8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 1/17

KNIFED IN THE ABDOM

Resident(s): Andrew Duarte, MDAttending(s): Ryan Scott, MD & David Kay, MD

Program/Dept(s): St. Joseph’s Hospital and Medical Center, Phoenix, AZ

Originally Posted: N

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 2/17

CHIEF COMPLAINT & HPI

24 year old male involved in recent penetrating (stab wound) traumaticinjury underwent exploratory laparotomy with cholecystectomy andprimary repair or the duodenum, IVC and liver lacerations.

Uneventful postoperative course interrupted by acute onset of vague rigabdominal pain related to movement on post-operative day 9, with risinleukocytosis and mild hyperbilirubinemia.

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 3/17

RELEVANT HISTORY

Past Medical HistoryNon contributory.

Past Surgical HistoryNon contributory.

MedicationsLovenox 40 mg BID (DVT prophylaxis)Pepcid 20 mg BID (GI prophylaxis)Percocet and morphine PRN painZosyn recently discontinued

AllergiesNKDA

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 4/17

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 5/17

CORRECT!

What salient findings are present on this axial imagefrom a CECT?

A. Irregular collection of contrast adjacent to the rightrenal artery/vein and asymmetric enhancement ofthe kidneys.

B. An accessory right renal artery and asymmetricenhancement of the kidneys.

C. A duplicated IVC and symmetric enhancement ofthe kidneys.

D. Irregular collection of contrast adjacent to the rightrenal artery/vein and symmetric enhancement ofthe kidneys.

CONTINUE WITH CASE

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 6/17

SORRY, THAT’S INCORRECT.

What salient findings are present on this axial imagefrom a CECT?

A. Irregular collection of contrast adjacent to the rightrenal artery/vein and asymmetric enhancement ofthe kidneys.

B. An accessory right renal artery and asymmetricenhancement of the kidneys.

C. A duplicated IVC and symmetric enhancement ofthe kidneys.

D. Irregular collection of contrast adjacent to the rightrenal artery/vein and symmetric enhancement ofthe kidneys.

CONTINUE WITH CASE

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 7/17

DIAGNOSTIC WORKUP

Non-Invasive ImagingContrast enhanced CT

Axial image demonstrates a lobulated contrastcollection in the right retroperitoneum associatedwith the right renal artery, right renal vein, andinferior vena cava (circle). The right kidneyhypoenhances compared with the left.

Sagittal reformat imdemonstrates the loretrocaval contrast mass effect on the I

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 8/17

DIAGNOSIS

Based on the contrast enhanced CT, the probable diagnosis was a renal arterypseudoaneurysm.

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 9/17

INTERVENTION

On aortography, a rapidly filling,irregular connection between theright renal artery and the suprarenalinferior vena cava was evident(circle). Findings are diagnostic of anarteriovenous fistula.

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 10/17

INTERVENTION

A covered stent (7 x 20 mm, iCast)was placed in the proximal rightrenal artery, at the site of the AVfistula (arrows). Nonselective aorticarteriography after placement of thestent demonstrates exclusion of thefistulous connection.

There is an abrupt cut-off of theright mid renal artery withnonopacification distally, consistentwith occlusion from acutethrombosis (circle).

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 11/17

INTERVENTION

A wire was placed across the rightrenal artery occlusion andangioplasty was performed.Post angioplasty selective right renalarteriogram shows filling of thepreviously nonopacified vessel.

Peripheral, wedge-shaped renalparenchymal defects are evident,consistent with infarcts (arrows).

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 12/17

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 13/17

CLINICAL FOLLOW UP- QUESTION

A renal artery to caval fistula, if left untreated (select one of the followiA. Will eventually resolve on its own.

B. Can lead to obstructive uropathy from increased renal calculi formation.

C. Can lead to high output heart failure and paradoxical pulmonary embolism

D. Can lead to portal hypertension and gastroesophageal varices.

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 14/17

CORRECT!

A renal artery to caval fistula, if left untreated:A. Will eventually resolve on its own.

B. Can lead to obstructive uropathy from increased renal calculi formation.

C. Can lead to high output heart failure and paradoxical pulmonary embolism

D. Can lead to portal hypertension and gastroesophageal varices.

CONTINUE WITH CASE

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 15/17

SORRY, THAT’S INCORRECT.

A renal artery to caval fistula, if left untreated:A. Will eventually resolve on its own.

B. Can lead to obstructive uropathy from increased renal calculi formation.

C. Can lead to high output heart failure and paradoxical pulmonary embolism

D. Can lead to portal hypertension and gastroesophageal varices.

CONTINUE WITH CASE

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 16/17

SUMMARY & TEACHING POINTS

The lesion represented a traumatic (primary vs iatrogenic) right renal artery tofistula with contained retroperitoneal hemorrhage/pseudoaneurysm.

A covered stent placed across the lesion successfully abolished the fistulousconnection.

Following covered stent placement, poor distal renal arterial flow was noted, an abrupt cut-off of the right mid renal artery. This was consistent with occlufrom an acute thrombus. Periprocedural heparinization was felt to be risky githe patient’s recent surgery.

Right renal artery angioplasty resulted in successful recanalization of the arte

Renal artery to caval fistula, if left untreated, can lead to hemorrhage,nephropathy, high-output heart failure and paradoxical pulmonary embolism

8/11/2019 SIR RFS Case Series: Knifed in the Abdomen

http://slidepdf.com/reader/full/sir-rfs-case-series-knifed-in-the-abdomen 17/17

REFERENCES & FURTHER READING

Tam J, Kossman T, Lyon S. Acute traumatic renal artery to inferior vena cavafistula treated with a covered stent. Cardiovasc Intervent Radiol. 2006 Nov-Dec;29(6):1129-31.

Wolosker N, Oba CM, Espirito Santo FR, Puech-Leao P. Endovascular treatmfor chronic arteriovenous fistula between renal artery and inferior vena cava:image in vascular surgery. Vasc and Endovascular Surg. 2010 Aug;44(6):489-