- Email: [email protected]
Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms
Accepted Manuscript Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms Fan Zhou, Yanfeng Cui, Qian Zhao, Hao Xu, Maoheng Zu, Wei Xu PII:
S0890-5096(19)30135-9
DOI:
https://doi.org/10.1016/j.avsg.2018.11.027
Reference:
AVSG 4247
To appear in:
Annals of Vascular Surgery
Received Date: 13 May 2018 Revised Date:
19 October 2018
Accepted Date: 11 November 2018
Please cite this article as: Zhou F, Cui Y, Zhao Q, Xu H, Zu M, Xu W, Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2018.11.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page
1 2 3
Title: Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms
4 Authors’ names: Fan Zhou1; Yanfeng Cui1; Qian Zhao2; Hao Xu1; Maoheng Zu1; Wei Xu1
6
Affiliations: 1. from the Department of Interventional Radiology, the Affiliated Hospital of Xuzhou
7
Medical University, Xuzhou, 221006, China; 2. from the Department of Endocrinology, the Affiliated
8
Hospital of Xuzhou Medical University, Xuzhou, 221006, China.
SC
RI PT
5
M AN U
9
Corresponding author: Wei Xu, present address: Department of Interventional Radiology, the
11
Affiliated Hospital of Xuzhou Medical University, No.99, Huaihai West Road, Xuzhou 221006, China;
12
business telephone number: +86 051685806752; home telephone number: +86 158 9522 5305; e-mail
13
address: [email protected]; fax number: +86 051685806752.
16 17 18 19
Present address: Department of Interventional Radiology, the Affiliated Hospital of Xuzhou Medical
EP
15
University, No.99, Huaihai West Road, Xuzhou 221006, China
AC C
14
TE D
10
20 21 22 23 1
ACCEPTED MANUSCRIPT 24
Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms
25 Abstract
27
Renal arteriovenous fistula with renal artery aneurysms and dilated renal veins presents as an
28
infrequent lesion. Endovascular therapy has recently been considered the first-line treatment for these
29
conditions. We report a case of a patient with idiopathic renal arteriovenous fistula concomitant with
30
multiple renal artery aneurysms that was successfully treated by the placement of a covered stent.
SC
RI PT
26
M AN U
31 Introduction
33
Renal arteriovenous fistula (RAVF) is uncommon but has a considerable clinical impact on
34
hypertension, abdominal pain, haematuria, high-output cardiac failure and retroperitoneal haemorrhage,
35
and its prevalence has been reported to be less than 0.04% [1]. These conditions are generally classified
36
into three main causes: congenital, idiopathic, and acquired; RAVF coexisting with renal artery
37
aneurysms (RAAs) is an extremely rare lesion [2]. To the best of our knowledge, there are few reports
38
of RAVF associated with RAAs. Herein, we report a case of a 30-year-old woman with hypertension
39
due to a RAVF with multiple RAAs.
EP
AC C
40
TE D
32
41
Case Report
42
A 30-year-old woman was admitted to our hospital because of headache and fatigue for a
43
twelve-months duration. On admission, her blood pressure was 200/125 mmHg, and her heart rate was
44
115 beats per minute. Electrocardiography revealed a sinus rhythm. She was pregnant three years ago
45
and expressed that she had no history of abdominal trauma or surgery. No rales were found on chest 2
ACCEPTED MANUSCRIPT examination. She did not have the clinical symptoms of chest congestion or dyspnea. Heart
47
auscultation revealed no obvious accentuated or attenuated first and second heart sounds. Furthermore,
48
there were no obvious pathological murmurs in all heart valve areas. Laboratory tests for thyroid and
49
suprarenal function were within normal limits. Serum creatinine and urea levels were 56 umol/L and
50
6.28 mmol/L, respectively. The N-terminal prohormone of the brain natriuretic peptide level was 536
51
pg/ml. Ultrasonic cardiogram showed that the left ventricular myocardium was slightly thickened, and
52
the ejection fraction was 64%. A renal ultrasonography scan indicated a well-demarcated hypoechoic
53
lesion in the hilus of the right kidney, containing a high velocity with aliasing and continuous turbulent
54
flows in this structure. Computed tomography angiography (CTA) demonstrated a malformation
55
between the main renal artery and dilated vein, and the inferior vena cava was fearfully enlarged; the
56
right kidney was slightly smaller than the left kidney (Fig. 1A). The renal artery contained multiple
57
RAAs adjacent to the ostium. According to the information we found, the large renal vein was the
58
result of fistula formation associated with the RAAs.
