case of the day november 2014...2014/11/18 · case of the day november 2014 case courtesy of drs....

Case of the Day

November 2014

Case courtesy of Drs. E. Zhang, R. Samji, J. Rempel and S. Shergill

Department of Radiology and Diagnostic Imaging

• Case 1• 76 year old female, incidental finding on CT

Dept of Radiology and Diagnostic Imaging


CT in the arterial phase shows an aneurysm arising from a superior branch of the left renal artery. Maximum dimension was 3.7 cm. There is delayed perfusion to the upper pole of the left kidney due to altered flow dynamics.

EZ1

EZ1 Edwin Zhang, 2014-05-11

• Report:

• “Saccular aneurysm arising from the left superior renal artery measuring up to 3.7 cm in maximum dimension. Referral to vascular surgery is recommended.”

• The patient never saw any specialist following the CT, neither urology nor interventional radiology…


• 2 months later, the patient presents to ER with sudden onset left flank pain.

• Vitals: BP 100 systolic, HR 100, RR 22, O2 97% on RA.

• Labs: Hb 131, WBC 13, PLT 218, GFR 44

• PMHx: COPD, CAD


CT in the arterial and portal venous phases show that the aneurysm contour has become more irregular, with retroperitoneal hemorrhage, but no active extravasation – suggesting intermittent rupture which has sealed.

• Urology was consulted, but endovascular management was considered a superior choice over surgery due to the risks of renal failure with nephrectomy and high perioperative mortality risk given her age and comorbidities.

• Plan: bring her to angio suite for stent-assisted embolization in the hopes of preserving her kidney.



Right femoral artery access. The left renal artery was selected with a 5 Fr C2 catheter, and angiogram confirmed a large renal artery aneurysm arising from the superior branch of the left renal artery. There was a single afferent and single efferent vessel. 5 Fr sheath was exchanged for a 7 Fr 45 cm long RDC sheath. The combination of 5 Fr C2 and 0.035 angled Glidewire was utilized to negotiate past the aneurysm into the efferent vessel.

The angled Glidewire was exchanged for an 0.035 Rosen and then 0.035 Amplatz, but the stiffer wires would not remain well positioned and continued to buckle into the aneurysm. In addition, a marked curve greater than 90 degrees was noted traversing from afferent to efferent vessel.

At this point, the patient’s left flank pain worsened, HR climbed to 160, and she was no longer able to lie still. Given clinical deterioration and the instability/tortuosity of the system, it was decided to go for coil embolization without stenting.


A 2.5 Fr renegade microcatheter was then advanced into the 2 large branches of the efferent artery and multiple detachableInterlock coils ranging in size from 4 mm to 6 mm were deployed. Coil embolization across the aneurysm neck and into the afferent artery using two 6 mm detachable Interlock coils was then performed. Detachable coils were used due to need for precision in preserving the inferior branch. Post coil angiogram demonstrate no more flow through the aneurysm and preserved flow in the inferior branch.

• Post-procedure, the patient’s Hb dropped to 90, requiring 4 units of blood transfusion.


• Follow-up CT shows complete embolization of the aneurysm, and infarction to the upper pole secondary to sacrifice of the superior renal artery branch. There was slightly more hemorrhage around the left kidney. (The 40 point Hb drop was likely due to hemodilution + further hemorrhage while on the angio table).

• The patient’s Hemoglobin subsequently stabilized and recovered.

• GFR dropped to 35 (pre-op was 44) immediately post-procedure, but did partially recover to 40 one month later.


• Case 2:• 65 year old female, query renal stones, right flank pain



CT Renal colic study report: “calcified cystic lesion in superior pole of the right kidney, likely a calcified cyst.”


US report: “Impression – No gallstones. Right kidney upper pole calcified cyst.”

She continues to have pain, this time more RUQ, so she gets an ultrasound to look for gallstones…


CTA was ordered by Urologist, query aneurysm: confirms the presence of a 2.4 cm right renal artery aneurysm with partially calcified rim.


Pre-op planning angiogram was performed: DSA projections demonstrated a 2.4 cm complex renal artery aneurysm arising from the superior ascending branch off of the main trunk. The aneurysm contained 3 efferent arteries perfusing a significantamount of the kidney, the largest of the 3 vessels originates from the posterior aspect of the proximal portion of the aneurysm showing inferior course to the mid kidney. This was accessed using a RIM catheter and Glidewire. A bifurcated vessel was seen originating from the anterior superior portion of the aneurysm. The inferiorly projecting segment was accessed using the RIM catheter and Glidewire. This inferior segment appears to perfuse a portion of the lower region of the kidney. The ascending segment was not accessed. This ascending segment appears to supply the uppermost superior pole.

