case report Wien Klin Wochenschr DOI 10.1007/s00508-015-0822-7
A curable cause of hypertension: renal artery pseudoaneurysm Ibrahim Halil Altiparmak · Muslihittin Emre Erkus · Ozgur Gunebakmaz · Yusuf Sezen · Zekeriya Kaya · Recep Demirbag
Received: 23 February 2015 / Accepted: 28 May 2015 © Springer-Verlag Wien 2015
Summary Renal artery aneurysms and pseudoaneurysms are rare vascular abnormalities. These anomalies, which are usually asymptomatic, may be associated with hypertension. Here, we present the successful treatment of a renal artery pseudoaneurysm in a patient with hypertension, with an overview of the literature.
Here, we report a case of renal artery pseudoaneurysm treated successfully by coil embolization in a hypertensive patient.
Keywords Hypertension · Renal artery · Pseudoaneurysm · Treatment · Coil embolization
A 44-year-old woman with a history of arterial hypertension presented with a complaint of abdominal pain. Her blood pressure was 160/100 mmHg under medical therapy of ramipril plus hydrochlorothiazide (5/12.5 mg). Complete blood count, biochemistry panel, and urinalysis were within normal limits. Abdominal ultrasonography demonstrated a mass on the left kidney. Both magnetic resonance and computed tomography angiography showed two renal artery aneurysms (RAA), sized 15 × 14 mm (true aneurysm) and 35 × 14 mm (pseudoaneurysm) (Figs. 1 and 2). Both aneurysms were also demonstrated by selective renal arteriogram (Fig. 3a). After interdisciplinary evaluation, the pseudoaneurysm was successfully treated with an embolization method using 16 coils (Axium Detachable Coil System manufactured by EV3, USA) (Fig. 3b). It was decided that the true aneurysm should be followed up without any intervention. She has not experienced any complaints and has been without medication for the last year.
Introduction Renal artery pseudoaneurysms are rare renovascular disorders. Penetrating trauma is the most commonly encountered underlying cause of these pathologies, but rarely any potential cause of the disease can be detected, despite a comprehensive examination. This pathology should be treated effectively given the risk of lethal complications [1]. Dr. I. H. Altiparmak, MD () · M. E. Erkus, MD · O. Gunebakmaz, MD · Y. Sezen, MD · Z. Kaya, MD · R. Demirbag, MD Medical Faculty, Department of Cardiology, Harran University, Sanliurfa, Turkey e-mail:
[email protected] M. E. Erkus, MD e-mail:
[email protected] O. Gunebakmaz, MD e-mail:
[email protected] Y. Sezen, MD e-mail:
[email protected] Z. Kaya, MD e-mail:
[email protected] R. Demirbag, MD e-mail:
[email protected]
13
Case report
Discussion Aneurysms are divided into two groups as true and pseudo. The former is composed of three layers of vessel wall, whereas the latter only includes the adventitia layer. RAA, usually incidentally recognized, are rare vascular anomalies [1]. Although patients with unruptured RAA are usually asymptomatic, rarely some patients may present with abdominal pain. Furthermore, RAA may sometimes lead to renovascular hypertension due to
A curable cause of hypertension: renal artery pseudoaneurysm
1
case report
Fig. 1 a Magnetic resonance imaging showing a mass on the left kidney (arrow). b Magnetic resonance imaging angiography displaying the left renal artery (thin arrow) and
Fig. 2 Computed tomographic angiography showing two masses associated with the left renal artery (arrows)
pseudoaneurysm along with the neck (thick arrow). c Magnetic resonance imaging angiography demonstrating also the pseudoaneurysm (arrow)
a dissecting aneurysm, distal thrombus embolization, altered renal flow, and concomitant renal artery stenosis [1, 2]. Risk factors for RAA are trauma, kidney surgery, atherosclerosis, inflammation (vasculitis such as polyarteritis nodosa and Kawasaki disease), segmental mediolytic arteriopaty, and mycotic infections. RAAs are anatomically classified according to the Rundbeck’s classification: Type I, RAA is located on the main renal artery trunk; type II, it is located at the proximal arterial bifurcation (extrarenal); and type III, it is located at the distal arterial branches (intrarenal). RAA may be treated by surgical or endovascular techniques, including covered stent, coil embolization, stent-assisted coil embolization, and vascular plug [3]. It is strongly suggested that aneurysms larger than 2 cm in size and all pseudoaneurysms should be treated due to the risk of lethal rupture of the sac, especially in women of childbearing age. However, true aneurysms less than 2 cm have a negligible risk of complications, and thus authors advise a follow-up with yearly imaging [1, 4]. While the Rundback type I aneurysm is a candidate for treatment with a covered stent, Rundback type II and III aneurysms likely can be man-
Fig. 3 a Renal arteriography displaying the aneurysm (thin arrow) and the pseudoaneurysm (thick arrow). b Renal arteriography after coil embolization (arrow)
2 A curable cause of hypertension: renal artery pseudoaneurysm
13
case report
aged by the other techniques. In our case, we treated a large pseudoaneurysm with coil occlusion. The other treatment option was closure of the two aneurysms using a covered stent. We did not prefer this option because of the high restenosis and thrombosis risk of the long- and small-diameter (especially