TE D
M AN U
SC
RI PT
46
After expert discussion, urology consultation and informed consent were obtained from the patient,
60
and endovascular therapy was performed. The patient was taken to the operating room, and selective
61
renal angiography, which was performed via a 6 F×100 cm guiding catheter (Codman＆Shurtleff Inc.,
62
Raynham, MA, USA), revealed the early filling of the inferior vena cava within seconds of contrast
63
injection and demonstrated the position and morphology of the RAVF with RAAs between the main
64
right artery and vein (Fig. 1B). After we evaluated the vascular structure, the characteristics of the
65
aneurysms’ necks and the haemodynamics of the fistula were assessed. Carefully, one 8 mm×2.5 cm
66
Viabahn covered stent (W.L. Gore, Newark, DE, USA) was placed across the aneurysm within the
67
renal artery. Subsequently, angiography showed the occlusion of the fistula and aneurysms, and the
AC C
EP
59
3
ACCEPTED MANUSCRIPT partial renal parenchyma did not develop (Fig. 2A). Furthermore, haemoperfusion via the main renal
69
artery was not affected discernibly. Moreover, the patient experienced no cardiovascular events or
70
related complications during the procedure, such as post-operative pain [3]. The patient was given 100
71
mg aspirin and 75 mg clopidogrel three days before the procedure. After stent deployment, she was
72
required to take 100 mg aspirin for life and 75 mg clopidogrel daily for three months. At the
73
three-month follow-up, a CTA showed thrombosis of the dilated renal venous and a decrease in the size
74
of the aneurysms (Fig. 2B). Furthermore, there were no signs of AVF recurrence. Her blood pressure
75
was 130/90 mmHg without taking hypotensive drugs. Her serum creatinine and urea levels were 62
76
umol/L and 7.16 mmol/L, respectively, indicating that her renal function remained relatively stable.
M AN U
SC
RI PT
68
77 Discussion
79
RAVF is an uncommon abnormality characterized by the communication between renal arteries and
80
veins [4], which can be classified as acquired, congenital, and idiopathic characteristics [2]. The
81
majority of RAVFs are acquired as secondary to trauma, nephrectomy, inflammation or percutaneous
82
needle biopsy. Congenital types of RAVFs are characterized by a tangle of cirsoid vessels of small
83
diameter and usually show a high incidence of gross haematuria (approximately 75%). While
84
idiopathic forms, which are the rarest types, usually have one or more large communications between
85
the artery and the vein, they present with cardiovascular symptoms predominantly [5]. The aetiology of
86
idiopathic RAVF cannot be expounded exactly, and it is hypothesized that it develops when
87
pre-existing renal aneurysms form shunts with adjacent renal segmental veins in almost all cases of
88
RAVF [6]. In our patient, the RAVF concomitant with multiple RAAs most likely had an idiopathic
89
cause since the patient had no history of trauma or other probable causes, such as procedure-related
AC C
EP
TE D
78
4
ACCEPTED MANUSCRIPT renal injury. Furthermore, haemodynamic changes, such as hyperdynamic circulation in pregnancy and
91
hormonal changes, may contribute to the formation of aneurysms [7] since the patient was pregnant
92
three years ago. Hypertension and hypertensive heart disease were major clinical complications of the
93
patient, attributing to the arteriovenous fistula redirected blood flow away from the renal parenchyma,
94
causing relative ischaemia and increased renin production [8].
RI PT
90
Endovascular treatment for RAVF has become an increasingly attractive option [9], and the most
96
common option is transcatheter embolization. However, central or pulmonary embolization of embolic
97
materials as a potential complication has limited the use of this method for the treatment of large
98
fistulas, especially in cases of fistulas with wide-neck aneurysms or high-output fistulas [10-12].
99
Further, the fistula in this patient involved the main renal artery and vein. In such cases, transcatheter
100
embolization is seen as especially hazardous and is not recommended, which effectively applies to the
101
treatment of small intrarenal AVFs.
