Cases reported "Renal Artery Obstruction"

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1/263. Gross hematuria of uncommon origin: the nutcracker syndrome.

    Left renal vein hypertension, also called "nutcracker phenomenon" or "nutcracker syndrome," is a rare vascular abnormality responsible for gross hematuria. The phenomenon is attributable to the idiopathic decrease in the angle between the aorta and the superior mesenteric artery with consequent compression of the left renal vein. The entrapment of the left renal vein is not easily detectable by ordinary diagnostic procedures. We report two cases of gross hematuria (persistent in one patient and recurrent in the other) caused by "nutcracker phenomenon." In both cases, no remarkable findings were obtained from medical history, urinary red blood cells morphology, repeated urinalysis, pyelography, cystoscopy, or ureteroscopy. Left renal vein dilation in one case was found with a computed tomography (CT) scan performed on the venous tree of left kidney. The diagnosis of "nutcracker phenomenon" was confirmed by renal venography with measurement of pressure gradient between left renal vein and inferior vena cava in both cases. In one case, the diagnosis was complicated by the presence of mycobacterium tuberculosis in urine. The "nutcracker phenomenon" is probably more common than thought. early diagnosis is important to avoid unnecessary diagnostic procedures and complications such as the thrombosis of the left renal vein. Many procedures are available to correct the compression of the left renal vein entrapped between the aorta and the superior mesenteric artery: Gortex graft vein interposition, nephropexy, stenting, and kidney autotransplantation. After surgery, gross hematuria ceases in almost all patients.
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2/263. Embolism in a single functioning kidney: report of two cases.

    2 cases of embolism in single functioning kidneys are reported. In the first case there was an occlusion of the main trunk of the renal artery; the patient was treated by embolectomy. In the second case the occlusion of a major arterial branch was demonstrated; because of the bad general conditions the patient was treated with medical therapy. The authors review the literature and the indications for embolectomy in embolism in a solitary kidney.
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3/263. Radionuclide renography: a personal approach.

    Recent advances have increased the value of radionuclide renography in evaluating the patient with suspected disease of the genitourinary tract. The use of the consensus process to help standardize procedures and recommend interpretative criteria provides guidance for the nuclear medicine practitioner, serves as a basis to improve the standard of practice, and facilitates pooling of data from different centers. This review draws on the consensus criteria to present a personal approach to radionuclide renography with a particular emphasis on diuresis renography and the detection of renovascular hypertension. patients are encouraged to come well hydrated and void immediately prior to the study. Our standard radiopharmaceutical is 99mTc mercaptoacetyltriglycine (MAG3). Routine quantitative indices include a MAG3 clearance, whole kidney and cortical (parenchymal) regions of interest, measurements of relative uptake, time to peak height (Tmax), 20 min/max count ratio, residual urine volume and a T(1/2) in patients undergoing diuresis renography. A 1-minute image of the injection site is obtained at the conclusion of the study to check for infiltration because infiltration can invalidate a plasma sample clearance and alter the renogram curve. A postvoid image of the kidneys and bladder is obtained to calculate residual urine volume and to better evaluate drainage from the collecting system. In patients undergoing diuresis renography, the T(1/2) is calculated using a region of interest around the activity in the dilated collecting system. A prolonged T(1/2), however, should never be the sole criterion for diagnosing the presence of obstruction; the T(1/2) must be interpreted in the context of the sequential images, total and individual kidney function, other quantitative indices and available diagnostic studies. The goal of ACE inhibitor renography is to detect renovascular hypertension, not renal artery stenosis. patients with a positive study have a high probability of cure or amelioration of the hypertension following revascularization. In patients with azotemia or in patients with a small, poorly functioning kidney, the test result is often indeterminate (intermediate probability) with an abnormal baseline study that does not change following ACE inhibition. In patients with normal renal function, the test is highly accurate. To avoid unrealistic expectations on the part of the referring physician, it is often helpful to explain the likely differences in test results in these two-patient populations prior to the study.
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4/263. The diagnosis of segmental transplant renal artery stenosis by captopril renography.

    The captopril renogram test has been shown to be a sensitive test for the diagnosis of renal artery stenosis in native and transplanted kidneys. Most reports have involved only stenosis of the main renal artery. Although segmental renal artery stenosis has been diagnosed successfully in native kidneys, it is not clear whether the captopril renogram test can diagnose segmental renal artery stenosis in a transplanted kidney. The authors report two cases of successful identification, by the captopril renogram test, of functionally significant stenosis in an intrarenal branch of a single transplant renal artery.
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5/263. Bilateral renal infarction secondary to paradoxical embolism.

