Renal arteriovenous fistula associated high-output heart failure treated with embolization

Abstract

Renal arteriovenous fistulas (AVFs) are rare, with an incidence of 0.04%, and can be congenital or acquired.1Isom N. Masoomi R. Alli A. Gupta K. Congenital Renal Arteriovenous Malformation: A 21 Rare but Treatable Cause of Hypertension.Am J Case Rep. 2019; 20: 314-317https://doi.org/10.12659/AJCR.912727Crossref Scopus (4) Google Scholar,2Gandhi S.P. Patel K. Pandya V. Raval M. Renal arteriovenous malformation presenting with massive hematuria.Radiol Case Rep. 2015; 10: 1068Crossref PubMed Scopus (13) Google Scholar, Patients present with hematuria, flank pain, flank bruit, hypertension, perirenal hematoma, and high output heart failure.1Isom N. Masoomi R. Alli A. Gupta K. Congenital Renal Arteriovenous Malformation: A 21 Rare but Treatable Cause of Hypertension.Am J Case Rep. 2019; 20: 314-317https://doi.org/10.12659/AJCR.912727Crossref Scopus (4) Google Scholar,3Khorrami M.H. Javadi N. Ebrahimi H. Khorrami F. Zandi Z. Congenital renal 7 arteriovenous fistula presenting with gross hematuria and its management.Urol Case 8 Rep. 2021; 39101818Google Scholar The majority of renal AVFs are acquired and associated with invasive procedures, malignancy, inflammation, or trauma.3Khorrami M.H. Javadi N. Ebrahimi H. Khorrami F. Zandi Z. Congenital renal 7 arteriovenous fistula presenting with gross hematuria and its management.Urol Case 8 Rep. 2021; 39101818Google Scholar The incidence of renal AVFs associated with fibromuscular dysplasia (FMD) is unknown with only few cases reported. Renal artery aneurysms have been reported in about 5.6% of patients with FMD, which can lead to AVF formation by rupturing into the renal vein.4Olin J.W. Froehlich J. Gu X. Bacharach J.M. Eagle K. Gray B.H. et al.The United States Registry for Fibromuscular 10 Dysplasia: results in the first 447 patients.Circulation. 2012; 125: 3182-3190Crossref PubMed Scopus (346) Google Scholar,5Varennes L. Tahon F. Kastler A. Grand S. Thony F. Baguet J.P. et al.Fibromuscular dysplasia: what the radiologist should know: a pictorial review.Insights Imaging. 2015; 6: 295-307Crossref PubMed Scopus (46) Google Scholar We report a case of a patient presenting with symptoms of high output heart failure due to a large AVF associated with FMD that was successfully treated with embolization. The patient has consented to this publication. A 69-year-old female with history of hypertension, hyperlipidemia, and atrial fibrillation presented with dyspnea on exertion. Computed tomography of the abdomen showed left renal AVF. Duplex ultrasound demonstrated a 4.0 x 4.0cm renal vein aneurysm with shunting between the renal artery and vein suggestive of an AVF (A). Based on imaging and symptoms, high output heart failure due to renal AVF was suspected and angiography with possible embolization was recommended. Vascular access was established via the right common femoral artery using a 5F sheath. The angiogram showed a “string-of-beads” appearance of the renal artery consistent with FMD and a large venous aneurysm and arteriovenous fistula arising from the hypertrophied branch of renal artery (B/Cover). A single communication between the artery and the vein was identified and detachable embolization coils (Penumbra, Alameda, CA, USA) and 0.2cc 50 % Trufill n-BCA glue (Cerenovus, Miami, Fl, USA) were used to embolize arterial branch feeding the fistula. Coils have the low risk of migration but are challenging to clot off in a high-flow vessel. Therefore, glue was used to fill the interstices and completion fluoroscopy demonstrated fistula occlusion and intact flow to the kidney (C). Catheterization of the fistula or concomitant venous access were not necessary. The patient had normal renal function preoperatively and it was preserved after the embolization. Her shortness of breath resolved after the procedure. Figure 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3View Large Image Figure ViewerDownload Hi-res image Download (PPT)