Return of Normal Kidney Function After Bilateral Renal Artery Stent Occlusion and Treatment Delay Following Fenestrated Endografting
Trishul Kapoor, MD, Gustavo Oderich, MD, Randall DeMartino, MD.
Mayo Clinic, Rochester, Rochester, MN, USA.
DEMOGRAPHICS:
Endovascular angioplasty and stenting has increased due to both treatment of atherosclerotic renal artery stenosis and use in complex endovascular aneurysm repair. Although renal artery restenosis and thrombotic stent occlusion are not rare occurrences, literature suggests prompt diagnosis and treatment are essential in order preserve renal function, particularly in the setting of occlusion.
HISTORY:
In this case report, we describe the a 75-year-old female who underwent fenestrated endovascular aneurysm repair who experienced acute anuric renal failure requiring dialysis secondary to bilateral renal artery stent occlusion for greater than 48 hours who was successfully treated with revisional endovascular therapy and full renal recovery.
PLAN:
She was taken immediately to the operating room with successful bilateral renal artery re-stent grafting with iCAST 6 x 22mm stents. She had return of renal function and did not require any further dialysis after revascularization. Six week renal ultrasound demonstrated patent bilateral renal artery stents with PSV and RI of 122 cm/s, 0.82 in the right and 76 cm/s, 0.81 in the left. Her sodium and potassium were within normal limits with a BUN of 19 mg/dL and creatinine of 1.0 mg/dL and a normal urine analysis.
DISCUSSION:
Renal failure secondary to renal artery thromboembolism tends to be uncommon. However, when a renal artery stent occlusion occurs with subsequent renal failure, the diagnosis can be delayed due to nonspecific clinical symptoms and laboratory studies. Although renal ultrasound with Doppler is a valid option for screening purposes, CT modalities are much more sensitive in detecting renal infarct. When the diagnosis of acute renal artery occlusion is made, urgent intervention should be considered. There is minimal literature on an optimal time frame for initiation of treatment. However, it is suggested to complete intervention in this setting within 72 hours of confirmed diagnosis. Urgent revascularization does not always result in return of baseline kidney function. There are several factors that determine the overall tolerance of renal ischemia in a patient - extent of thrombus, location of thrombus, presence of vascular collaterals, accessary vasculature, and extent of underlying renal disease. Current literature suggests irreversible renal damage can occur within three hours renal artery occlusion.
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