TE D
M AN U
SC
95
In our case, endovascular placement of a covered stent excluded the fistula and the aneurysms,
103
which provided our patient a minimally invasive procedure that was both effective and safe. The
104
objective of achieving closure of the fistula and aneurysms was accomplished under local anaesthesia
105
with minimal morbidity and low risk of complications. Moreover, the method we utilized can prevent
106
the further expansion and rupture of the aneurysm, resulting in a satisfactory therapeutic outcome. In
107
addition, repeat endovascular intervention and remedy surgery were avoided in our patient.
AC C
108
EP
102
109
Conclusion
110
Endovascular treatment in the case of RAVF associated with multiple RAAs is feasible and can provide
111
good therapeutic results in selected patients, such as ours and as those reported in the literature. 5
ACCEPTED MANUSCRIPT 112
Moreover, endovascular treatment is a less invasive alternative to open surgery.
113 References
115
1. Sakoda T, Nishimukai A, Tsujino T, Masuyama T, Miyamoto Y, Oyanagi M. Two giant renal
116
aneurysms and renal arteriovenous fistula associated with cardiac insufficiency and a sustained
117
elevation of atrial natriuretic peptide and brain natriuretic peptide. Am J Med Sci,2007;333:300-304.
118
2. Crotty KL, Orihuera E, Warren MM. Recent advances in the diagnosis and treatment of renal
119
arteriovenous malformations and fistulas. J Urol,1993;150:1355-1359.
120
3. Zhang Z, Yang M, Song L, Tong X, Zou Y. Endovascular treatment of renal artery aneurysms and
121
renal arteriovenous fistulas. J Vasc Surg,2013;57:765-770.
122
4 Giavroglou CE, Farmakis TM, Kiskinis D. Idiopathic renal arteriovenous fistula treated by
123
transcatheter embolization. Acta Radiol,2005;46:368-370.
124
5. Yao M, Zhang Q, Wang J, et al. Congenital renal arteriovenous fistula during the first trimester
125
diagnosed with ultrasonography. J Med Ultrason (2001),2017;44:141-145.
126
6. Takeuchi N, Nomura Y. Ruptured renal arteriovenous malformation successfully treated by catheter
127
embolization: a case report. BMC Res Notes,2014;7:19.
128
7. Hellmund A, Meyer C, Fingerhut D, Müller SC, Merz WM, Gembruch U. Rupture of renal artery
129
aneurysm
130
Obstet,2016;293:505-508.
131
8. Cura M, Elmerhi F, Suri R, Bugnone A, Dalsaso T. Vascular malformations and arteriovenous
132
fistulas of the kidney. Acta Raidol,2010;51:144-149.
133
9. Chatziioannou A, Brountzog E, Primetis E, et al. Effects of superselective embolization for renal
AC C
EP
TE D
M AN U
SC
RI PT
114
during
late
pregnancy:
clinical
6
features
and
diagnosis.
Arch
Gynecol
ACCEPTED MANUSCRIPT vascular injuries on renal parenchyma function. Eur J Vasc Endovasc Surg,2004;28:201-206.
135
10. Eskandari MK, Resnick SA. Aneurysms of the renal artery. Semin Vasc Surg,2005;18:202-208.
136
11. Trocciola SM, Chaer RA, Lin SC, et al. Embolization of renal artery aneurysm and arteriovenous
137
fistula-a case report. Vasc Endovascular Surg,2005;39:525-529.
138
12. Calligaro KD, Dougherty MJ. Renal arteriovenous malformations and fistulae. In: Rutherford RB,
139
editor. Rutherford's vascular surgery. Philadelphia: WB Saunders; 2000. p. 1697-1706.
RI PT
134
140
M AN U
SC
Fig.1. Images before intervention(A)Computed tomography angiography (CTA) showing the renal arteriovenous fistula (RAVF) with multiple renal artery aneurysms (RAAs) between the main renal artery and renal vein. (B)Selective digital subtraction angiography (DSA) showing the detection of contrast within the inferior vena cava (IVC) in the arterial phase.
EP
TE D
Fig.2. Images after intervention(A)Selective DSA showing the RAVF was disappeared, the partial of renal parenchyma did not develop and the contrast was not detected within the IVC in the arterial phase after placing the covered stent. (B)CTA showing the aneurysms was shrunken, and the covered stent (blue arrow) was not migrated.
