Traumatic Giant Renal Arteriovenous Fistula

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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00297. Epub November 6, 2024.

A 46-year-old man presented with bilateral lower extremity edema for more than 3 months. He had a history of bruising to the left abdominal area as a result of a motorcycle accident several years ago. Cardiac auscultation revealed hyperactive P2 heart sound and a grade 2/6 systolic murmur between the second and third intercostals on the left side of the sternum. Laboratory tests revealed a hemoglobin level of 108 g/L (reference range, 130-170 g/L) and a pro-brain natriuretic peptide (BNP) level of 2991 pg/mL (reference range, <125 pg/mL). The electrocardiogram was unremarkable. Transthoracic echocardiography showed whole heart enlargement, severe tricuspid valve insufficiency, and moderate pulmonary hypertension. The computer tomographic angiography (CTA) images suggested a giant left arteriovenous fistula (AVF) with renal artery aneurysm (RAA) (Figure A-D), and angiography showed the giant left AVF with RAA (40.5 x 30.7 mm) and a dilated and elongated renal artery (Video). After a comprehensive preoperative assessment, the patient was recommended for a surgical approach, but he refused the procedure.

Renal AVF is a high-flow vascular malformation characterized by anomalous direct communications between the renal arteries and veins. The prevalence of renal AVF is approximately 0.04%,¹ and it is typically classified as congenital, acquired, or idiopathic. Causes may include renal interventions, biopsy, trauma, nephrectomy, malignancy, or inflammation. Traumatic AVF is a rare but severe complication associated with massive hematuria, retroperitoneal hemorrhage, and high-output heart failure. CTA and angiography play an important role in providing precise information about the angioarchitecture of renal AVF before treatment. The optimal treatment method is determined by cause, classification, and some other aspects of the angioarchitecture of renal AVF.

Reference

1. Luo J, Liu P. Cinematic rendering of giant renal arteriovenous fistula. Radiology. 2023;309(3):e231045. doi:10.1148/radiol.231045

Affiliations and Disclosures

Leizhi Ku, MD; Yuhang Wang, MD; Zheng Liu, MD; Xiaojing Ma, PhD

From the Department of Echocardiography, Wuhan Asia Heart Hospital Affiliated Wuhan University of Science and Technology, Wuhan, China.

Dr Ku and Dr Wang contributed equally to the article.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Funding: This work is funded by the 2021 General Project Health and Family Planning Commission of Wuhan municipality scientific research project (WX21D46), Wuhan Clinical Medical Research Center for Cardiovascular Imaging (CMRC202307)

Consent statement: The authors confirm that informed consent was obtained from the patient for the procedures described in this manuscript.

Address for correspondence: Xiaojing Ma, PhD, Department of Echocardiography, Wuhan Asia Heart Hospital Affiliated Wuhan University of Science and Technology, No.753 Jinghan Road, Hankou District, Wuhan 430022, China. Email: klz1534292102@163.com