• The plan was to embolize the aneurysm while preserving the major efferent vessel and sacrificing the other two minor efferent vessels.

• A covered stent was felt to be not feasible due to tortuous anatomy and acute angulation at the neck of the aneurysm.

• Instead, the plan was to perform stent-assisted coil embolization.



Patient returned for the actual embolization procedure: Right femoral artery access. A 6 Fr 45 cm Terumo RDC glide sheath was placed. A C2 catheter was used to engage the right renal artery. The major efferent artery was then accessed across the aneurysm using a 5 French RIM catheter and Glidewire. Through the catheter, a transcend 300 floppy wire was then placed distally within a subsegmental artery branch. The RIM catheter was removed and an Orion microcatheter was placed into the segmental artery.


The IR staff was relatively new, so at this point there was an intra-operative consultation to our interventional neuroradiologist for the stent-assisted portion of the procedure. Through the catheter, the neuroradiologist crossed the aneurysm with a 6 mm x 30 mm Solitaire stent placed into ideal position. Adjacent to the microcatheter, Echelon 14, 45 degree microcatheter was placed through the interstices of the stent into the aneurysm.


A total of 42 EV3 Axium and Prime 3-D detachable coils were then successfully packed into the aneurysm. These detachable coils were used because the neuroradiologist was more familiar with them, and due to concern of coils prolapsing through the stent interstices into the efferent vessel we were trying to preserve. There was flow limitation to the 2 minor efferent vessels and decreased perfusion to those portions of the kidney. The stented major efferent branch remained widely patent. The Solitaire stent was then completely deployed without complication.


Follow-up MR angiogram in one month time shows almost compete occlusion of the aneurysm, with slight residual filling which will likely thrombose soon. There was also infarction of a portion of the upper pole of the right kidney. GFR was normal.

• Renal artery aneurysms are relatively rare, with an incidence in angiographic series of 0.1-1% in normal population.1

• Slight female predilection (? Higher incidence of fibromuscular dysplasia)

• Presentation:• Work-up for secondary hypertension: most common presenting

symptom• Flank pain or back pain• Hematuria• Aneurysmal rupture is noted in 5.6%


• Indications for treatment: (controversial)• Symptomatic: pain, hematuria, hypertension.• Asymptomatic:

- Women planning pregnancy (80% rate of rupture during pregnancy)1

- Size greater than 2 cm, or rapid growth· If < 2 cm, can do annual follow-up. Literature shows

mean growth rate of 0.6 +/- 0.16 mm per year.2

· Literature shows no significant difference in growth or rupture rate between calcified and noncalcified aneurysms.


• Endovascular therapy:

• Endovascular therapy is now the first line therapy for treatment of renal artery aneurysms, with higher technical success, and lower morbidity and mortality than surgical alternatives.3

• Goal of therapy is to exclude the aneurysm sac from the circulation while preserving as much renal parenchyma as possible.

• However, in the emergent setting / unstable delivery system, you may have to sacrifice more renal parenchyma than originally planned.


• Simple, narrow neck, saccular aneurysms with single afferent and efferent vessels: coiling- Inflow and outflow vessels can simply be occluded,

without having to embolize the aneurysm sac itself- Positional stability of the delivery catheter is of utmost

importance to minimize nontarget embolization.3

- Glue can be an alternative to coiling to reduce costs and time


• Wide neck, multiple afferent and efferent vessels, or fusiform shape:- Bridge across the dominant afferent and efferent vessels to

minimize the amount of renal infarction.- Relatively straight anatomy: covered stent / stent graft

· If multiple inflow and outflow vessels are present, those that are not bridged by the stent-graft can continue to expose the aneurysm to systemic blood pressures and be a source of type II endoleak. These should ideally be embolized before stent graft deployment.3

- Tortuous anatomy with acute angulations: stent-assisted embolization


Summary• Important to educate our diagnostic radiology and non-

radiologist colleagues on IR procedures, so patients don’t fall through the cracks.

• Endovascular therapy is now considered first line for treatment of renal artery aneurysms

• Know the indications for treatment• The choice of endovascular therapy depends on clinical and

technical factors.


References:1. Elaassar et al. Endovascular Techniques for the Treatment of Renal

Artery Aneurysms. Cardiovasc Intervent Radiol (2011); 34:926–935.

2. Klausner et al. Current treatment of renal artery aneurysms may be too aggressive. Journal of Vascular Surgery (2014); 59(5):1356-1361.

3. Etezadi et al. Endovascular Treatment of Visceral and Renal Artery Aneurysms. J Vasc Interv Radiol 2011; 22:1246–1253.


case of the day november 2014...2014/11/18 · case of the day november 2014 case courtesy of drs....

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