AC C
141 142 143 144 145 146 147 148 149
7
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SC
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
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ACCEPTED MANUSCRIPT
S0890-5096(19)30135-9
DOI:
https://doi.org/10.1016/j.avsg.2018.11.027
Reference:
AVSG 4247
To appear in:
Annals of Vascular Surgery
Received Date: 13 May 2018 Revised Date:
19 October 2018
Accepted Date: 11 November 2018
Please cite this article as: Zhou F, Cui Y, Zhao Q, Xu H, Zu M, Xu W, Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms, Annals of Vascular Surgery (2019), doi: https://doi.org/10.1016/j.avsg.2018.11.027. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Title Page
1 2 3
Title: Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms
4 Authors’ names: Fan Zhou1; Yanfeng Cui1; Qian Zhao2; Hao Xu1; Maoheng Zu1; Wei Xu1
6
Affiliations: 1. from the Department of Interventional Radiology, the Affiliated Hospital of Xuzhou
7
Medical University, Xuzhou, 221006, China; 2. from the Department of Endocrinology, the Affiliated
8
Hospital of Xuzhou Medical University, Xuzhou, 221006, China.
SC
RI PT
5
M AN U
9
Corresponding author: Wei Xu, present address: Department of Interventional Radiology, the
11
Affiliated Hospital of Xuzhou Medical University, No.99, Huaihai West Road, Xuzhou 221006, China;
12
business telephone number: +86 051685806752; home telephone number: +86 158 9522 5305; e-mail
13
address: [email protected]; fax number: +86 051685806752.
16 17 18 19
Present address: Department of Interventional Radiology, the Affiliated Hospital of Xuzhou Medical
EP
15
University, No.99, Huaihai West Road, Xuzhou 221006, China
AC C
14
TE D
10
20 21 22 23 1
ACCEPTED MANUSCRIPT 24
Hypertension Caused by Renal Arteriovenous Fistula with Multiple Renal Artery Aneurysms
25 Abstract
27
Renal arteriovenous fistula with renal artery aneurysms and dilated renal veins presents as an
28
infrequent lesion. Endovascular therapy has recently been considered the first-line treatment for these
29
conditions. We report a case of a patient with idiopathic renal arteriovenous fistula concomitant with
30
multiple renal artery aneurysms that was successfully treated by the placement of a covered stent.
SC
RI PT
26
M AN U
31 Introduction
33
Renal arteriovenous fistula (RAVF) is uncommon but has a considerable clinical impact on
34
hypertension, abdominal pain, haematuria, high-output cardiac failure and retroperitoneal haemorrhage,
35
and its prevalence has been reported to be less than 0.04% [1]. These conditions are generally classified
36
into three main causes: congenital, idiopathic, and acquired; RAVF coexisting with renal artery
37
aneurysms (RAAs) is an extremely rare lesion [2]. To the best of our knowledge, there are few reports
38
of RAVF associated with RAAs. Herein, we report a case of a 30-year-old woman with hypertension
39
due to a RAVF with multiple RAAs.
EP
AC C
40
TE D
32
41
Case Report
42
A 30-year-old woman was admitted to our hospital because of headache and fatigue for a
43
twelve-months duration. On admission, her blood pressure was 200/125 mmHg, and her heart rate was
44
115 beats per minute. Electrocardiography revealed a sinus rhythm. She was pregnant three years ago
45
and expressed that she had no history of abdominal trauma or surgery. No rales were found on chest 2
ACCEPTED MANUSCRIPT examination. She did not have the clinical symptoms of chest congestion or dyspnea. Heart
47
auscultation revealed no obvious accentuated or attenuated first and second heart sounds. Furthermore,
48
there were no obvious pathological murmurs in all heart valve areas. Laboratory tests for thyroid and
49
suprarenal function were within normal limits. Serum creatinine and urea levels were 56 umol/L and
50
6.28 mmol/L, respectively. The N-terminal prohormone of the brain natriuretic peptide level was 536
51
pg/ml. Ultrasonic cardiogram showed that the left ventricular myocardium was slightly thickened, and
52
the ejection fraction was 64%. A renal ultrasonography scan indicated a well-demarcated hypoechoic
53
lesion in the hilus of the right kidney, containing a high velocity with aliasing and continuous turbulent
54
flows in this structure. Computed tomography angiography (CTA) demonstrated a malformation
55
between the main renal artery and dilated vein, and the inferior vena cava was fearfully enlarged; the
56
right kidney was slightly smaller than the left kidney (Fig. 1A). The renal artery contained multiple
57
RAAs adjacent to the ostium. According to the information we found, the large renal vein was the
58
result of fistula formation associated with the RAAs.
