PMC6930724_01
Clinical finding and imaging prior to renal arterio-venous fistula (RAVF) occlusion. (a) Electrocardiogram (ECG) with sinus tachycardia in precordial right heart leads V1-3. No pathological ECG intervals. (b) multiple renal vein aneurysm (RVA) with broadening of spectral waveforms suggesting arterial aneurysm perfusion. (c) Renal scintigraphy (MAG-3) found a split renal function of left: 33% vs. right: 67% since a proximal high-flow RAVF caused reduced kidney perfusion. (d) 3D and coronal reconstruction. RVA (blue arrows, dashed) which are likely to be a long-term sequalae from a proximal high-flow RAVF. Recognize the straight proximal segment of the left renal artery (LRA) (red arrow, dashed, and dotted) for Amplatzer Vascular Plug (AVP) placement. Recognize the diameter enlargement of the Inferior Vena Cava (IVC) (green arrow, dotted) caused by increased volume load.
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On physical examination the patient was normotensive while the electrocardiogram (ECG) revealed a resting sinus tachycardia (Figure 1(a)). RVAs and the typical broadening of spectral waveform suggested a RAVF with arterial flow (Figure 1(b)). Renal scintigraphy revealed split residual renal function of 33% vs. 67% (left vs. right kidney) (Figure 1(c)). The diameter-enlarged LRA mimicked the aortic bifurcation with a similar take-off angle and a straight proximal segment (Figure 1(d)).
Echocardiography before (a), 2-days (b), and 3-months (c) after occlusion of the proximal high-flow renal arteriovenous fistula (RAVF) by Amplatzer Vascular Plug (AVP) Device II placement into the left renal artery (LRA). (a) 4-Chamber view with Doppler ultrasound found a functional (secondary) tricuspid regurgitation (Grade I). Recognize the enlargement of the right atrium due to increased volume load. (b and c) 4-Chamber view with Doppler ultrasound found no tricuspid regurgitation 2-days and 3 months after RAVF occlusion. Also recognize normalization of the right atrium dimensions due to reduced volume load.
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In comparison to pre-intervention findings, there was no residual tricuspid regurgitation and the right atrium dimensions were reduced (Table 1, Figures 2(b) and 2(c)).
Representative images of an angiography during surgery and a CT scan one-month post-surgery. (a) Angiography before and after Amplatzer Vascular Plug (AVP) II Device placement. No perfusion of the left renal artery (LRA) after AVP II placement. Red arrow (dashed and dotted) = RVA; Green arrow (dotted) = correct positioned central and displaced peripheral AVP II. (b) alpha: arterial phase images. alpha1: no perfusion of the LRA distal of the central AVP II. alpha2: minimal residual cortical perfusion over a side-branch originating from the LRA proximal of the central AVP II. beta: venous phase image: no contrast in the left vs. right kidney indicating subtotal infarction, despite insignificant residual cortical perfusion. No residual perfusion of the RVA (red arrows, dashed, and dotted) and marked reduction of the IVC diameter (blue arrow, dashed).
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The subsequent control angiography confirmed the complete occlusion of the LRA with no residual perfusion, demonstrating successful blocking of arterial perfusion of the RVA (Figure 3(a)). Notably, a small proximal side-branch sustained an insignificant residual cortical renal perfusion (Figure 3(b)). Further, the CT scan confirmed subtotal infarction of the left kidney and marked reduction of IVC diameter (Figure 3(b)).