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Case 202

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36 year-old male patient, bearer of systemic hypertension and fibromuscular dysplasia of renal arteries, previously submitted to left renal artery angioplasty with Stent implant in 2004. He was admitted in an urgency service, reporting sudden and intense pain in his left side and iliac fossa. Upon internment, his serum creatinine levels were 1,9mg/dl and the following imaging exams were requested: renal artery angiography, static renal scintigraphy with Tc-99m DSMA and angiotomography.

Based on the clinical picture and the images, which one of the following is the best managemant?

a) Left nephrectomy

25%

b) Expectant management

25%

c) Aneurysm embolization

25%

d) Surgical removal of the aneurysm

25%
   

Image analysis

Image 1: Abdominal aorta angiography showcases severe stenosis in 80% of the left renal artery, over the previously implanted Stent (red arrow). Next to the stenosis there is a voluminous saccular aneurysm with partial thrombosis (green circle). There is also moderate (50-60%) right renal artery stenosis

 

 

Image 2: Static renal scintigraphy with Tc-99m DSMA showcases hypo-uptake in the left kidney parenchyma (red circle), with some renal function still remaining.

 

Image 3: Computed tridimensional abdominal angiotomography demonstrates the anatomical relations between the aneurysm and other vascular structures: left kidney (green arrow), right kidney (red arrow), Stent inside the left renal artery (pink arrow), aneurysm (purple arrow), splenic artery (yellow arrow), common hepatic artery (orange arrow) and abdominal aorta (blue arrow).

 

 

Video 1: Selective angiography of the left renal artery gives further detail on the findings of Image 1.

Highlights

- Renal artery aneurysms are rare, with a prevalence of 0,01% in autopsy studies.

- The diagnosis is usually done with renal arteriography.

- Are more common in females, due to the strong association with fibromuscular dysplasia.

- If the renal scintigraphy with Tc-99m DSMA indicates preserved renal function, one can choose to perform the embolization of the aneurysm, unless there is some contraindication.

- These aneurysms can be classified according to their location, which helps to establish management strategies.

- The renal artery aneurysm embolization is considered a minimally invasive technique and, when indicated correctly, enables the preservation of the organ and its functions.

References

- Barros K, Metzger P, Rossi F, Rodrigues T, Moreira S, Petisco A, Izukawa N, Kambara A. Técnicas e táticas no tratamento endovascular do Aneurisma da Artéria Renal. Rev Bras Cardiol Invasiva. 2014;22(1):64-72

- Karkos CD, D’Souza SP, Thomson GJ, Chomal A, Matanhelia SS. Renal artery aneurysm: endovascular treatment by coil embolisation with preservation of renal blood flow. Eur J Vasc Endovasc Surg. 2000;19:214-6

- Abath C, Andrade G, Cavalcanti D, Brito N, Marques R. Complex renal artery aneurysms: liquids or coils? Tech Vasc Interv Radiol. 2007;10:299-307.

- Eskandari MK, Resnick SA. Aneurysms of the renal artery. Semin Vasc Surg. 2005;18:202-8.

- Brito LC, Martins JT, Passos E, Santos AJ, Gama RA, Furlani GX. Tratamento de aneurisma da artéria renal por embolização e técnica de remodelamento de colo: relato de caso. J Vasc Bras. 2011;10(2):181-184.

- Moret J, Pierot L, Boulin A, Castaings L, Rey A. Endovascular treatment of anterior communicating artery aneurysms using Guglielmi detachable coils. Neuroradiology. 1996;38:800-5.

Authors

Gustavo Campos, 6th year medical student at UFMG.

E-mail: fcamposgustavo[at]gmail.com

 

Caroline dos Reis, 6th year medical student at UFMG.

E-mail: creis.caroline[at]gmail.com

Supervisors

Marcos Antonio Marino, coordenator of the Departament of Hemodynamics, Cardiology and Intervencionist Vascular Radiology of Madre Teresa-BH Hospital. SBHCIs director of Continued Education.

E-mail: marcosamarino[arroba]yahoo.com.br

 

Ronald de Souza, specializing in Hemodynamics, Cardiology and Intervencionist Vascular Radiology in Madre Teresa-BH Hospital.

E-mail: souza.ronald[arroba]cardiol.br

Reviewers

Barbara Queiroz, Júlia Petrocchi and Professor Viviane Parisotto.

Translated by

Rafael Fusaro Aguiar Oliveira, 4th year medical student at UFMG.

E-mail: rafusaro[at]hotmail.com

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