Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 3  |  Page : 290-292

Delayed salvage of renal function in acute suprarenal aortic occlusion


Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India

Date of Submission20-Jul-2020
Date of Acceptance03-Aug-2020
Date of Web Publication6-Jul-2021

Correspondence Address:
Shivanesan Pitchai
Department of Cardiovascular and Thoracic Surgery, Division of Vascular Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_102_20

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  Abstract 


Acute suprarenal aortic occlusion, though rarely reported carries a high morbidity and mortality. Renal ischemia is one of the usual presenting features. Limb salvage and renal preservation depend on prompt diagnosis and management. A young patient with acute suprarenal aortic occlusion having renal failure and limb ischemia was managed with suprarenal thrombectomy and aortobifemoral bypass at our centre. Even though the presentation was delayed, renal functions were restored post procedure. This case highlights that renal revascularisation can be attempted in select cases with delayed presentation.

Keywords: Acute suprarenal aortic occlusion, aortobifemoral bypass, renal revascularization, suprarenal thrombectomy


How to cite this article:
Pandey AK, Katoor TT, Kumar P M, Nair HR, Pitchai S. Delayed salvage of renal function in acute suprarenal aortic occlusion. Indian J Vasc Endovasc Surg 2021;8:290-2

How to cite this URL:
Pandey AK, Katoor TT, Kumar P M, Nair HR, Pitchai S. Delayed salvage of renal function in acute suprarenal aortic occlusion. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Jul 25];8:290-2. Available from: https://www.indjvascsurg.org/text.asp?2021/8/3/290/320605




  Introduction Top


Suprarenal aortic occlusion, a rarely reported condition, refers to complete aortic occlusion, with thrombus extension to one or more renal arteries.[1] Usually, it is a result of a proximal progression of a distal preexisting aortic thrombus, which may lead to a sudden worsening of ischemic symptoms and acute renal failure.[2],[3] The condition carries high morbidity and mortality; hence, timely and pertinent diagnostic and management strategies are required.[3],[4],[5] Here, we describe the case of a young male with renal failure and limb ischemia, secondary to acute suprarenal aortic occlusion.


  Case Report Top


A 35-year-old gentleman was referred to our center for evaluation of impaired renal function and bilateral limb ischemia, symptoms being diffuse abdominal pain, oliguria, and rest pain for the past 2 weeks. A previous history of claudication for the past 4 years along with heavy smoking was present. He had been noncompliant to medical therapy and follow-up after being diagnosed with acute coronary event 10 years back. A left lower limb femoral embolectomy was also done 2 years back following an episode of severe left lower limb pain at another center. On examination, he was hypertensive and bilateral femoral pulses were absent along with monophasic pedal Doppler signals. Ankle–brachial index was 0.3 and 0.5 in the left and right lower limb, respectively. Blood panel had a serum creatinine of 6.9 mg/dl which was progressively worsening for the past 2 weeks (baseline: 1.3 mg/dl). Echocardiogram revealed a global wall-motion abnormality and an ejection fraction of 45%. On color Doppler study, a significant decrease in bilateral intrarenal perfusion was noticed, kidney size being 9.5 cm bilaterally. Computed tomography angiogram was performed from outside which revealed complete aortic occlusion from the level of superior mesenteric artery to bilateral iliac. The right renal artery was completely thrombosed with a patent upper polar artery and the left renal artery had proximal occlusion, though distal opacification was noted [Figure 1]. In view of worsening renal failure and severe rest pain, an open surgical approach was considered with an aim to salvage renal function along with the restoration of blood flow to lower limbs. After proper informed consent, he was posted for laparotomy and bypass. Intraoperatively, a nonpulsatile occluded aorta was noted till the level of superior mesenteric artery origin, bilateral renal arteries were also nonpulsatile [Figure 2]a. A suprarenal clamp space was created, and after heparinization aorta was opened longitudinally and fresh thrombus was removed from the pararenal aorta and left renal arteries, the right renal origin was noted to be chronically occluded [Figure 2]b. Good back bleed from the left renal artery was noted, following which the cranial end of aortotomy was primarily suture closed and clamp was shifted to infrarenal location [Figure 2]c and a 14 × 7 polyester graft was anastomosed in the end-to-side manner. Distal graft limbs were anastomosed to both common femoral arteries.
Figure 1: Computed angiogram showing an extension of thrombus to the suprarenal aorta, distal opacification of the left renal artery can be noticed

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Figure 2: Illustration demonstrating suprarenalaortic thrombectomy (a) thrombus extent; (b) suprarenal clamp and vertical aortotomy, removal of thrombus; (c) proximal aortotomy closed and clamp shifted to the infrarenal aorta

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He had a stable postoperative course and had normal urine output. The serum creatinine values had an initial raise, followed by a downward trend (without the requirement of dialysis). At the time of discharge, it was 2.4 mg/dl/and had normalized at the 1-month follow-up. At the 9-month follow–up, he had a normal serum creatinine and has no lower limb claudication.


