Successful Aspiration and Rheolytic Thrombectomy of a Renal Artery Infarct and Review of the Current Literature

doi:10.1016/j.cjca.2012.06.020

Canadian Journal of Cardiology

Volume 28, Issue 6, November–December 2012, Pages 760.e1-760.e3

https://doi.org/10.1016/j.cjca.2012.06.020 Get rights and content

Abstract

The use of revascularization techniques including angioplasty, thrombectomy, and stenting in the coronary, cerebral, and peripheral arteries has revolutionized the entire field of endovascular therapeutics. In renal thromboembolism, the classic treatment has been anticoagulation with possible thrombolysis and surgical thrombectomy. The role of endovascular therapy in renal thromboembolism remains controversial. There are a few anecdotal reports about the use of aspiration and rheolytic thrombectomy in the renal arteries. We present a case of acute renal infarction resulting from systemic embolism secondary to atrial fibrillation. This was treated with revascularization, including aspiration and rheolytic thrombectomy, with excellent results.

Résumé

L'utilisation de techniques de revascularisation, incluant l'angioplastie, la thrombectomie et l'implantation d'endoprothèse vasculaire, des artères coronaires, cérébrales et périphériques a entièrement révolutionné le domaine de la thérapeutique endovasculaire. Pour ce qui est de la thromboembolie rénale, le traitement classique a été l'anticoagulation associée possiblement à la thrombolyse et à la thrombectomie. Le rôle du traitement endovasculaire lors d'une thromboembolie rénale semble controversé. Il existe quelques rapports anecdotiques sur l'utilisation de l'aspiration et de la thrombectomie rhéolytique des artères rénales. Nous présentons un cas d'infarctus rénal aigu résultant d'une embolie systémique secondaire à la fibrillation auriculaire. Il a été traité par la revascularisation, incluant l'aspiration et la thrombectomie rhéolytique, qui ont donné d'excellents résultats.

Section snippets

Case Presentation

A 48-year-old African American male with history of ischemic cardiomyopathy, heart failure, atrial fibrillation, and post-implantable cardioverter-defibrillator device placement presented with sudden onset of severe right-sided flank pain. He denied any fever, chills, dysuria, or hematuria. He denied any similar previous events or any other symptoms.

His vital signs were stable. Aside from right flank tenderness, his physical exam was unremarkable. It was noted that his international normalized

Discussion

Renal artery thromboembolism is a rare condition with reported postmortem incidence of 1.4%, although its clinical significant incidence is in the order of 0.007% of hospitalized patients. Most of the cases reported with renal artery embolism are in patients with atrial fibrillation. Less common risk factors include ischemic heart disease, cardiomyopathy, and valvular disease.¹

The kidney can tolerate no blood flow for approximately 60-90 minutes, however successful revascularization has been

Disclosures

The authors have no conflicts of interest to disclose.

References (5)

S. Kansal et al.
Renal artery embolismA case report and review
J Gen Intern Med
(2008)
J.M. Greenberg et al.
Acute renal artery thrombosis treated by percutaneous rheolytic thrombectomy
Catheter Cardiovasc Interv
(2002)

There are more references available in the full text version of this article.

Cited by (23)

