Delayed Revascularization Of Thrombosed Renal Artery Stent After Endovascular Repair Of Juxtarenal Aortic Aneurysm With Snorkels
Mohammed I. Dairywala, BS, Tomasso Cambiaghi, MD, Naveed U. Saqib, MD.
McGovern Medical School at UTHealth, Houston, TX, USA.
DEMOGRAPHICS: 63 year old male
HISTORY: We present the case of a patient with history of EVAR with bilateral renal snorkels who presented four months after the index procedure with severe left flank pain that began 72 hours prior to admission. The patient also admitted not to be compliant with the dual anti-platelet therapy prescribed at discharge from his index aortic procedure. Creatinine was elevated to 2.44 mg/dL from baseline of 1.33 mg/dL at time of discharge post EVAR. CTA demonstrated left renal stent thrombosis with residual flow in the distal native artery (Figure 1).
PLAN: Given the CTA findings and overall clinical picture the decision was made to proceed with endovascular revascularization via left brachial artery approach. The renal artery was catheterized and patency of the distal artery was confirmed via angiography. Low dose TPA was then administered, followed by mechanical suction thrombectomy. Lastly, the original stent graft was relined and completion angiography demonstrated perfusion of all renal branches (Figure 2). Postoperatively the patient had gradual improvement in renal function evidenced by reduction in creatinine and resolution of his flank pain. By the third post-operative day the pain had completely resolved, and the patient was discharged home. At 6-week follow-up the patient continued to be pain-free and denied any new symptoms.
DISCUSSION: Renal ischemia due to stent thrombosis is a potential complication of renal artery stenting. As endovascular repair of juxtarenal aneurysms became more popular, with parallel grafting and branched and fenestrated devices, the prevalence of renal artery stent thrombosis has increased accordingly. Despite the growing prevalence, only limited experience with delayed revascularization is available and no clear guidelines exist yet. Here we demonstrate that delayed revascularization (> 48 hours of warm ischemic time) of thrombosed renal artery stent grafts is a safe procedure which can lead to improvement in both patient symptoms and objective renal function. Further studies are warranted to identify the timeline and patientsí characteristics associated to meaningful recovery after delayed revascularization.
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