PMC6159121_01
Multiplanar intravenous contrast-enhanced CT of the abdomen and pelvis demonstrates enlargement of the left kidney, moderate left-sided perinephric free fluid (a) and a delayed left nephrogram (white arrow:b). Acute thrombus was noted in a tortuous circumaortic left renal vein, which extends into the inferior vena cava and measures up to 12.0 cm in craniocaudal dimension (black arrows:b, c). Subsequent anteroposterior projection cavogram demonstrates inferior vena cava thrombus, which extends downstream to the approximate level of the right renal vein (black arrow:d).
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A contrast-enhanced CT scan of the abdomen and pelvis was then ordered, which demonstrated enlargement of the left kidney, moderate perinephric free fluid and a delayed left nephrogram [Figure 1]. Acute complete thrombosis was noted of the circumaortic left renal vein, with extension into the IVC, where it was non-occlusive but measured up to 12.0 cm in craniocaudal dimension [Figure 1]. A cavogram was performed in the anteroposterior projection, demonstrating the known IVC thrombus, with tailing thrombus extending downstream to at least the level of the right renal vein [Figure 1].
By utilizing the neck access, an inferior vena cava filter was inserted above the level of the inferior vena cava thrombus (white arrow:a), which acted as a safeguard against potential periprocedural thromboembolic events. Hand injection venography via the retroaortic limb of the left renal vein demonstrated complete occlusion of the left renal vein (white arrow:b) with venous return occurring through numerous capsular collaterals extending along the left lateral aspect of the spine (black arrows:b, c).
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From the neck access, an Option Elite IVC filter (Argon Medical Devices Inc., Plano, TX) was inserted in a suprarenal position above the level of the IVC thrombus [Figure 2], which acted as a safeguard against potential periprocedural thromboembolic events. Hand injection venography was then performed, demonstrating no patency of the left renal vein with numerous capsular collaterals extending to venous pathways along the left lateral aspect of the spine [Figure 2].
Angiography before (a) and after (b-d) Angiojet pulse spray tissue plasminogen activator thrombolysis and balloon angioplasty demonstrate progressive recanalization of the left renal vein, with opacification now seen in the anterior and posterior limbs of the renal vein and flow extending into the IVC (black arrows:b, c). Pigtail angiography performed following aspiration thrombectomy shows wide patency of the left renal vein (black arrows:d) with a large thrombus having been captured by the in situ IVC filter (white arrow:d), demonstrating the utility and efficacy of prophylactic filter placement when performing such intervention.
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Angiojet device for a total of 6 minutes, divided between the left renal vein and IVC thrombus. Angiography demonstrated progressive recanalization of the left renal vein with visualization of the anterior limb of the circumaortic left renal vein and restored flow into the IVC [Figure 3]. Balloon angioplasty of the retroaortic limb of the left renal vein was then performed to macerate all remaining thrombus and increase the surface area of thrombus available for exposure to blood flow, which further improved patency of the left renal vein [Figure 3]. Pigtail angiography performed following IVC aspiration thrombectomy showed wide patency, with a large thrombus having been captured by the recently placed IVC filter [Figure 3]. Repeat angiogram demonstrated good flow in the left renal vein [Figure 3], and as such, no further recanalization intervention was pursued.