O-092 - ENDOVASCULAR THROMBECTOMY AND LYSIS FOR ACUTE RENAL VEIN THROMBOSIS: INDICATIONS, TECHNICAL ASPECTS, OUTCOME AND AETIOLOGY

TOPIC:
Case Reports
AUTHORS:
Low R. (Faculty of Medicine, Imperial College London ~ London ~ United Kingdom) , Crane J. (West London Renal and Transplant Center, Hammersmith Hospital ~ London ~ United Kingdom) , Sackey F. (Accident and Emergency Department, Ealing Hospital ~ London ~ United Kingdom) , Malina M. (West London Vascular and Interventional Center, Northwick Park and St Mark's Hospital ~ London ~ United Kingdom)
Introduction:
Acute renal vein thrombosis (RVT) is uncommon and typically associated with nephrotic syndrome or known coagulopathies. Prompt diagnosis in individuals with no apparent risk factors remains a challenge. The main treatment options are systemic anticoagulation alone or a catheter-directed endovascular thrombectomy. Indications for thrombectomy are unclear. We report a rare case of acute RVT that was treated with endovascular thrombectomy and lysis.
Methods:
A 21-year-old female athlete presented with sudden pain in her left flank and vomiting. A 3-phase CT angiogram identified total occlusion of the left renal vein with no excretion from the swollen and tender left kidney (Figure 1A and B). Catheter-directed thrombolysis and thrombectomy were initiated 24 hours after onset of symptoms. This involved infusion of recombinant tissue plasminogen activator via the catheter and a subsequent Fogarty manoeuvre to clear remaining massive thrombi (Figure 2A and B).
Results:
Complete resolution of the RVT with normalized renal function was achieved within 42 hours (Figure 1C). Post-operative CT venogram (Figure 2C) and doppler ultrasound scan confirmed patent renal vein and normal renal resistance. The patient was discharged on Apixaban and remains well at six months. Combined hormonal contraception via an intra-vaginal ring and retrospectively-discovered raised Factor VIII activity were the only identified risk factors.
Conclusion:
Rapid recanalization of RVT thrombosis with full recovery of renal function was achieved by endovascular thrombolysis and thrombectomy. The indication was complete venous obstruction with urgently compromised kidney in a low risk patient. To our best knowledge, this is the first report of acute RVT associated with the intra-vaginal ring, supplementing other reports of rare venous thromboembolisms with this product. Increased Factor VIII activity was another risk factor, which has not been associated with acute RVT independently. We propose catheter-directed thrombolysis and thrombectomy for total RVT in fit patients with acutely compromised renal function. Further evaluation of an endovascular approach versus systemic anticoagulation alone is warranted.
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