Successful Percutaneous Renal Intervention in a Patient With Acute Traumatic Renal Artery Thrombosis
A 20-year-old male who had fallen from the third floor of a building after excessive alcohol intake presented to our emergency room. He complained of flank pain, and subsequent simple x-ray and pelvis computed tomography revealed a right acetabular fracture, which we decided to treat conservatively. There were no other major injuries. An abdominal computed tomography scan (Figure 1A and 1B) revealed bilateral multifocal renal infarction. An urgent technetium-labeled dimercaptosuccinic acid renal scan (Figure 1C and 1D) showed significantly reduced perfusion in both lower lobes of the kidney. An emergent renal angiogram showed normal right main renal artery (Figure 2A). The anomalous right inferior polar artery showed complete thrombotic occlusion (Figure 2B). We prudently pursued the percutaneous renal intervention because there were no other major injuries or bleeding. After the lesion was crossed with a coronary guide wire, a balloon occlusive type of distal protection device (PercuSurge, Medtronic) (Figure 2C) was placed distal to the culprit lesion. Repetitive thrombosuction with an aspiration catheter (Export catheter, Boston Scientific) was performed (Figure 2D). There was still sluggish flow in the distal renal artery. The culprit lesion was directly stented with 2 overlapping 4.5×24-mm and 4.5×15-mm Driver stents (Medtronic) at 12 and 16 atm, respectively (Figure 3A and 3C). After the procedure, an angiogram showed good patency in the stented renal artery without visible thrombi, but it also showed mild distal slow reflow (Figure 4B). With adequate antiplatelet administration, follow-up renal angiograms at 1 and 2 weeks showed significantly improved distal renal flow without any visible residual thrombus (Figure 4C and 4D).
Acute posttraumatic bilateral renal artery thrombosis is a rare phenomenon and has been sparsely described in the literature. The possible reported mechanisms are the subintimal tears produced by sudden deceleration, followed by subintimal dissection and thrombosis.1 The injury site is usually 1 or 2 cm from the aorta because of the possible maximal angulation and traction on the artery at the point of fixation near the aorta.2 Another suggested mechanism is contusion of the renal artery caused by compressed between the anterior abdominal wall and the vertebral bodies.3 The renal tissue can maintain viability for around 24 hours.4 Hence, it requires immediate management, and in cases where there are no other major injuries or bleeding problems, we may choose the percutaneous revascularization, rather than thrombolysis or surgical management, for faster treatment of the thrombotic occlusion.
We have chosen the balloon occlusive distal protection device rather than a filter-based distal protection device based on our experience (unpublished data). At 6 months, the patient was free of renal disease and hypertension, and his fracture had completely healed without complications. Immediate percutaneous renal artery intervention with a distal protection for managing acute renal thrombotic occlusion seems to be safe and feasible.