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Imaging Findings of Spontaneous Bilateral Renal Artery Dissection
Images in Clinical Urology Imaging Findings of Spontaneous Bilateral Renal Artery Dissection Naman S. Desai, Sachin S. Saboo, Ashish Khandelwal, Michael L. Steigner, and Frank J. Rybicki Bilateral spontaneous renal artery dissection is extremely rare with computed tomography angiography being an efficient noninvasive alternative to catheter angiography for its diagnosis. We report the case of a 65-year-old woman with bilateral spontaneous renal artery dissection resulting in bilateral renal infarctions and hydroureteronephrosis. UROLOGY 82: e33ee34, 2013. 2013 Elsevier Inc.
Figure 1. (A, B) Axial oblique reformatted contrast enhanced computed tomography (CECT) images reveal focal anterior left renal infarct (bold arrow) secondary to dissection of upper division (thin arrow) left renal artery. Coronal digital subtraction angiography (DSA) images prestenting (C) and poststenting (D) images reveal diffusely narrowed true lumen of the left upper division renal artery (thin arrow) with restoration of the flow though the stent lumen after stent placement. Note moderate left hydronephrosis and proximal hydroureter containing blood (D).
A
65-year-old woman without significant past history presented with sharp left flank pain, tenderness, hematuria, and blood pressure of 144/78 mm Hg.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA Reprint requests: Sachin S. Saboo, M.D., F.R.C.R., Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected] Submitted: May 24, 2013, accepted (with revisions): July 24, 2013
ª 2013 Elsevier Inc. All Rights Reserved
Contrast enhanced computed tomography revealed focal left renal infarct secondary to dissection of left upper pole renal artery (Fig. 1A,B). She was initially started on enoxaparin and discharged on warfarin with a therapeutic INR; however, she returned few days later with gross hematuria, extension of her infarcts and 90% occlusion of flow. She subsequently received intraarterial thrombolysis with tissue plasminogen activator and left renal artery stenting (Fig. 1C,D), followed by 0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.07.034
e33
Figure 2. (A, B) Axial oblique reformatted and (C) coronal reformat computed tomography (CT) angiogram images and (D) coronal maximum intensity projection images performed after 3 weeks reveal interval infarction of entire left kidney (thin arrows, A; bold arrow, B) secondary to proximal left renal artery dissection with thrombosed false lumen, partly patent true lumen (thin arrow, A). Note normal stent in the upper division left renal artery (thin black arrow, D). In addition, focal dissection of the right lower pole renal artery at the renal hilum (thin arrows, B-D) with thrombosis of the false lumen and infarction of lower pole of right kidney was also seen (bold arrow, C). Note mild right hydronephrosis and moderate left hydroureteronephrosis containing blood (arrowheads, A-C) and blood clot in the urinary bladder.
heparin, warfarin, and aspirin. Computed tomography angiography performed 3 weeks later revealed infarction of entire left kidney from proximal extension of left renal artery dissection (Fig. 2A) and focal dissection of the right lower pole renal artery with lower pole infarction (Fig. 2B-D). Patient received anticoagulation for 2 weeks and later remained asymptomatic. This report illustrates the evolution of bilateral spontaneous renal artery dissection, which is an extremely rare entity of unknown cause.1 Spontaneous renal artery dissection is associated with fibromuscular dysplasia, malignant hypertension, atherosclerosis, Marfan’s syndrome, collagen vascular disease, and trauma,2 with most common association being fibromuscular dysplasia.3 The treatment options include medical management, endovascular procedure, or surgery.4-6
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References 1. Mori H, Hayashi K, Tasaki T, et al. Spontaneous resolution of bilateral renal artery dissection: a case report. J Urol. 1986;135: 114-116. 2. Ramamoorthy SL, Vasquez JC, Taft PM, et al. Nonoperative management of acute spontaneous renal artery dissection. Ann Vasc Surg. 2002;16:157-162. 3. Lacombe M. Isolated spontaneous dissection of the renal artery. J Vasc Surg. 2001;33:385-391. 4. Lee SH, Lee HC, Oh SJ, et al. Percutaneous intervention of spontaneous renal artery dissection complicated with renal infarction: a case report and literature review. Catheter Cardiovasc Interv. 2003; 60:335-338. 5. Misrai V, Peyromaure M, Poiree S, et al. Spontaneous dissection of branch renal artery e is conservative management safe and effective? J Urol. 2006;176:2125-2129. 6. Afshinnia F, Sundaram B, Rao P, et al. Evaluation of characteristics, associations and clinical course of isolated spontaneous renal artery dissection. Nephrol Dial Transplant. 2013;28:2089-2098.
