ACUTE RENAL ISCHEMIA, A SURGICAL VASCULAR EMERGENCE WITH A STILL UNKNOWN EVOLUTION
Introduction: Acute renal ischemia has a low incidence. Literature evidence of its surgical treatment is based on case series, and there are no well-defined indications for renal revascularization in this setting.
Methods: Observational and retrospective study, based on clinical records from patients that underwent renal artery revascularization due to acute renal ischemia, at a tertiary university hospital, from January 2011 to June 2020. Primary endpoint was 30 days dialysis rate, and secondary endpoints were 30 days de novo chronic kidney disease rate and 30 days survival.
Results: Eleven patients with acute renal ischemia were included. The causes of renal artery occlusion were: aortic dissection (N=3), native renal artery thrombosis (N=3), thrombosis of a previously revascularized renal artery (N=3), embolism (N=1) and closed trauma (N=1). Two of these affected patients with a single kidney. The median time from symptom onset to surgical revascularization was 24 hours. Two patients had previously known chronic kidney disease. Clinical presentation was lumbar or abdominal pain (n=8), non-controlled hypertension (N=5), or oligoanuria (N=5). The diagnosis was made by CTA in all patients. In all cases, the main renal artery was involved (N=9 from its ostium), and there was some degree of affected kidney contrast enhancement. Unilateral endovascular revascularization was performed with angiographic success in 10 patients; it was performed a bilateral endovascular revascularization in one of the three patients who had bilateral renal ischemia. Except for one patient with stent occlusion (that underwent DCB angioplasty), all patients underwent stent angioplasty (6 using covered stents). Two patients presented postoperative oligoanuria, and four required at least one dialysis session. At 30 days, the rate of dialysis was 11% (one patient with traumatic bilateral acute renal ischemia with 13 hours evolution), and the percentage of de novo chronic kidney disease was 22%. The 30-day survival was 90%.
Conclusion: In this population, we can foresee the reversion of acute renal ischemia, even after prolonged renal artery occlusions. However, with our data, it is not possible to predict which patients will recover previous renal function after urgent revascularization with angiographic success. For being prompt and less invasive, endovascular treatment is the first surgical option for acute renal ischemia treatment at our institution.
2. Velazquez-Ramirez G, Corriere MA, Renovascular disease: acute occlusive and ischemic events. Rutherford’s Vascular Surgery
and Endovascular Therapy 9th edition 2020;
3. Silverberg D, Menes T, Rimon U et al. Acute renal artery occlusion: Presentation, treatment, and outcome. J Vasc Surg 2016;64:1026-32;
4. Kuker R, Anaya CA, Gomez AM et al. Vascular Emergencies. Emergency Radiology: The Requisites, 2nd edition 2017;
5. Arabi M, Vellody R, Cho K. Acute Renal Artery Occlusion with Prolonged Renal Ischemia: A Case of Successful Treatment with Stent Placement and Catheter-directed Thrombolysis. Clin Imaging Sci 2011;1:11;
6. Huang HS, Hsu CC, Chen KT. Acute Renal Artery Embolism: A Case Report and Literature Review. Gen Med (Los Angel) 2016: 4: 245;
7. Heidemann F, Kölbel T, Debus ES, et al. Renal Function Salvage After Delayed Endovascular Revascularization of Acute Renal
Artery Occlusion in Patients With Fenestrated-Branched Endovascular Aneurysm Repair or Visceral Debranching. J Endovasc Ther. 2018; 25(4):466-473;
8. Blum U, Billmann P, Krause T, et al. Effect of local low-dose thrombolysis on clinical outcome in acute embolic renal artery occlusion. Radiology. 1993;189:549–54.