KNIFED IN THE ABDOMEN
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1 Originally Posted: November 01, 2014 KNIFED IN THE ABDOMEN Resident(s): Andrew Duarte, MD Attending(s): Ryan Scott, MD & David Kay, MD Program/Dept(s): St. Joseph s Hospital and Medical Center, Phoenix, AZ
2 CHIEF COMPLAINT & HPI 24 year old male involved in recent penetrating (stab wound) traumatic injury underwent exploratory laparotomy with cholecystectomy and primary repair or the duodenum, IVC and liver lacerations. Uneventful postoperative course interrupted by acute onset of vague right abdominal pain related to movement on post-operative day 9, with rising leukocytosis and mild hyperbilirubinemia.
3 RELEVANT HISTORY Past Medical History Non contributory. Past Surgical History Non contributory. Medications Lovenox 40 mg BID (DVT prophylaxis) Pepcid 20 mg BID (GI prophylaxis) Percocet and morphine PRN pain Zosyn recently discontinued Allergies NKDA
4 DIAGNOSTIC WORKUP - QUESTION What salient findings are present on this axial image from a CECT? (Select one of the following) A. Irregular collection of contrast adjacent to the right renal artery/vein and asymmetric enhancement of B. An accessory right renal artery and asymmetric enhancement of C. A duplicated IVC and symmetric enhancement of D. Irregular collection of contrast adjacent to the right renal artery/vein and symmetric enhancement of
5 CORRECT! What salient findings are present on this axial image from a CECT? A. Irregular collection of contrast adjacent to the right renal artery/vein and asymmetric enhancement of B. An accessory right renal artery and asymmetric enhancement of C. A duplicated IVC and symmetric enhancement of D. Irregular collection of contrast adjacent to the right renal artery/vein and symmetric enhancement of CONTINUE WITH CASE
6 SORRY, THAT S INCORRECT. What salient findings are present on this axial image from a CECT? A. Irregular collection of contrast adjacent to the right renal artery/vein and asymmetric enhancement of B. An accessory right renal artery and asymmetric enhancement of C. A duplicated IVC and symmetric enhancement of D. Irregular collection of contrast adjacent to the right renal artery/vein and symmetric enhancement of CONTINUE WITH CASE
7 DIAGNOSTIC WORKUP Non-Invasive Imaging Contrast enhanced CT Axial image demonstrates a lobulated contrast collection in the right retroperitoneum associated with the right renal artery, right renal vein, and inferior vena cava (circle). The right kidney hypoenhances compared with the left. Sagittal reformat image demonstrates the lobulated retrocaval contrast collection with mass effect on the IVC (circle).
8 DIAGNOSIS Based on the contrast enhanced CT, the probable diagnosis was a renal artery pseudoaneurysm.
9 INTERVENTION On aortography, a rapidly filling, irregular connection between the right renal artery and the suprarenal inferior vena cava was evident (circle). Findings are diagnostic of an arteriovenous fistula.
10 INTERVENTION A covered stent (7 x 20 mm, icast) was placed in the proximal right renal artery, at the site of the AV fistula (arrows). Nonselective aortic arteriography after placement of the stent demonstrates exclusion of the fistulous connection. There is an abrupt cut-off of the right mid renal artery with nonopacification distally, consistent with occlusion from acute thrombosis (circle).
11 INTERVENTION A wire was placed across the right renal artery occlusion and angioplasty was performed. Post angioplasty selective right renal arteriogram shows filling of the previously nonopacified vessel. Peripheral, wedge-shaped renal parenchymal defects are evident, consistent with infarcts (arrows).
12 CLINICAL FOLLOW UP Follow-up labs showed no indication of renal insufficiency, despite several segmental renal infarcts. The patient left the interventional department in stable condition. After discussion with the surgical team, he was discharged on Plavix in addition to his other medications.
13 CLINICAL FOLLOW UP- QUESTION A renal artery to caval fistula, if left untreated (select one of the following): A. Will eventually resolve on its own. B. Can lead to obstructive uropathy from increased renal calculi formation. C. Can lead to high output heart failure and paradoxical pulmonary embolism. D. Can lead to portal hypertension and gastroesophageal varices.
14 CORRECT! A renal artery to caval fistula, if left untreated: A. Will eventually resolve on its own. B. Can lead to obstructive uropathy from increased renal calculi formation. C. Can lead to high output heart failure and paradoxical pulmonary embolism. D. Can lead to portal hypertension and gastroesophageal varices. CONTINUE WITH CASE
15 SORRY, THAT S INCORRECT. A renal artery to caval fistula, if left untreated: A. Will eventually resolve on its own. B. Can lead to obstructive uropathy from increased renal calculi formation. C. Can lead to high output heart failure and paradoxical pulmonary embolism. D. Can lead to portal hypertension and gastroesophageal varices. CONTINUE WITH CASE
16 SUMMARY & TEACHING POINTS The lesion represented a traumatic (primary vs iatrogenic) right renal artery to IVC fistula with contained retroperitoneal hemorrhage/pseudoaneurysm. A covered stent placed across the lesion successfully abolished the fistulous connection. Following covered stent placement, poor distal renal arterial flow was noted, with an abrupt cut-off of the right mid renal artery. This was consistent with occlusion from an acute thrombus. Periprocedural heparinization was felt to be risky given the patient s recent surgery. Right renal artery angioplasty resulted in successful recanalization of the artery. Renal artery to caval fistula, if left untreated, can lead to hemorrhage, nephropathy, high-output heart failure and paradoxical pulmonary embolism.
17 REFERENCES & FURTHER READING Tam J, Kossman T, Lyon S. Acute traumatic renal artery to inferior vena cava fistula treated with a covered stent. Cardiovasc Intervent Radiol Nov- Dec;29(6): Wolosker N, Oba CM, Espirito Santo FR, Puech-Leao P. Endovascular treatment for chronic arteriovenous fistula between renal artery and inferior vena cava: image in vascular surgery. Vasc and Endovascular Surg Aug;44(6):
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