UROLOGY 82 (5), 2013
Figure 1. (A, B) Axial oblique reformatted contrast enhanced computed tomography (CECT) images reveal focal anterior left renal infarct (bold arrow) secondary to dissection of upper division (thin arrow) left renal artery. Coronal digital subtraction angiography (DSA) images prestenting (C) and poststenting (D) images reveal diffusely narrowed true lumen of the left upper division renal artery (thin arrow) with restoration of the flow though the stent lumen after stent placement. Note moderate left hydronephrosis and proximal hydroureter containing blood (D).
A
65-year-old woman without significant past history presented with sharp left flank pain, tenderness, hematuria, and blood pressure of 144/78 mm Hg.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Applied Imaging Science Laboratory, Department of Radiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA Reprint requests: Sachin S. Saboo, M.D., F.R.C.R., Department of Radiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115. E-mail: [email protected] Submitted: May 24, 2013, accepted (with revisions): July 24, 2013
ª 2013 Elsevier Inc. All Rights Reserved
Contrast enhanced computed tomography revealed focal left renal infarct secondary to dissection of left upper pole renal artery (Fig. 1A,B). She was initially started on enoxaparin and discharged on warfarin with a therapeutic INR; however, she returned few days later with gross hematuria, extension of her infarcts and 90% occlusion of flow. She subsequently received intraarterial thrombolysis with tissue plasminogen activator and left renal artery stenting (Fig. 1C,D), followed by 0090-4295/13/$36.00 http://dx.doi.org/10.1016/j.urology.2013.07.034
e33
Figure 2. (A, B) Axial oblique reformatted and (C) coronal reformat computed tomography (CT) angiogram images and (D) coronal maximum intensity projection images performed after 3 weeks reveal interval infarction of entire left kidney (thin arrows, A; bold arrow, B) secondary to proximal left renal artery dissection with thrombosed false lumen, partly patent true lumen (thin arrow, A). Note normal stent in the upper division left renal artery (thin black arrow, D). In addition, focal dissection of the right lower pole renal artery at the renal hilum (thin arrows, B-D) with thrombosis of the false lumen and infarction of lower pole of right kidney was also seen (bold arrow, C). Note mild right hydronephrosis and moderate left hydroureteronephrosis containing blood (arrowheads, A-C) and blood clot in the urinary bladder.
heparin, warfarin, and aspirin. Computed tomography angiography performed 3 weeks later revealed infarction of entire left kidney from proximal extension of left renal artery dissection (Fig. 2A) and focal dissection of the right lower pole renal artery with lower pole infarction (Fig. 2B-D). Patient received anticoagulation for 2 weeks and later remained asymptomatic. This report illustrates the evolution of bilateral spontaneous renal artery dissection, which is an extremely rare entity of unknown cause.1 Spontaneous renal artery dissection is associated with fibromuscular dysplasia, malignant hypertension, atherosclerosis, Marfan’s syndrome, collagen vascular disease, and trauma,2 with most common association being fibromuscular dysplasia.3 The treatment options include medical management, endovascular procedure, or surgery.4-6
e34
References 1. Mori H, Hayashi K, Tasaki T, et al. Spontaneous resolution of bilateral renal artery dissection: a case report. J Urol. 1986;135: 114-116. 2. Ramamoorthy SL, Vasquez JC, Taft PM, et al. Nonoperative management of acute spontaneous renal artery dissection. Ann Vasc Surg. 2002;16:157-162. 3. Lacombe M. Isolated spontaneous dissection of the renal artery. J Vasc Surg. 2001;33:385-391. 4. Lee SH, Lee HC, Oh SJ, et al. Percutaneous intervention of spontaneous renal artery dissection complicated with renal infarction: a case report and literature review. Catheter Cardiovasc Interv. 2003; 60:335-338. 5. Misrai V, Peyromaure M, Poiree S, et al. Spontaneous dissection of branch renal artery e is conservative management safe and effective? J Urol. 2006;176:2125-2129. 6. Afshinnia F, Sundaram B, Rao P, et al. Evaluation of characteristics, associations and clinical course of isolated spontaneous renal artery dissection. Nephrol Dial Transplant. 2013;28:2089-2098.
UROLOGY 82 (5), 2013