TE D
M AN U
SC
RI PT
46
After expert discussion, urology consultation and informed consent were obtained from the patient,
60
and endovascular therapy was performed. The patient was taken to the operating room, and selective
61
renal angiography, which was performed via a 6 F×100 cm guiding catheter (Codman＆Shurtleff Inc.,
62
Raynham, MA, USA), revealed the early filling of the inferior vena cava within seconds of contrast
63
injection and demonstrated the position and morphology of the RAVF with RAAs between the main
64
right artery and vein (Fig. 1B). After we evaluated the vascular structure, the characteristics of the
65
aneurysms’ necks and the haemodynamics of the fistula were assessed. Carefully, one 8 mm×2.5 cm
66
Viabahn covered stent (W.L. Gore, Newark, DE, USA) was placed across the aneurysm within the
67
renal artery. Subsequently, angiography showed the occlusion of the fistula and aneurysms, and the
AC C
EP
59
3
ACCEPTED MANUSCRIPT partial renal parenchyma did not develop (Fig. 2A). Furthermore, haemoperfusion via the main renal
69
artery was not affected discernibly. Moreover, the patient experienced no cardiovascular events or
70
related complications during the procedure, such as post-operative pain [3]. The patient was given 100
71
mg aspirin and 75 mg clopidogrel three days before the procedure. After stent deployment, she was
72
required to take 100 mg aspirin for life and 75 mg clopidogrel daily for three months. At the
73
three-month follow-up, a CTA showed thrombosis of the dilated renal venous and a decrease in the size
74
of the aneurysms (Fig. 2B). Furthermore, there were no signs of AVF recurrence. Her blood pressure
75
was 130/90 mmHg without taking hypotensive drugs. Her serum creatinine and urea levels were 62
76
umol/L and 7.16 mmol/L, respectively, indicating that her renal function remained relatively stable.
M AN U
SC
RI PT
68
77 Discussion
79
RAVF is an uncommon abnormality characterized by the communication between renal arteries and
80
veins [4], which can be classified as acquired, congenital, and idiopathic characteristics [2]. The
81
majority of RAVFs are acquired as secondary to trauma, nephrectomy, inflammation or percutaneous
82
needle biopsy. Congenital types of RAVFs are characterized by a tangle of cirsoid vessels of small
83
diameter and usually show a high incidence of gross haematuria (approximately 75%). While
84
idiopathic forms, which are the rarest types, usually have one or more large communications between
85
the artery and the vein, they present with cardiovascular symptoms predominantly [5]. The aetiology of
86
idiopathic RAVF cannot be expounded exactly, and it is hypothesized that it develops when
87
pre-existing renal aneurysms form shunts with adjacent renal segmental veins in almost all cases of
88
RAVF [6]. In our patient, the RAVF concomitant with multiple RAAs most likely had an idiopathic
89
cause since the patient had no history of trauma or other probable causes, such as procedure-related
AC C
EP
TE D
78
4
ACCEPTED MANUSCRIPT renal injury. Furthermore, haemodynamic changes, such as hyperdynamic circulation in pregnancy and
91
hormonal changes, may contribute to the formation of aneurysms [7] since the patient was pregnant
92
three years ago. Hypertension and hypertensive heart disease were major clinical complications of the
93
patient, attributing to the arteriovenous fistula redirected blood flow away from the renal parenchyma,
94
causing relative ischaemia and increased renin production [8].
RI PT
90
Endovascular treatment for RAVF has become an increasingly attractive option [9], and the most
96
common option is transcatheter embolization. However, central or pulmonary embolization of embolic
97
materials as a potential complication has limited the use of this method for the treatment of large
98
fistulas, especially in cases of fistulas with wide-neck aneurysms or high-output fistulas [10-12].
99
Further, the fistula in this patient involved the main renal artery and vein. In such cases, transcatheter
100
embolization is seen as especially hazardous and is not recommended, which effectively applies to the
101
treatment of small intrarenal AVFs.