  Discussion Top


Acute renal failure secondary to aortic and renal artery occlusion, though seldom reported, carries a high risk of morbidity and mortality, necessitating prompt diagnosis and intervention.[4],[5]

Typically, the patient presents with severe bilateral limb pain, abdominal symptoms, and or refractory hypertension.[3] The symptom complex of acute abdominal pain and hypertension is highly suggestive of acute renal artery occlusion.[6]

Suprarenal aortic occlusion has been commonly attributed to clot progression in an infrarenal thrombus where any impediment to renal outflow leads to stasis, turbulence, and local flow.[1] This theory is supported by the gross characteristics of the proximal clot which is softer, less mature, and easily removable as compared to fibrotic adhered distal clot.[7] Low-flow state induced by a poor cardiac performance has also been found to be contributory in acute occlusion.[2] A high incidence of hypercoagulability in these patients highlights the importance of a hypercoagulable workup in these patients.[8] We did not do any hypercoagulable workup in our index case because of the urgent nature of the procedure and regardless of results, prolonged anticoagulation was planned considering the recurrent thrombotic events in the past.

In cases of acute renal artery occlusion, collateral flow from adrenal, lumbar, and capsular collaterals can preserve glomerular viability and prevents ischemic necrosis, though tubular atrophy occurs which is reversible with revascularization.[9] This forms the basis of delayed salvage of renal function after prolonged ischemia. The predictors of a successful salvage are normal kidney size, patent distal renal artery, and viable glomerular histology.[4],[6]

The first operative intervention for acute renal artery occlusion was an embolectomy by Westerborn in 1937.[10] Even with the evolution of vascular techniques over the time, open repair holds its place in the management of juxtarenal occlusion, with fair long-term results.[11] Very few reports of acute suprarenal aortic and renal artery occlusion are available, with a very small subset reporting successfully delayed salvage of renal function.[1],[4],[5]


  Conclusion Top


Sudden worsening of renal function and increased lower limb pain, in patients with preexisting aortic thrombus should raise suspicion for acute suprarenal occlusion. This condition warrants an aggressive approach in diagnosis and management. Renal revascularization can be considered in selected cases, even after a delayed presentation. In our index case since the patient was young with documented recent worsening of renal function with normal kidney size and patent distal renal artery (by imaging), we opted for surgical intervention and were able to salvage the renal function.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understand that HIS names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Tapper SS, Edwards WH, Edwards WH Jr., Mulherin JL, Martin RS 3rd. Suprarenal aortic occlusion. J Vasc Surg 1993;18:372e9.  Back to cited text no. 1
    
2.
Babu SC, Shah PM, Nitahara J. Acute aortic occlusion--factors that influence outcome. J Vasc Surg 1995;21:567-72.  Back to cited text no. 2
    
3.
Perrino C, Scudiero L, Petretta MP, Schiattarella GG, De Laurentis M, Ilardi F, et al. Total occlusion of the abdominal aorta in a patient with renal failure and refractory hypertension: A case report. Monaldi Arch Chest Dis 2011;76:43-6.  Back to cited text no. 3
    
4.
Jongkind V, Kievit JK, Wiersema AM. Recovery of renal function after prolonged Anuria in acute suprarenal aortic occlusion. Ann Vasc Surg 2016;30:307.e11-4.  Back to cited text no. 4
    
5.
Pontremoli R, Rampoldi V, Morbidelli A, Fiorini F, Ranise A, Garibotto G. Acute renal failure due to acute bilateral renal artery thrombosis: Successful surgical revascularization after prolonged anuria. Nephron 1990;56:322-4.  Back to cited text no. 5
    
6.
Ouriel K, Andrus CH, Ricotta JJ, DeWeese JA, Green RM. Acute renal artery occlusion: when is revascularization justified? J Vasc Surg 1987;5:348-55.  Back to cited text no. 6
    
7.
Traverso LW, Baker JD, Dainko EA, Machleder HI. Infrarenal aortic occlusion. Ann Surg 1978;187:397.  Back to cited text no. 7
    
8.
Crawford JD, Perrone KH, Wong VW, Mitchell EL, Azarbal AF, Liem TK, et al. A modern series of acute aortic occlusion. J Vasc Surg 2014;59:1044-50.  Back to cited text no. 8
    
9.
Towne JB, Bernhard VM. Revascularization of the ischemic kidney. Arch Surg 1978;113:216-8.  Back to cited text no. 9
    
10.
Westerborn A. Embolie in der arteria renalis. Z Urol 1937;21:687.  Back to cited text no. 10
    
11.
Marrocco-Trischitta MM, Bertoglio L, Tshomba Y, Kahlberg A, Marone EM, Chiesa R. The best treatment of juxtarenal aortic occlusion is and will be open surgery. J Cardiovasc Surg (Torino) 2012;53:307-12.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2]



 

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