A patient with hypertension was cured after resection of a renal AV fistula

Dominik M. Alscher1, Thomas Hupp2, Thomas Mettang1 and Ulrich Kuhlmann1

1 Robert-Bosch Krankenhaus, Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Stuttgart and 2 Katharinenhospital, Department of Surgery, Division of Vascular Surgery, Stuttgart, Germany

Correspondence and offprint requests to: Dr Dominik M. Alscher, Robert-Bosch Krankenhaus, Department of Internal Medicine, Division of General Internal Medicine and Nephrology, Auerbachstr. 110, D-70376 Stuttgart, Germany.

Keywords: hypertension; fistula



   Introduction
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 Introduction
 Case
 Discussion
 References
 
In the evaluation of hypertension, an abdominal bruit normally suggests renal artery stenosis as the cause of the hypertension. Here we present an astonishing finding in the expression of hypertension in a female patient with an abdominal bruit, which led to surgery and subsequent resolution of the hypertension.



   Case
 Top
 Introduction
 Case
 Discussion
 References
 
A 50-year-old woman was admitted to the clinic because of an abdominal bruit on the left side and hypertension diagnosed 6 years ago. Blood pressure was 150/95 mmHg on the right and 150/100 mmHg on the left arm. The patient complained of dizziness and an increased susceptibility to headache. Her family history was unremarkable. Hypertension was being treated with 2.5 mg bisoprolol per day. Physical examination showed a grade 2 systolic murmur along the left sternal border. In addition, marked distension of the jugular vein was seen in the upright position. The hepatojugular reflux was positive. Fundoscopy demonstrated hypertensive retinopathy (grade II). The laboratory results showed normal values. Urinalysis was unremarkable. The electrocardiogram recorded a right bundle branch block pattern (QRS 0.09 s) with a normal QRS axis and sinus bradycardia (HR=55 beat/min). Thoracic radiographs showed enlargement of the heart with widening of the right-outflow tract. An echocardiogram demonstrated right ventricular enlargement and the left ventricle displayed concentric hypertrophy. Ultrasound of the abdomen demonstrated normal-sized kidneys with a cystic formation (65x31 mm) in the hilar region of the left kidney with a turbulent current. Renal angiography (Figure 1Go) established the diagnosis of a renal arteriovenous fistula (AVF). Since the patient exhibited initial signs of volume loading and heart failure due to the shunt volume caused by the fistula, we recommended surgery of the AVF with closure of the shunt. Because of the enlargement and the multiplicity of the shunt vessels, a surgical procedure similar to the standard procedure for allogenic kidney transplantation was chosen with explantation of the kidney (Figure 2Go). Resection of the fistula was performed on the operating table (ex situ). The kidney was then reimplanted into the pelvic region. The 12-month follow-up period has been unremarkable. Blood pressure is now in the range 120–135/75–85 mmHg without any medication.



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Fig. 1. Renal angiography show an enlarged left renal artery with direct connections to a bridging cystic formation located in the hilar region of the left kidney draining into the renal vein.

 


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Fig. 2. Left kidney ex situ showing an AVF with multiple shunt vessels in the renal pelvis of a patient with hypertension. -> AVF, still not cut; {Rightarrow} AVF, already cut; A renal artery main trunk (hypertrophic dilatation); V renal vein; VA venous aneurysm (held up with forceps).

 


   Discussion
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 Introduction
 Case
 Discussion
 References
 
Spontaneous renal AVFs are rare [1]. The classification of spontaneous AVFs separates into two types: cirsoid/congenital and idiopathic/aneurysmal fistulas [1]. Cirsoid AVFs are composed of tortuous, varix-like vessels. In contrast, the idiopathic subtype is characterized by a single enlarged vessel [1]. The intra-operative findings in our patient, who had multiple shunt vessels, led to the diagnosis of a cirsoid AVF.

Hypertension accompanying renal AVF is caused by renal ischaemia with secondary activation of the renin–angiotensin–aldosterone system [2,3]. Hypertension is found in ~40% of cases [1]. Abdominal bruits and cardiomegaly are characteristics of idiopathic AVFs, but cirsoid AVFs can also exhibit these signs [1]. In symptomatic patients AVFs are treated by obliteration of the fistula [4]. In our patient, we first discussed the possibility of primary angiographic embolization since case reports in the literature preferred this procedure [1,4]. However, the magnitude and multiplicity of the shunt vessels were strong arguments for an alternative surgical procedure with direct clipping of the shunt vessels. Because of the large shunt volume and the operative situs, preparation and ligature were performed ex situ after explantation of the kidney. The reimplantation site was chosen in accordance with the standard procedure for allogenic kidney transplantation. The patient remained healthy during follow-up. The observations in our patient contribute to the recommended treatment of AVFs. In symptomatic patients with volume loading and heart failure, closure of the AVF is indicated with good chances of a definitive cure [1]. The surgical procedure chosen here, however, is feasible for only a few patients. These include those who are not candidates for the commonly elected procedure of embolization of shunt vessels, primarily because of anatomic reasons.



   References
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 Introduction
 Case
 Discussion
 References
 

  1. Fogazzi GB, Moriggi M, Fontanella U. Spontaneous renal arteriovenous fistula as a cause of haematuria. Nephrol Dial Transplant 1997; 12: 350–356[Abstract]
  2. Sarramon JP, Cerene A, Gorodetski N, Bernadet P, Durand D. Spontaneous renal arteriovenous fistula and arterial hypertension— conservative treatment and healing. Eur Urol 1978; 4: 214–216[ISI][Medline]
  3. Sidi AA, Jonas P, Rosenthal T, Many M. Intrarenal arteriovenous fistula: a cause of reversible hypertension. Br J Urol 1986; 58: 334–335[ISI][Medline]
  4. Schwab M, Boswald M, Kandler M, Ruder H, Hildebrandt R. Transcatheter intravascular embolotherapy of renal arteriovenous fistula—method of choice. Nephrol Dial Transplant 1996; 11: 2523–2524
Received for publication: 13. 7.99
Accepted in revised form: 4.10.99





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