Abstract
Purpose
To describe a new application of tissue plasminogen activator (t-PA) power-pulse spray rheolytic (pharmacomechanical) thrombectomy in the treatment of acute renal artery thrombosis.
Case Report
Acute renal artery thrombosis is a relatively rare, but serious condition in which it is imperative to restore perfusion as quickly as possible. Percutaneous pharmacomechanical thrombectomy technique was utilized to provide an effective means of restoring renal flow and function. We therefore present two unique cases of spontaneous and iatrogenic renal artery thromboses that were treated successfully with t-PA power-pulse spray rheolytic thrombectomy.
Conclusion
t-PA Power-pulse spray rheolytic (pharmacomechanical) thrombectomy has the potential to be a useful means to restore perfusion and function in the setting of acute renal artery thrombosis.
1
Introduction
Renal artery thrombosis is a rare condition caused by many etiologies. Previously described treatments have included surgical embolectomy, surgical bypass, catheter-directed thrombolytic infusion, and mechanical thrombectomy. We present two unique cases of spontaneous and iatrogenic renal artery thromboses which were treated successfully with tissue plasminogen activator (t-PA) power-pulse spray rheolytic thrombectomy.
2
Case report
2.1
Case 1
A 37-year-old male with no prior medical history presented to the emergency room with 3-day history of progressively worsening, unbearable left flank and abdominal pain. Pain was inadequately controlled with high doses of intravenous narcotics. His vital signs revealed that he was afebrile with a blood pressure of 130/60 and heart rate of 82. The rest of the physical exam result was within normal limits except for left flank and abdominal tenderness. Laboratory analysis revealed a slightly increased white blood cell count of 12,000 with normal differential, normal hemoglobin, and normal platelet count. The renal panel showed normal electrolytes and creatinine level was 1.0 mg/dl. EKG revealed a normal sinus rhythm. He underwent a CT of the abdomen and pelvis with contrast, which revealed left renal artery thrombosis. He was transferred to our institution by 5 p.m. because of the availability of an interventional radiologist.
2.1.1
Procedure
A 6-French sheath was placed in the right common femoral artery with ultrasound guidance. An angiogram of the abdominal aorta demonstrated that there were two renal arteries on each side including the main renal arteries bilaterally and accessory upper pole renal arteries. The main right renal artery, accessory right upper pole renal artery, and accessory left upper pole renal artery were widely patent, while there was a complete occlusion of the mid portion of the left main renal artery. There was no parenchymal enhancement of the majority of the left kidney except for the upper pole supplied by a small accessory left upper pole renal artery ( Fig. 1 ). The left renal artery was selected using a 4-French C-2 catheter.
Despite multiple attempts, a .018-in. Thruway (nonhydrophilic) guidewire (Boston Scientific, Natick, MA, USA) was unable to be advanced beyond the occlusion, even with a 6-French RDC guiding catheter (Boston Scientific) for support. The occlusion was traversed using a combination of a Roadrunner hydrophilic .035-in. guidewire (Cook, Inc., Bloomington, IN, USA) and a 4-French angle-tipped Glidecath (Boston Scientific) through the guide catheter. An Ironman (Guidant Corporation, Saint Paul, MN, USA) 0.014-in. coronary guidewire was able to be placed past the occlusion. Power-pulse spray infusion with the XMI AngioJet catheter (Possis, Inc., Minneapolis, MN, USA) was initiated with a total of 15 mg of t-PA.
To perform power-pulse spray thrombectomy, the AngioJet (Possis) is set up in the standard way but with the return port closed on the catheter with a stopcock. A thrombolytic agent (20 mg of tissue plasminogen activator in 50 ml of saline, depending on the length and chronicity of the embolus/thrombus being treated) is used instead of pure saline. With the return port or outflow of the AngioJet machine closed, a powerful spray of diluted thrombolytic drug is injected with each pulse of the AngioJet catheter throughout the length of the clot. Once the entire dose is administered, the clot is given a wait time to lyse for 5 to 45 min. Our wait time in this case was 15 min. After lysing the entire clot with a lytic agent, the AngioJet was used in its normal mode with the return port open to aspirate as much clot as possible from the arterial system.
Following t-PA power-pulse spray rheolytic thrombectomy, there was a positive angiographic result with restoration of patency of the left renal artery and its branches ( Figs. 2 and 3 ) and dramatic improvement in pain. However, some residual thrombus was still present. Overnight continuous intra-arterial t-PA infusion therapy was therefore initiated using a 4-French C-2 catheter. The patient tolerated the entire procedure well without immediate complication. The subsequent angiogram revealed maintenance of patency of the renal artery. Overnight t-PA infusion did result in improved perfusion of the left kidney via thrombolysis within the intrarenal branches ( Fig. 4 ). Nuclear medicine scan obtained 3 days later demonstrated continued perfusion of the left renal parenchyma where flow was restored. There was minimal function in the left kidney, however, at 3 days. His creatinine level remained normal (1.1 mg/dl) at the time of discharge on the fifth hospital day and his flank pain remained completely resolved. Follow-up nuclear medicine scan at 2 years postprocedure revealed that the left kidney had regained significant function, such that it accounted for 30% of the total renal function (of both kidneys) ( Figs. 5-9 ). The size of the left kidney was smaller compared to the initial size on CT 2 years earlier by ultrasound indicating atrophy of the kidney; it had shrunken from a height of 11.0 to 9.8 cm; however, the transverse and AP dimensions remained the same.
