Percutaneous Treatment of Traumatic Renal-Caval Arteriovenous Fistula Presenting 50 years After a Gunshot Wound with Kidney Involution
Amanda G. Fobare, MD, Ravi R. Rajani, MD.
Grady Memorial Hospital, Emory University, Atlanta, GA, USA.
DEMOGRAPHICS: Traumatic arteriovenous fistulas (AVF) involving the renal artery and the inferior vena cava (IVC) are rare. Management of this anomalous connection may be necessary give the propensity for these patients to develop heart failure and impaired renal function. Historically, laparotomy with or without nephrectomy has been the 'gold standard' of therapy, though endovascular techniques are an option in selected patients.
HISTORY: We present a 66-year-old woman with a past medical history significant for persistent hypertension despite two antihypertensive agents and lower extremity edema. Of note, she suffered a GSW to the abdomen at the age of 16, and underwent an exploratory laparotomy for unknown reasons at that time. Fifty years later she underwent a computed tomography (CT) scan of her abdomen for unrelated reasons, which demonstrated complete atrophy of her right kidney and a large right renal artery to inferior vena cava arteriovenous fistula.
PLAN: Given her persistent hypertension and concern for the progression of high output heart failure, it was recommended that she undergo treatment for her renal-caval AVF. She subsequently underwent coil embolization of the right renal artery with improvement in her hypertension and dyspnea.
DISCUSSION: We report a very rare case of a renal-caval AVF presenting 50 years after a GSW to the abdomen with kidney involution, preserved renal function, hypertension and evidence of heart failure. Long-standing steal of blood flow to the kidney can lead to near-complete organ involution and secondary symptoms. Select cases can be managed with endovascular techniques.
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