Endovascular repair of a giant renal vein aneurysm arising from an arteriovenous fistula

Abstract

A 57-year-old woman presented to the emergency department with a 2-week history of palpitations and shortness of breath. She denied chest or abdominal pain, or a history of abdominal trauma, melena, hematuria, weight loss, night sweats, or fever. Her medical history included rheumatic fever as a child and mitral valve prolapse. The patient had undergone no prior surgical interventions except a remote history of cervix conization. She took no prescription medications and denied smoking tobacco, drinking alcohol, or using illicit drugs. Vital signs showed tachypnea with tachycardia at 142 beats/min. On examination, she had prominent neck venous pulsations. Heart sounds were irregular, with a III/VI ejection systolic murmur best heard at the left sternal border. A loud continuous bruit and significant palpable thrill was felt in the left lumbar region. The rest of the physical examination was unremarkable. An electrocardiogram showed atrial fibrillation with rapid ventricular response. A contrast computed tomography scan of the chest and abdomen showed a markedly dilated renal vein measuring 12.9 10.6 9.7 cm (A-C, and Cover) with mass effect to the left kidney and diffuse dilation of the left renal artery (D) with an arteriovenous fistula (AVF; smaller arrow). An echocardiogram showed an ejection fraction of 35%, with moderate tricuspid and mitral regurgitation. High output cardiac failure from the congenital renal AVF was suspected. The patient’s heart rate was stabilized with calcium channel blockers, and the AVF was repaired using endovascular coiling with Nester Embolization Coils (Cook Medical, Bloomington, Ind) and a 22-mm-diameter Amplatzer (AGA Medical Corp, Plymouth, Minn) vascular plug occlusion device (Videos 1 and 2, online only). Aneurysmectomy and left nephrectomy were done later.