Case Report

The opinioof the authorsviews of the DNavy Departm

1San Anto2Multicare

CorrespondVascular SurgBrooke Dr #36gmail.com

Ann Vasc Surghttp://dx.doi.or� 2014 Elsevi

Manuscript rec

24, 2013; pub

Combined Arteriovenous ThrombolyticInfusion for Refractory Renal VeinThrombosis

Thomas A. Heafner,1 Daniel Scott,1 J. Devin Watson,1 Brandon Propper,1 Chatt Johnson,2

and Zachary M. Arthurs,1 San Antonio, Texas and Tacoma, Washington

Acute renal vein thrombosis can rapidly lead to significant impairment and eventual loss of renalfunction. Classically presenting with flank pain, hematuria, and laboratory markers consistentwith acute kidney injury, therapeutic anticoagulation is the mainstay of treatment. However,endovascular surgery offers a safe and effective alternative for renal salvage in the setting ofacute renal vein thrombosis. Described is the use of combined arteriovenous thrombolyticinfusion for refractory renal vein thromboses to quickly and effectively decrease clot burden inthe micro- and macrovenous circulations while limiting systemic exposure.

Acute thrombosis of the renal vein can quickly lead

to impairment and eventual loss of renal function.1

Most often a consequence of primary renal disease

(e.g. nephrotic syndrome), it classically presents

with flank pain, hematuria, and decline in renal

function. The mainstay of therapy has transitioned

from open thrombectomy to long-term systemic

anticoagulation.2 While this halts thrombus pro-

gression, irreversible damage may occur as collater-

alization and recanalization ensues.

Recently, multiple catheter-directed techniques

have emerged as a safe and effective means of

ns and assertions contained herein are the private viewsand are not to be construed as official or reflecting theepartment of the Army, Department of the Air Force,ent, or Department of Defense.

nio Military Medical Center, San Antonio, TX.

Health System, Tacoma, WA.

ence to: Cpt. Thomas A. Heafner, MD, Department ofery, San Antonio Military Medical Center, 3851 Roger00, San Antonio, TX 78219, USA; E-mail: heafnert@

2014; -: 1–4g/10.1016/j.avsg.2013.12.019er Inc. All rights reserved.

eived: November 4, 2013; manuscript accepted: December

lished online: ---.

quickly restoring luminal patency, but the optimal

method has yet to be determined. Documented is

the use of dual arterial and venous thrombolysis

for the treatment of acute renal vein thrombosis.

CASE REPORT

A 42-year-old female presented to the emergency depart-

ment 1 month following total laparoscopic hysterectomy

with complaints of 24 hr of severe pelvic cramping and

back pain. Initial laboratory evaluation was normal.

Radiologic work-up with computed tomography angiog-

raphy (CTA) revealed left renal vein thrombosis and

limited renal parenchymal enhancement (Fig. 1).

Therapeutic anticoagulation with unfractionated hep-

arin was initiated. Given the patient’s young age,

evidence of renal malperfusion, and absence of under-

lying renal disease, catheter-directed thrombolysis was

recommended.

Following consent, the patient was taken to the

vascular suite for intervention. The right femoral vein

was cannulated. An initial venogram showed complete

occlusion of the left renal vein with numerous collaterals

draining to the inferior vena cava (IVC) via lumbar veins.

Mechanical thrombectomy using the AngioJet

(MedRad, Inc., Warrendale, PA) catheter was performed

with the following technique: (1) power-pulse irrigation

with 16 mg of tissue plasminogen activator (TPA), (2) 25

1

Fig. 1. Axial imaging demonstrating acute renal vein

thrombosis of the left renal vein. The left renal vein is

dilated, does not enhance, and there is fat stranding

around the edges of the vein. In addition, the left kidney

is engorged, the cortex is thinned, and there is capsule fat

stranding. Compared to the right kidney, it measured 1.5

times larger and the Hounsfield units were lower

compared to the right kidney.

2 Case Report Annals of Vascular Surgery

min dwell time, and (3) aspiration thrombectomy with

4 passes. A 9 mm � 4 mm high-pressure balloon was

then placed and inflated to the profile twice; no venous

webs were visualized. Completion venogram showed

improved outflow but still with a significant amount of

luminal thrombus extending to the renal hilum. Given

the proximal extent of the thrombus into the small renal

hilar vessels, a single venous thrombolytic catheter would

not suffice in addressing the entire clot burden. A com-

bined arteriovenous approach using the right femoral

artery was chosen. A CraggeMcNamara (ev3 Endovascu-

lar, Inc., Plymouth, MN) catheter was positioned in the

left renal artery (Fig. 2A). This was placed through a 6F

11-cm sheath in the right femoral artery, which was

nonocclusive to the artery. Only the CraggeMcNamara

catheter was left in the renal artery for continuous throm-

bolytic infusion. Given the timing of thrombolysis in rela-

tionship to her recent surgery, a relatively low dose

(0.5 mg/hr) of TPA was infused overnight. In addition,

500 U/hr of heparin was administered through the side

port of the sheath. Serial fibrinogen, hematocrit, and par-

tial thromboplastin times were checked every 6 hr and

remained normal throughout the night.

After 13 hr of thrombolysis, the patient was taken back

to the vascular suite where an angiogram showed filling of

the left kidney with brisk outflow through the left renal

vein on delayed images. A venogram was performed con-

firming prompt egress of contrast exclusively via the renal

vein into the IVC (Fig. 2B).

The patient was observed in the intensive care unit for

24 hr where a heparin drip was continued. As this was

considered a provoked renal vein thrombosis following

surgery, she was maintained on warfarin for 6 months.

