosis with hypertension by percutaneous transluminal angioplasty

A 12 year old girl with severe arterial hypertension was found to have neurofibromatosis associated bilateral stenoses of the main renal arteries and elevated plasma renin activity in the right main renal vein. Antihypertensive treatment was unable to normalize blood pressure. PTA of the right renal artery from a left axillary approach resulted in normalization of blood pressure and peripheral plasma renin activity. PTA seems to be an effective and safe method for treatment even of complicated forms of renal artery stenosis.