Pharmarcomechanical thrombectomy combined with transluminal balloon angioplasty for treating transplant renal vein thrombosis

Abstract

Renal vein thrombosis (RVT) is a rare vascular complication that occurs after renal transplantation and usually results in irreversible kidney damage and graft loss. We report the case of a patient who underwent right iliac fossa allogeneic kidney transplantation and developed RVT combined with ipsilateral thrombosis from the popliteal to the femoral veins, with extension to the common iliac veins, 4 months after transplantation. Under unfractionated heparin anticoagulation, an Aegisy (Life Tech Scientific Co., Ltd., Shenzhen, China) vena cava filter was placed to prevent pulmonary embolism. Percutaneous mechanical thrombectomy combined with balloon angioplasty was performed to aspirate the thrombus and successfully dilate the narrow venous lumen. The patient's renal function was restored postoperatively. Ultrasonography showed the allograft and ipsilateral lower extremity deep veins to be fluent and patent. To conclude, in patients with RVT after renal transplantation, percutaneous mechanical thrombectomy in conjunction with balloon angioplasty can be performed with desirable outcomes and no severe adverse effects. This method reduces the risk of bleeding from exposure to systemic intravenous thrombolysis and avoids surgery-associated trauma.

Figure 1

(a) An emergency Doppler ultrasound examination showed an anastomosis of thevein of the transplanted kidney to the right external iliac vein, with a widening of the renal vein and a heterogeneous hypoechoic filling of the lumen (Red arrow shows thrombosis of the main vein of the transplanted kidney), extending into the right external iliac vein (Blue arrow shows right superficial iliac vein thrombosis). (b) There was no significant flow in the renal vein or the right external iliac vein on Doppler ultrasound and the transplanted renal artery showed high resistance to flow with a resistance index (RI) of 0.94, which was significantly higher than normal and the patient’s previous baseline level. The intrarenal vein is slightly widened, with poor internal sound transmission and stagnant blood flow. Doppler ultrasound showed heterogeneous hypoechoic filling of the lumen of most segments of the deep veins of the right lower limb, with no significant blood flow signal. The rest of the segmental lumen is poorly permeable and the blood flow is stagnant. (c) Right femoral deep vein thrombosis shown by red arrow, no blood flow signal seen. (d) Partial thrombus filling of the lumen of the right posterior tibial vein shown by the blue arrow.

Figure 2

(a) Transverse section, (b) Coronal section, (c) Median sagittal. Emergency computed tomography shows swelling of the right iliac fossa graft kidney with varying renal cortical density, with patchy isoslightly hypodense foci, which are relatively hypodense on enhancement, partially indistinct, and with the tip directed towards the renal hilum; renal infarction was considered (indicated by white arrows). A filling defect is seen in the grafted right renal vein and is thrombosed (indicated by a red arrow). Filling defects in the right common iliac vein, the right internal and external iliac veins, the ingested portion of the right femoral vein, and the grafted renal vein is seen to be thrombosed (Blue arrow shows right superficial iliac vein thrombosis, median sagittal section shows continuity with right central renal vein thrombosis). Perirenal and adjacent pelvic fatty interstitial exudates and effusions.

Figure 3

(a)–(e): DSA post-anterior view showing filling defects in the proximal main vein of the transplanted kidney and the right popliteal vein, femoral vein, common femoral vein, external iliac vein and common iliac vein. (a): The red arrow shows a limited filling defect at the confluence of the vein of the transplanted kidney into the right external iliac vein. (b): The lumen of the original vascular filling defect in the vein of the transplanted kidney, shown by the red arrow, is open and restored to its normal lumen diameter. Pharmarcomechanical mechanical thrombectomy plus transluminal balloon angioplasty after post-DSA contrast angiography shows a significant improvement in the lumen of the former limited filling defect in the vein of the transplanted kidney after treatment, with contrast filling. (c): Blue arrows show contrast filling defects and stagnant flow in the lumen of the right external iliac vein and common iliac vein. (d): Patency of the right external iliac vein and common iliac vein lumen, as indicated by the blue arrows, with thrombus clearance and smooth contrast reflux. The original right lower limb DVT-filled vessel lumen was largely cleared and the vessel lumen was restored to patency with smooth contrast return, no contrast stagnation, reflux or collateral vessel formation was observed. (e): Free thrombus captured underneath the pre-positioned inferior vena cava filter shown by the green arrow. Partial thrombus dislodgement during Pharmarcomechanical mechanical thrombectomy plus transluminal balloon angioplasty, DSA angiography shows a limited filling defect in the lumen of the inferior vena cava below the filter as a dislodged thrombus. (f)–(g): Doppler ultrasound 6 months after surgery. (f): Six months after the operation, Doppler ultrasound showed that the transplanted kidney could be detected in the right iliac fossa, with normal kidney morphology, parenchymal echogenicity, and no significant abnormalities in the renal sinuses. End-lateral anastomosis of the renal artery to the right external iliac artery, average renal artery resistance index, RI: 0.82, end-lateral anastomosis of the renal vein to the right external iliac vein. No significant abnormalities in renal artery and renal vein blood flow were noted. (The lumen of the aortic vessel of the transplanted kidney is patent, as indicated by the red arrow) (The lumen of the central vein of the transplanted kidney is patent, as indicated by the blue arrow). (g): The right common femoral, femoral, deep femoral, anterior tibial, posterior tibial, and popliteal veins are normal in diameter, with good intraventricular sound, unobstructed flow, and average flow spectrum pattern.