At a 3month follow-up, repeat CTA demonstrated normal

vascular and renal anatomy (Fig. 3).

DISCUSSION

Renal vein thrombosis was first described in 1840 by

Rayer.3 The true incidence of renal vein thrombosis

is unknown as it remains asymptomatic a majority

of the time.2 The causes can be because of a primary

(nephrotic syndrome) or secondary (trauma) dis-

ease process. Acute renal vein thrombosis typically

presents with hematuria, flank pain, and a decrease

in renal function.2 The affected kidney increases in

size because of congestion, which stretches the

capsule and causes pain. Serum creatinine levels

may not be immediately increased, but it can rise

rapidly in the days after the event, depending on

the extent of the injury.4 Chronic renal thrombosis

may remain asymptomatic and only discovered inci-

dentally on imaging. Routine laboratory studies

may not detect a decline in renal function as collat-

erals maintain venous drainage. In other cases, uri-

nalysis shows nonspecific changes that may be

missed if the diagnosis is not considered. Systemic

anticoagulation alone is sufficient for chronic

thrombosis as a collateral circulation has already

developed to preserve outflow.

The management of acute renal vein thrombosis

hinges on timely diagnosis, preventing progression

and swift re-establishment of venous drainage.

Therapeutic anticoagulation and volume resuscita-

tion should be initiated immediately unless there

are contraindications. Given the rarity of this disease

process, however, the optimal therapeutic approach

is not well established. Nevertheless, given the

decreased morbidity, catheter-directed therapy is

increasingly becoming the preferred approach in

the absence of contraindications.

Since the early 1980s, multiple single institution

cohort studies and case reports have demonstrated

the effectiveness and safety of using catheter-

directed techniques. However, most of these have

preferentially accessed only the venous system.5e10

As demonstrated by Kim et al. in a recent cohort

study, 7 renal veins were successfully treated with

percutaneous mechanical thrombectomy, thrombol-

ysis, or both. Exclusively via venous access, throm-

bectomy alone achieved patency in 2 veins, with

Fig. 2. Completion angiogram following thrombolytic

therapy. (A) With arterial injection, there was complete

enhancement symmetrically throughout the entire left

kidney. (B) On delayed imaging, the contrast emptied

preferentially through the renal vein. The black arrow

marks the border of the inferior vena cava.

Fig. 3. The left renal vein is normal caliber and now en-

hances appropriately. The kidney has also returned to

normal size. The size is now symmetric with the right

at 10.5 cm.

Vol. -, No. -, - 2014 Case Report 3

the remaining 5 requiring adjunctive thrombolytic

therapy.10 In contrast to the presented patient, com-

plete recanalization of the renal veins post procedure

was demonstrated.

The rationale for choosing a combined arteriove-

nous infusion approach was based on the need to

address the clot burden within both the micro-

and macrovascular renal circulation. In addition,

the collateral flow noted in this patient was via the

lumbar veins. The primary collateral of the left renal

vein is typically the gonadal vein, and with gonadal

vein compromise outflow was insufficient. Only 2

case reports in the literature describe using this tech-

nique for acute renal vein thrombosis; both demon-

strated successful recanalization of the renal veins

within 48 hr, normal kidney function, and complete

resolution of their symptoms (e.g. flank pain).11,12

There are several advantages to using the dual

approach. As described in the treatment of superior

mesenteric vein thromboses, dual therapy provides

direct and indirect access to the clot burden allowing

maximal outflow after thrombolysis.13,14 Patency in

our patient was evident by inline flow to the IVC

with loss of collaterals. Another advantage of this

technique is that low-dose infusions can be used,

thus reducing the side effects caused by these

drugs.13 Although there can be increased complica-

tions with an arterial catheter such as catheter

thrombosis or pseudoaneurysm formation, these

can be minimized with heparinization and proper

arteriotomy management.

Inevaluating futurepatientswith similar presenta-

tion, a venous-only approach will initially be utilized

to assess the extent of the thrombus and to decrease

the clot burden by mechanochemical thrombolysis.

If the thrombus is isolated to the main renal vein

and can be crossed, it is reasonable to pursue vein-

only access. Additionally, the use of EndoWave Infu-

sion Catheter System (EKOS Corporation, Bothell,

WA) could be utilized as an additional adjunct in

these cases. However, with extensive thrombosis

4 Case Report Annals of Vascular Surgery

extending to the renal hilum, as in our patient,

arteriovenous thrombolysis is the only therapy to

completely clear the venous microcirculation of clot.

CONCLUSIONS

Acute renal vein thrombosis, either primary or

secondary, can impose significant morbidity on

patients. Percutaneous catheter-directed thrombol-

ysis should be utilized to salvage patients with

impending renal loss. Presented here is a case report

of acute renal vein thrombosis refractory to venous

mechanochemical thrombolysis and venoplasty

with need for subsequent institution of arteriove-

nous thrombolysisda proposed next step in the

treatment algorithm.

Thomas Heafner, MD: Study conception and design, Data

Collection, Writing the Article, Final approval of the article.

Daniel Scott, MD: Study analysis and interpretation, Data

Collection, Writing the Article, Critical revision of the article,

Final approval of the article.

J. Devin Watson, MD: Study analysis and interpretation,

Critical revision of the article, Final approval of the article.

Brandon Propper, MD: Study conception and design, Critical

revision of the article, Final approval of the article.

Chatt Johnson, MD: Study conception and design, Data

Collection, Critical revision of the article, Final approval of the

article.

Zachary Arthurs, MD: Study conception and design, Critical

revision of the article, Final approval of the article.

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