Scientific articleRenal arteriovenous fistula following nephrectomy
Abstract
Three cases of postnephrectomy renal arteriovenous fistula are described. A review of the literature shows the rarity of this complication since only 62 cases (including the author's cases) are known. Reported cases have been recognized after intervals up to forty years. The major complication is cardiac failure. Surgical treatment gives satisfactory results, but nonsurgical closure has now become possible. Early diagnosis is easy by auscultation of the loin which constantly reveals a continuous bruit.
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Cited by (46)
En Bloc Stapling of the Renal Hilum During Laparoscopic Nephrectomy: A Double-institutional Analysis of Safety and Efficacy
2017, UrologyCitation Excerpt :In 1934, Hollingsworth was the first to report AVF after open en bloc ligation of the renal hilum in a patient with tuberculosis.17 Since then, most reported cases of AVF seem to be linked to cases involving severe infection or inflammation.5 Our study is unique in the inclusion of 69 LNx for infection or inflammation or chronic obstruction indications.
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.
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.
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.
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.
Safety and Efficacy of En Bloc Renal Hilar Vascular Staple Ligation: A Meta-Analysis
2017, Journal of UrologyWe reviewed the literature on the safety of en bloc ligation. We also performed a meta-analysis of the effect of using this technique with vascular staplers on perioperative factors compared to conventional renal pedicle dissection and isolated staple ligation of the renal artery and vein.
A literature search was performed to include all primary studies related to the safety of en bloc ligation of the renal hilum. After exclusion criteria were applied 9 studies were identified for review, of which 4 included a control group and were used in the meta-analysis. The primary end point was the incidence of arteriovenous fistula. Secondary end points were procedure duration, blood loss and the number of perioperative complications.
None of the total population of 595 patients in whom en bloc ligation was performed for nephrectomy were diagnosed with arteriovenous fistula formation at an average postoperative followup of 26.5 months. When comparing en bloc and isolated ligation of the renal artery and vein, the meta-analysis showed a significant improvement in procedure duration for en bloc nephrectomy. There was no difference in estimated blood loss or the number of complications.
En bloc ligation appears to be as safe as and potentially more beneficial in terms of perioperative factors than conventional renal pedicle dissection and isolated vascular ligation.
Laparoscopic repair of a right renal artery to vena cava fistula after right radical nephrectomy
2016, Revista Mexicana de UrologiaLa fístula arteriovenosa posnefrectomía es poco frecuente a pesar del número de nefrectomías que se realizan en el mundo, y ocurren más a menudo en el lado derecho, como el caso que presentamos.
Mujer de 66 años de edad. En enero 2005 se realizó nefrectomía radical derecha. En mayo 2015 se presenta a la consulta de cardiología en anasarca y con un soplo abdominal, se realiza tomografía de abdomen, se diagnostica fístula de arteria renal derecha a cava. Hemodinamista descarta tratamiento endovascular, es enviada a nuestro servicio de urología.
Por laparoscopia, en decúbito lateral derecho se extraen 2 l de ascitis y se diseca el nacimiento de la «arteria renal derecha» y se aplican 2 grapas de Hem-o-lok de 10 mm. El primer día de postoperatorio: mínimo dolor abdominal, toleró vía oral, canalizó gases y signos vitales normales, sin embargo, se sigue escuchando soplo abdominal (30 h de postoperatorio); se hace tomografía de abdomen. La fístula arteriovenosa sin cambio y doble grapa Hem-o-lok en la arteria mesentérica superior, pero con flujo a pesar de las 2 grapas (obstrucción parcial). Hicimos laparoscopia de urgencia, se retiran grapas de la arteria mesentérica superior, se localiza la arteria renal derecha, doble grapa Hem-o-lok, desaparece el soplo. Postoperatorio excelente. Tomografía de control, sin fístula arteriovenosa y arteria mesentérica superior normal sin grapas.
Caso complejo, poco común, que se resolvió con técnica laparoscópica. Quizá una placa de ateroma evitó la obstrucción completa de la arteria mesentérica superior. La posición del paciente fue un factor importante para encontrar la arteria renal derecha.
Post-nephrectomy arteriovenous fistula is rare in relation to the number of nephrectomies performed worldwide and they are more frequent on the right side, as was true for the case presented herein.
A 66-year-old woman underwent right radical nephrectomy in January 2005. In May 2015 she came to a cardiology consultation presenting with anasarca and an abdominal murmur. An abdominal tomography scan was done and an arteriovenous fistula involving the right renal artery and the vena cava was diagnosed. The hemodynamics specialist ruled out endovascular treatment and the patient was referred to our urology service.
Through laparoscopy performed with the patient in the right lateral decubitus position, 2 L of ascites were extracted and the origin of the right renal artery was dissected. Two 10 mm Hem-o-Lok staples were applied. On the first postoperative day the patient had minimal abdominal pain, tolerated a liquid diet, passed gases, and had normal vital signs, but the abdominal murmur continued to be heard. At 30 h after the procedure, an abdominal tomography scan was carried out that revealed no change in the arteriovenous fistula. The double Hem-o-Lok staples were observed in the superior mesenteric artery, but there was flow despite the 2 staples (partial obstruction). Emergency laparoscopy was performed, removing the staples from the superior mesenteric artery. The right renal artery was located and 2 Hem-o-Lok staples were placed. The murmur ceased. The patient had excellent postoperative progression. The control tomography scan showed there was no arteriovenous fistula and the superior mesenteric artery was normal with no staples.
This was an unusual and complex case that was resolved through laparoscopy. Perhaps an atheroma prevented complete superior mesenteric artery obstruction. The position of the patient was an important factor in locating the right renal artery.
