1Shaker Alshehri,1,2Raad Madkhali, 3Dr. Mahdi Aljawad
1King Abdulaziz Medical City, 2King Fahad Hofuf Hospital, 3King Fahad Hospital
We present one of the unusual and rare presentation of TA of a 47-year-old male presented with an abrupt onset of anuria for 3 days duration, with 10 days prior to presentation he was complaining of central abdominal pain.On the physical exam the lower limbs pulse was palpable but weak bilaterally. The abdominal exam revealed mild tenderness more on the right side. The remainder of the exam was normal. Patient was anuric even after Foleys catheter insertion. Non-enhanced CT showed no obstructive uropathy or renal stones. Next day of admission his creatinine level jumped to 900 mmol/L. Urgent renal Doppler ultrasound results were highly concerning for bilateral main renal artery thrombosis versus stenosis. Enhanced CT angiography revealed thrombosed abdominal aorta extending to the iliac branches and involving the proximal renal arteries, distal splenic artery, SMA and IMA with bilateral renal and splenic infarctions. The thrombosed vessels have enhancing thickened wall with progressive delayed enhancement. Interventional radiology consulted and left brachial artery access was obtained, aortogram and renal angiogram was done through a pigtail catheter, revealed chronic total aortoiliac occlusion, bilateral renal arteries and origin of the superior mesenteric arteries occlusion. Right renal artery was recanalized, 6 mg t-PA was given as bolus. Then Left radial artery access was done and Left renal artery was recanalized, 6 mg t-PA was given as bolus. 135 cm x 10 cm CRAGG MC-NAMARA catheter directed thrombolysis was placed in the right and left renal arteries. Both catheters and sheaths were fixed. Catheter directed thrombolysis was started using t-PA infusion through the catheters and heparin infusion through the sheaths.
Material(s) and Method(s):
Aortogram next day demonstrated complete patency of the renal arteries bilaterally and the flow was resumed to the kidneys parenchyma. Renal Doppler ultrasound confirmed no thrombus in renal arteries. Patient received 3 session of hemodialysis in the first few days, however after thrombolysis he start to produce urine 3L per day, he did not receive any dialysis session after that.
Bilateral renal arteries thrombosis as a cause of acute renal failure in TA managed by catheter directed thrombolysis, lead to immediate improvement in kidney function and avoid renal ischemia and chronic renal failure.