AngioJetTM rheolytic thrombectomy induced intravascular haemolysis leading to Acute Kidney Injury requiring Dialysis

Abstract

Background: AngioJet TM rheolytic thrombectomy has been used in the treatment of deep vein thrombosis (DVT) to prevent post-thrombotic syndrome. Though not widely appreciated, it has the potential to cause intravascular haemolysis.Report: A 37 year old man with no previous medical history presented to his GP with a three week history of progressive right upper limb swelling. Doppler imaging confi rmed right upper limb DVT and CT scan demonstrated thoracic outlet syndrome. The patient underwent AngioJet TM thrombectomy followed by IV heparin infusion. Successful revascularisation of the occluded vein was achieved. Overnight he developed haematuria, which was initially attributed to IV heparin. Urinalysis however revealed no red cells or casts. Apart from an Hb drop from 134 to 117 his blood profi le and blood fi lm showed no abnormality. He subsequently developed progressive oliguria with marked oedema and acute kidney injury (AKI). His creatinine peaked at 1070umol/l at 96 hours post procedure and he was started on intermittent dialysis. He remained dialysis dependent for 6 days. Ultrasound imaging excluded urinary obstruction. Autoimmune and vasculitic serology were negative. Intravascular haemolysis and haemoglobinuria was confi rmed by raised LDH (1714u/L) and low haptoglobin (<0.1units). Direct Coomb's test, Cold agglutinin test and paroxysmal nocturnal haemoglobinuria screen were negative. The patient's renal function normalised over 3 months. Conclusions:The likely cause of this man's AKI is heme pigment nephropathy from intra-vascular haemolysis. Increased awareness of this condition may allow early identifi cation and intervention to reduce the risk of renal injury from AngioJet TM associated haemolysis.

Unclogging the effects of the Angiojet® thrombectomy system on kidney function: a case report

“…The case presented appears typical when compared to other reported cases of significant AKI following Angio-Jet ® [4][5][6][7][8]. Our patient developed AKI immediately postprocedure with associated haematuria and evidence of haemolysis, despite aggressive intravenous rehydration.…”

“…AngioJet ® has previously been shown to universally result in postprocedural gross haematuria, following intravascular haemolysis caused by the high-pressure saline jets [11]. Furthermore, previous cases of AKI secondary to AngioJet ® -induced intravascular haemolysis have also been reported [4][5][6][7][8]. The occurrence of haemolysis in the case presented, as evidenced by the passage of dark red urine post-procedure, fall in haemoglobin and haptoglobin, and rise in serum LDH, was an anticipated consequence of the procedure.…”

“…This in turn can cause acute kidney injury (AKI), which although an increasingly recognized complication of Angiojet ® , remains underappreciated in clinical practice. Five previous cases of AKI following Angiojet ® have been reported in the literature, one of which was in a child [4][5][6][7][8]. We report the case of a 29 year old male who developed a severe Stage 3 AKI [9], requiring renal replacement therapy (RRT), following AngioJet ® thrombectomy of an occluded iliac vein stent.…”

Angiojet™ mechanical thrombectomy‐induced hemolysis triggering blood‐leak alarms

“…Furthermore, there have been case reports of severe acute kidney injury occurring due to hem-pigment induced nephropathy from hemolysis following AngioJet™ thrombectomy for deep vein thrombosis and thrombosed intrahepatic portosystemic shunt. 9,10 These two cases are the first reports of hemolysis following AngioJet™ thrombectomy of AV fistulas resulting in blood-leak alarms that made it impossible to provide hemodialysis. Both patients were dialyzed successfully using an alternative temporary access.…”

“…This occurs as thrombi are trapped into a retrogradely oriented high speed saline vacuum causing clot fragmentation and hemolysis. Furthermore, there have been case reports of severe acute kidney injury occurring due to hem‐pigment induced nephropathy from hemolysis following AngioJet™ thrombectomy for deep vein thrombosis and thrombosed intrahepatic portosystemic shunt 9,10 . These two cases are the first reports of hemolysis following AngioJet™ thrombectomy of AV fistulas resulting in blood‐leak alarms that made it impossible to provide hemodialysis.…”