    Paradoxical embolism is an uncommon but increasingly reported cause of arterial embolic events. Involvement of the kidney is rarely reported. autopsy studies suggest, however, that embolic renal infarction is underdiagnosed antemortem. We report a case of bilateral, main renal artery occlusion and acute renal failure secondary to paradoxical embolism. Clinical and laboratory data at presentation were not suggestive of renal infarction. Support for the diagnosis of paradoxical embolism, which most commonly occurs across a patent foramen ovale, was made by contrast echocardiography, which provides a sensitive method for detecting right-to-left intracardiac shunts. The often subtle presentation of renal infarction suggests patients with peripheral or central arterial embolic events should be carefully observed for occult renal involvement. Contrast echocardiography should be performed when renal infarction occurs without a clear embolic source to evaluate for paradoxical embolism.
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6/263. fibromuscular dysplasia: a rare cause of cilioretinal artery occlusion in childhood.

    OBJECTIVE: To report a case of cilioretinal artery occlusion with angiographic findings characteristic of the "string of beads" associated with renovascular hypertension secondary to fibromuscular dysplasia of the renal artery in a child. DESIGN: Case report. INTERVENTION: The patient underwent ex vivo renal artery reconstruction with saphenous vein graft and reimplantation. MAIN OUTCOME MEASURES: The main clinical outcomes were control of severe hypertension, reversible hypertensive retinopathy, and improvement of vision. RESULTS: Revascularization of the kidney improved renal function, and renovascular hypertension was clearly improved. visual acuity improved to 20/200. CONCLUSIONS: A child with hypertensive retinopathy and arterial occlusion in the retina should undergo investigation to rule out a surgically curable hypertension. magnetic resonance angiography of extrarenal vessels may reveal other sites of involvement of fibromuscular dysplasia. Evaluation and early diagnosis of renovascular hypertension will prevent severe end-organ damage.
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7/263. Endovascular treatment of multiple visceral artery paradoxical emboli with mechanical and pharmacological thrombolysis.

    PURPOSE: To report a case of paradoxical emboli to multiple visceral vessels treated with both mechanical (AngioJet device) and pharmacological (urokinase) thrombolysis. methods AND RESULTS: A 72-year-old man presented with a 48-hour history of symptomatic right renal ischemia, which was treated with heparinization. Five days later, an abrupt creatinine elevation prompted arteriography, which demonstrated thromboembolism of the superior mesenteric artery (SMA) and both renal arteries. The AngioJet aspiration device was employed to successfully remove the clot from the SMA; urokinase infusion restored flow to the left kidney. At the 16-month follow-up evaluation, the patient was normotensive without medication and had a stable creatinine (1.4 mg/dL). CONCLUSIONS: Because of its speed and minimal morbidity, the AngioJet device may be an attractive alternative to surgical embolectomy or pharmacological thrombolysis in highly selected cases of acute visceral artery thromboembolism.
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8/263. Kawasaki disease complicated by renal artery stenosis.

    We report the case of a child who developed severe renovascular hypertension six months after acute Kawasaki disease. The hypertension was well controlled with enalapril, but there was a gradual decrease in function of the affected kidney. The lesion, an ostial stenosis of the right main renal artery, was not amenable to percutaneous balloon angioplasty, so was treated with bypass surgery. Vasculitis is an important cause of renovascular hypertension in children. This case highlights the importance of regular blood pressure monitoring in children with a history of systemic vasculitis.
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9/263. Renal arterial intervention and angiotensin blockade in atherosclerotic nephropathy.

    Atherosclerotic renal arterial disease (ARAD) is becoming a more important cause of end-stage renal failure. Diagnosis is more easily achieved because of greater clinical suspicion and more refined screening tools. However, the medical and interventional management of patients with ARAD is not well defined in the literature because there have been few randomized trials. Because the use of angiotensin-converting enzymes (ACE) inhibitors, and more recently angiotensin-antagonists, has become much more widespread, it is inevitable that we should, knowingly or not, give these drugs to patients with ARAD. We describe 2 case studies in which the angiotensin-antagonist irbesartan was given to 2 patients with effectively single-functional kidneys after successful renal arterial radiologic intervention. The rationale for the use of irbesartan was to control BP, which had not responded to the initial arterial intervention, and took place in patients both refractory to, and intolerant of, many other anti-hypertensive drugs. Irbesartan successfully and safely reduced systemic BP, measured by use of ambulatory BP, without prejudicing renal function (measured by use of individual kidney function GFR).
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10/263. Acute renal failure after redo thoracoabdominal aortic aneurysm repair in a patient with a solitary kidney: successful percutaneous treatment.

    PURPOSE: To report the successful percutaneous treatment of renal artery stenosis that precipitated renal failure following surgical repair of a thoracoabdominal aortic aneurysm (TAAA). methods AND RESULTS: A 70-year-old woman with a solitary kidney became anuric 2 hours after urgent repair of a symptomatic true aneurysm of the Carrel patch from an 8-year-old TAAA repair. After medical treatment failed, aortography was performed, identifying complete occlusion of the solitary renal artery. Balloon dilation and implantation of a Palmaz stent restored renal perfusion and improved function. At 6-month follow-up, she was normotensive and her creatinine within normal limits. CONCLUSIONS: renal artery stenosis or occlusion is a treatable cause of acute renal failure after TAAA repair. Percutaneous treatment options are likely to be better tolerated than surgical revascularization in this patient population.
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