TE D
M AN U
SC
95
In our case, endovascular placement of a covered stent excluded the fistula and the aneurysms,
103
which provided our patient a minimally invasive procedure that was both effective and safe. The
104
objective of achieving closure of the fistula and aneurysms was accomplished under local anaesthesia
105
with minimal morbidity and low risk of complications. Moreover, the method we utilized can prevent
106
the further expansion and rupture of the aneurysm, resulting in a satisfactory therapeutic outcome. In
107
addition, repeat endovascular intervention and remedy surgery were avoided in our patient.
AC C
108
EP
102
109
Conclusion
110
Endovascular treatment in the case of RAVF associated with multiple RAAs is feasible and can provide
111
good therapeutic results in selected patients, such as ours and as those reported in the literature. 5
ACCEPTED MANUSCRIPT 112
Moreover, endovascular treatment is a less invasive alternative to open surgery.
113 References
115
1. Sakoda T, Nishimukai A, Tsujino T, Masuyama T, Miyamoto Y, Oyanagi M. Two giant renal
116
aneurysms and renal arteriovenous fistula associated with cardiac insufficiency and a sustained
117
elevation of atrial natriuretic peptide and brain natriuretic peptide. Am J Med Sci,2007;333:300-304.
118
2. Crotty KL, Orihuera E, Warren MM. Recent advances in the diagnosis and treatment of renal
119
arteriovenous malformations and fistulas. J Urol,1993;150:1355-1359.
120
3. Zhang Z, Yang M, Song L, Tong X, Zou Y. Endovascular treatment of renal artery aneurysms and
121
renal arteriovenous fistulas. J Vasc Surg,2013;57:765-770.
122
4 Giavroglou CE, Farmakis TM, Kiskinis D. Idiopathic renal arteriovenous fistula treated by
123
transcatheter embolization. Acta Radiol,2005;46:368-370.
124
5. Yao M, Zhang Q, Wang J, et al. Congenital renal arteriovenous fistula during the first trimester
125
diagnosed with ultrasonography. J Med Ultrason (2001),2017;44:141-145.
126
6. Takeuchi N, Nomura Y. Ruptured renal arteriovenous malformation successfully treated by catheter
127
embolization: a case report. BMC Res Notes,2014;7:19.
128
7. Hellmund A, Meyer C, Fingerhut D, Müller SC, Merz WM, Gembruch U. Rupture of renal artery
129
aneurysm
130
Obstet,2016;293:505-508.
131
8. Cura M, Elmerhi F, Suri R, Bugnone A, Dalsaso T. Vascular malformations and arteriovenous
132
fistulas of the kidney. Acta Raidol,2010;51:144-149.
133
9. Chatziioannou A, Brountzog E, Primetis E, et al. Effects of superselective embolization for renal
AC C
EP
TE D
M AN U
SC
RI PT
114
during
late
pregnancy:
clinical
6
features
and
diagnosis.
Arch
Gynecol
ACCEPTED MANUSCRIPT vascular injuries on renal parenchyma function. Eur J Vasc Endovasc Surg,2004;28:201-206.
135
10. Eskandari MK, Resnick SA. Aneurysms of the renal artery. Semin Vasc Surg,2005;18:202-208.
136
11. Trocciola SM, Chaer RA, Lin SC, et al. Embolization of renal artery aneurysm and arteriovenous
137
fistula-a case report. Vasc Endovascular Surg,2005;39:525-529.
138
12. Calligaro KD, Dougherty MJ. Renal arteriovenous malformations and fistulae. In: Rutherford RB,
139
editor. Rutherford's vascular surgery. Philadelphia: WB Saunders; 2000. p. 1697-1706.
RI PT
134
140
M AN U
SC
Fig.1. Images before intervention(A)Computed tomography angiography (CTA) showing the renal arteriovenous fistula (RAVF) with multiple renal artery aneurysms (RAAs) between the main renal artery and renal vein. (B)Selective digital subtraction angiography (DSA) showing the detection of contrast within the inferior vena cava (IVC) in the arterial phase.
EP
TE D
Fig.2. Images after intervention(A)Selective DSA showing the RAVF was disappeared, the partial of renal parenchyma did not develop and the contrast was not detected within the IVC in the arterial phase after placing the covered stent. (B)CTA showing the aneurysms was shrunken, and the covered stent (blue arrow) was not migrated.
AC C
141 142 143 144 145 146 147 148 149
7
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EP
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M AN U
SC
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ACCEPTED MANUSCRIPT
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EP
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