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Relevant clinical history and physical exam
A 70 year-old male developed sudden onset of severe left flank pain associated with nausea and vomiting. He presented to our hospital after a day at the onset of symptoms. He diagnosed paroxysmal atrial fibrillation 2 years ago, but anticoagulant therapy wasn’t started since his CHADS2 score was 0 point. On examination, he had ill appearance and febrile to 37.5°C. His blood pressure was 134/68 mmHg. Abdominal examination showed remarkable tenderness over the left flank area.
Relevant test results prior to catheterization
On admission, initial investigations revealed white blood cell count 12.4 × 103 mL, ALT 87 U/L, AST 39 U/L, LDH 378 U/L, and serum creatinine 1.89 mg/dL. ECG showed atrial fibrillation. The etiology of abdominal pain was unclear by plain CT, therefore, we performed contrast-enhanced CT. It revealed no flow at the origin of left renal artery with no enhancement of the left kidney. It hadn’t started renal atrophy, so we diagnosed acute renal artery embolism.
Relevant catheterization findings
We performed emergent catheter angiography. The initial abdominal aortography confirmed a completely occluded left renal artery. Abdominal aortography could not confirm the origin of left renal artery, so we used contrast CT image to reveal the ostium of the left renal artery.
A 6Fr guiding catheter (Sheath Less PV Angle 80) was positioned at the ostial part of the left renal artery, using the aorta no touch technique. A 0.014 inch guide wire (Chevalier Universal) was crossed into superior brunch of renal artery, supporting with micro catheter (Quick-cross 135 cm). Repetitive thrombectomy with an aspiration catheter was performed. However, blood flow was not restored, so predilation with a 2.0 × 20 mm balloon (Coyote) was performed. At the proximal area, further dilation was performed with a 5.0 × 20 mm balloon (Sterling). Despite additional thrombectomy and balloon dilation performed, distal blood flow could not be established at the superior polar brunch. Because most of renal artery got better blood flow and his abdominal pain completely disappeared, we finished this procedure. After the revascularization, we started anticoagulation therapy with heparin immediately. A week after intervention, transesophageal echocardiography revealed left atrial thrombus in diameter of 15 mm.
Renal artery embolism is rare and the diagnosis is often delayed or missed due to its rarity and non-specific clinical presentation. Optimal therapy for renal artery embolism still remains controversial. Even though various methods of management have been applied including surgical intervention, anticoagulant therapy, and systemic or selective thrombolytic therapy. The method of intervention was mainly performed selective thrombolytic therapy. In the past series of renal artery embolism, revascularization with thrombectomy and balloon dilation was seen in a few reports. Emergency renal artery revascularization was useful to improve abdominal pain and to prevent progression in renal failure.