Renal Ischemia
2020, Image-Guided Interventions: Expert Radiology Series, Third Edition
Acute renal ischemia occurs because of a transient sudden drop of total or regional blood flow to the kidney. Acutely diminished renal perfusion results in acute kidney injury. Impaired blood flow to both kidneys or to a solitary functional kidney can occur due to generalized hypoperfusion in case of hypovolemia or decreased cardiac output in acute cardiac decompensation, leading to acute renal failure. Acute unilateral renal artery occlusion is usually noted as a result of trauma or embolism leading to acute renal ischemia. Patients usually present with acute onset of loin pain, vomiting, and hematuria. The precise role of revascularization and the optimal timing of intervention in patients with acute renal occlusion are not clearly defined. The goals of revascularization include the preservation of renal function and the amelioration of renovascular hypertension. Salvage of viable parenchyma requires revascularization before ischemia has progressed to infarction. The relief of renovascular hypertension is a secondary goal in acute ischemic kidney and may be accomplished by either revascularization or nephrectomy. The choice between these two alternatives requires an assessment of the quantity of the remaining functional renal tissue. Endovascular treatment options such as balloon angioplasty and stenting are today established methods for the management of acute renal ischemia. In this chapter the indications, techniques, and outcomes of endovascular revascularization for acute renal ischemia are discussed.
Rheolytic Thrombectomy with AngioJet<sup>®</sup> Is Safe and Effective in Revascularization of Renal Arteries' Acute Occlusion on Previous Complex Aortic Endovascular Repair
2017, Annals of Vascular Surgery
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.
Aspiration Thrombectomy of Acute Atrial Fibrillation-related Renal Artery Thromboembolism in a Patient with Horseshoe Kidney
2016, Annals of Vascular Surgery
Citation Excerpt :
A 5F Simmons 2 catheter (Cordis, Miami Lakes, FL) was placed into the right renal artery, and multiple manual attempts at suction thrombectomy were performed to no avail, followed by successful use of the rinspirator device (ev3, Plymouth, MN) through the guiding catheter over a 0.014-inch Mailman Wire (Boston Scientific, Natick, MA) with repeated 7F sheath suction thrombectomy, eventually retrieving which yielded multiple particles that were irregular and rubbery in texture which grew β-hemolytic streptococcus. Komolafe et al.12 reported the use of aspiration and rheolytic thrombectomy followed by insertion of a 3.5 × 28 mm Promus drug-eluting stent (Abbott Laboratories, Abbott Park, IL) in the left renal artery of a patient with acute thromboembolism as a result of atrial fibrillation and postimplantable cardioverter-defibrillator device. In our patient, simple manual aspiration thrombectomy using syringe attached to a Cobra-1 catheter (Terumo Medical Corporation, Somerset, NJ) was successful, as the patient's symptoms were recent onset and therefore the thromboemboli may be relatively fresh and therefore easily aspirated.
Acute arterial thromboembolism to the renal arteries can be treated promptly by local thrombolysis, conventional surgical thrombectomy, or anticoagulation.
We report a patient who presented with acute loin pain as a result of atrial fibrillation-related thromboembolism to the right renal artery supplying his horseshoe kidney. He was already on warfarin treatment with international normalized ratio of 1.7 and had acute bleeding from malignant peptic ulcer disease, so thrombolysis was contraindicated.
He underwent timely endovascular revascularization with aspiration thrombectomy, with good clinical and radiological consequence. He subsequently underwent curative partial gastrectomy and made a steady recovery.
Early endovascular target-directed therapy such as intra-arterial thrombolysis and mechanical aspiration in combination with intravenous heparin therapy will result in renal salvage.
Long-term follow-up results of acute renal embolism after anticoagulation therapy
2015, Annals of Vascular Surgery
Citation Excerpt :
But, this technique is hardly used nowadays because of the associated morbidity and mortality.9,14 Instead, less-invasive endovascular treatments, such as thrombolysis and aspiration thrombectomy, have been introduced.3–8 These techniques are very effective in removing the emboli that are lodged in the renal artery.
Acute renal embolism (ARE) is a rare cause of acute abdominal pain. However, there are only a few studies on the clinical course of ARE. We attempted to investigate the clinical manifestations and long-term follow-up results of ARE.
From September 2006 to August 2012, 47 patients, who were diagnosed with ARE by computed tomography (CT), were enrolled. Patient demographic and clinical data were retrospectively reviewed. For the long-term outcomes, change in the serum creatinine (s-Cr) level, change in renal infarction on follow-up CT, recurrent embolism, and dialysis-free survival were investigated.
The mean age of patients was 61 years (range, 29–89 years), and 51% of the patients were men. All the patients presented with abdominal or flank pain. The sites of ARE were the right kidney in 57% of the patients, the left kidney in 36% of the patients, and both the kidneys in 6% of the patients. The infarction volume was less than 50% of renal volume in 54% of infarcted kidneys. Six patients had a concurrent infarction in other organs (3 cases of splenic infarction and 3 cases of cerebral infarction). Etiology of embolism was cardiogenic in 55% and idiopathic in 45%. Mean s-Cr level was 1.2 mg/dL (range, 0.6–3.7 mg/dL). s-Cr elevation >0.5 mg/dL was detected in 19% of patients during the follow-up (6 of 31 patients; mean duration, 31 months). Follow-up CT was performed in 23 patients (mean duration, 29 months). The infarcted lesions showed atrophic changes in all the cases except for 1 case. During the mean follow-up period of 41 months (1–118 months), recurrent embolism developed in 8 patients (6 cases of cerebral artery embolism, 1 case of superior mesenteric artery embolism, and 1 case of renal artery embolism). Dialysis was necessary in 1 patient, and dialysis-free survival rates were 91%, 82%, and 64% at 1 year, 3 years, and 5 years, respectively.
Although ARE causes irreversible loss of renal mass, it rarely leads to end-stage renal disease or long-term mortality. Therefore, the treatment should focus on the prevention of subsequent embolism to other vital organs.
Successful catheter aspiration and local low-dose thrombolysis in an acute renal artery embolism
2013, Cardiovascular Revascularization Medicine
Citation Excerpt :
However, thrombolytic therapy has no definite optimal timing and has hemorrhage as its most feared complication, with nearly 6% of the patients receiving the therapy suffering from intracranial hemorrhage and hemorrhagic stroke [5]. With the advancement of medical technologies, transcatheter thrombus aspiration supplemented combined with local low dose thrombolysis is considered the most effective method [6]. The role of endovascular therapy in renal thromboembolism remains controversial.
Acute renal artery embolism (RAE) is a clinical rare condition and diagnosis of it is often delayed or missed due to both the rarity of the disease and its non-specific clinical presentation. The exact role and optimal timing of endovascular revascularization remain controversial and uncertain. This article discusses a case of acute renal artery embolism caused by atrial fibrillation. Endovascular renal thrombus aspiration combined with local low-dose thrombolysis reversed the renal ischemia with restoration of renal function despite prolonged ischemia.
Inflammation and Biomarkers in Vascular Disease: Emerging Insights and Opportunities
2012, Canadian Journal of Cardiology

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Case reportSuccessful Aspiration and Rheolytic Thrombectomy of a Renal Artery Infarct and Review of the Current Literature

Abstract

Résumé

Section snippets

Case Presentation

Discussion

Disclosures

Renal artery embolismA case report and review

J Gen Intern Med

Acute renal artery thrombosis treated by percutaneous rheolytic thrombectomy

Catheter Cardiovasc Interv

Case report
Successful Aspiration and Rheolytic Thrombectomy of a Renal Artery Infarct and Review of the Current Literature