接受主動脈腔靜脈腫瘤摘除後的右腎梗塞 - 一個罕見的病例報告
Right Renal Infarction after an Aortocaval Tumor Excision – A Rare Case Report
Tsae-Ni, Lee、Chao-Yuan, Huang
Department of Urology, National Taiwan University Hospital
Renal infarction, with an estimated incidence rate around 0.004-0.007%, is rare. Several etiologies, including thromboemboli and in situ thrombosis, have been proposed. Symptoms include acute onset of flank or abdominal pain, nausea, vomiting, hematuria, and fever. Lab data may show leukocytosis or an elevated CRP level. Diagnosis is often delayed for the symptoms mimic more common condition, such as renal colic and acute pyelonephritis. The gold standard of diagnosis is a computed tomography (CT) with contrast. Here we present a case of right renal infarction after receiving a robot-assisted laparoscopic aortocaval tumor excision.
A case of a 52-year-old man who presented with fever 2 days after receiving a robot-assisted laparoscopic aortocaval tumor excision (preoperative CT shown in figure 1). The patient denied having chills, coldness, dyspnea, dysuria, flank pain, nor abdominal pain. Empirical Flumarin was administered but his fever persisted. Lab data showed leukocytosis, elevated CRP and serum creatinine level (from 0.9 to 1.6 mg/dL). An abdominal and pelvis CT was arranged and revealed right renal infarction (figure 2). Angiography revealed dissection and a 72% stenosis of the proximal right renal artery (figure 3). Percutaneous transluminal angioplasty was performed and a stent was placed. His fever gradually subsided. Follow up echo showed lab showed increased renal blood flow and lab data showed decreased serum creatinine level (1.2 mg/dL). He was then discharged with Plavix and Aspirin.
Renal infarction, which results from an acute disruption of renal blood flow, is uncommon and frequently misdiagnosed. In our case, right renal infarction occurred after a robot-assisted laparoscopic aortocaval tumor excision, and further angiography revealed a right renal artery dissection. Renal artery dissection occurs mainly in hypertensive patients with underlying arterial disease (e.g. atherosclerosis) or after direct vessel injury (e.g. endovascular intervention or trauma). Despite this, our patient does not have a history of hypertension nor heart disease. It is known that endovascular intervention may damage vessel wall and cause dissection. However, the effect of lifting and moving blood vessels during a surgery on the vessel wall remains unknown. Further research may be done, and surgeons should be aware of the possibility of a renal artery infarction, especially if persistent fever and elevated serum creatinine level are noted after surgery.
For patients with fever and elevated serum creatinine level after an aortocaval tumor excision, a diagnosis of renal artery infarction should be kept in mind, especially if there are no specific signs of infection and if persistent fever is noted despite antibiotic treatment. We still could not establish the correlation between renal artery dissection and robot-assisted laparoscopic aortocaval tumor excision, and further research may be done in the future.