Endovascular management of a patient with massive renal arteriovenous fistula: challenges and tricks

Abstract

We describe the endovascular management of a patient with a massive renal arteriovenous fistula and a huge venous aneurysmal sac, who presented with features of cardiac failure and fever. The challenges faced and the outcomes are discussed with relevant literature review.

Keywords: renal intervention; renal system.

Figure 1

DSA and schematic diagram. (A) Large right renal arteriovenous fistula (AVF) through a dilated and elongated renal artery with aneurysmal dilatation of the venous end. (B) Right kidney rotated anteriorly to depict the coarse segments of abnormal renal artery (two vertical and one horizontal segments). Arrow indicates the posterior branch supplying normal renal parenchyma. DSA, Digital subtraction angiography.

Figure 2

DSA. (A) Post embolisation angiography showed flow reduction. (B) Demonstration of normal renal artery branch supplying the parenchyma posteriorly. DSA, Digital subtraction angiography.

Figure 3

Digital subtraction angiography (DSA) and contrast enhanced computed tomography (CECT) abdomen. (A) Dislodged Amplatzer vascular plug into the venous sac and impinged over the posterior wall. (B) Same in CT with contrast filled venous sac.

Figure 4

Digital subtraction angiography (DSA) and schematic diagram. (A) Complete occlusion of vertical segment of renal artery and no flow to fistula an venous sac with normally opacified parenchymal branch. (B) Schematic diagram depicting the packing of Amplatzer vascular plugs and coils in vertical segment of renal artery. Arrow indicates location of old dislodged plug.

Figure 5

Immediate postprocedure MRI depicting the thrombosed venous sac.

Figure 6

Chest radiograph on admission and after 6 months. (A) Chest radiograph before the procedure with cardiothoracic ratio (CTR) 0.7. (B) Postprocedure chest radiograph after 5 months post embolisation.