Transarterial treatment of congenital renal arteriovenous fistulas
2013, Journal of Vascular SurgeryCongenital renal arteriovenous fistulas (CRAVF) represent a distinct clinical entity with characteristic hemodynamic and angiographic features. Treatment is warranted given potential for growth with renal and hemodynamic compromise. We report our experience in a rare series of treated symptomatic CRAVFs.
Over a 10-year period, patients treated for symptomatic CRAVFs (no history of predisposing renal pathology, instrumentation, neoplasm, or trauma) were retrospectively investigated for clinical presentation, imaging features, treatment outcomes, and complications. Technical success included delivery of embolic agent with complete obliteration of fistula. Clinical success included resolution of symptoms and freedom from recurrence and/or reintervention. Renal parenchymal loss was estimated by postembolization angiography and categorized as 0%, <25%, 25%-50%, or >50%.
Twenty-five patients were referred with a presumptive diagnosis of intraparenchymal renal artery aneurysms. Of these, 10 had true intrarenal aneurysms, three had angiomyolipomas, and 12 had CRAVFs (mean age, 54; range, 29-71 years; eight women). Presenting symptoms included hematuria (eight gross, eight microscopic), refractory hypertension (diastolic blood pressure ≥90 mm Hg despite three or more medications; n = 6), flank pain (n = 8), high-output state (HOS; featuring tachycardia and jugular venous distention; n = 3), and flank bruit (n = 1). Defining angiographic features included a high-flow AVF fed by a single, enlarged intrarenal branch shunting into an aneurismal draining vein, occasionally featuring a calcified rim (four patients). All patients underwent transarterial embolization with coils (n = 5), coils and n-butylcyanoacrylate (n = 3), detachable balloons (n = 2), or Amplatzer plugs (n = 2). Technical success was 100%. Hematuria, tachycardia, jugular venous distension, pain, and bruit resolved in all. Hypertension improved in four of six patients (required less than three medications postembolization). Complications included postembolization syndrome in nine patients. Parenchymal loss was limited to <25% and observed in five patients without development of acute kidney injury or worsening hypertension. There were no recurrences or reinterventions at a mean follow-up of 55 months (range, 5-96 months). There was one death at 8 years follow-up from intercurrent coronary disease in a patient without high-output state.
With greater awareness and accurate diagnosis, effective and durable transarterial treatment of CRAVFs can be safely performed.
En Bloc Stapling of Renal Hilum During Hand-Assisted Retroperitoneoscopic Nephroureterectomy in Dialysis Patients
2008, UrologyTo report our experience in routine en bloc stapling of the renal hilum during hand-assisted retroperitoneoscopic nephroureterectomy in dialysis patients.
From October 2003 to June 2006, hand-assisted retroperitoneoscopic nephroureterectomy with open bladder cuff excision for upper tract transitional cell carcinoma was performed in 23 dialysis patients. En bloc mass stapling of the renal pedicle with an endovascular gastrointestinal anastomosis (Endo-GIA) stapler without individual dissection of the renal artery and vein was done.
All procedures were successful. No hilar bleeding was encountered during the process of hilar division. The overall success rate of en bloc stapling to control the renal hilum in the 23 patients was 100%. The average patient age was 59.0 years (range 32-78), the operative time was 177.3 minutes (range 135-343), and the estimated blood loss was 117 mL (range 50-500). The time to oral intake and ambulation was 2.0 and 3.1 days, respectively. Two patients had postoperative complications, one pneumonia and the other wound hematoma. No immediate or short-term complications were related to this method of en bloc hilar division. No case of symptoms or imaging findings of arteriovenous fistula had developed at a mean follow-up of 24.5 months. No statistically significant difference was found in preoperative and postoperative systolic and diastolic blood pressure.
Routine use of en bloc stapling and division of the renal pedicle in dialysis patients with upper urinary tract transitional cell carcinoma is safe. Without separating the renal artery from the vein with the laparoscopic instrument, the risk of hilar bleeding can be avoided.
Prospective Radiographic Followup After En Bloc Ligation of the Renal Hilum
2007, Journal of UrologyWe determined the risk of arteriovenous fistula after en bloc ligation of the renal hilum.
A prospective evaluation of all patients who underwent en bloc ligation of the renal hilum during nephrectomy for malignant disease was performed. Pertinent operative data were recorded and patients were followed for clinical evidence of arteriovenous fistula formation, including hypertension, abdominal bruit and new onset congestive heart failure. Patients with at least 12 months of followup underwent computerized tomographic arteriography to assess arteriovenous fistula formation.
A total of 94 patients underwent en bloc renal hilar ligation during open (43) and laparoscopic (51) nephrectomy using a 45 mm titanium endovascular stapler. Of this cohort 11 patients were lost to followup and 3 died of disease. The remaining 80 patients were followed an average of 35.2 months with no clinical evidence of arteriovenous fistula formation. Specifically there was no statistically significant difference in preoperative and postoperative blood pressure (p = 0.18 and 0.62, respectively), no evidence of abdominal bruit on examination and no new onset congestive heart failure. A total of 32 had increased serum creatinine and, therefore, they were excluded from followup computerized tomographic arteriography. Eight patients had a followup of less than 1 year and they were not yet eligible for evaluation. In the 40 patients who underwent computerized tomographic arteriography no fistulas were noted.
Based on clinical followup and prospective radiographic evaluation there appears to be a low risk of arteriovenous fistula formation after en bloc ligation of the renal hilum using a titanium endovascular stapler.