Ex Vivo Resection and Renal Autotransplantation for the Treatment of a Large Renal Vein Aneurysm Causing Recurrent Pulmonary Embolism and a Coexisting Vascular Malformation

Abstract

A 36-year-old young woman with a medical history of recurrent pulmonary embolism and chronic pelvic pain was admitted to our hospital. Contrast-enhanced imaging techniques revealed a large left renal vein aneurysm with a coexisting vascular mass. The patient was operated on electively, and the left kidney was autotransplanted to the right ileac fossa following the ex vivo resection of the vascular mass and the left renal vein aneurysm. Herein, we report an unusual coexistence of a vascular mass and recurrent pulmonary embolism treated successfully with our surgical treatment strategy.

Left renal vein aneurysm in a young woman with renal nutcracker syndrome

“…Although NCS is associated with dilation of the renal pelvis and surrounding venous structures causing varices, to our knowledge, there has been only one other documented case of a distinct saccular left renal vein aneurysm in the setting of NCS 11 . Although the few renal vein aneurysm cases published often observed these patients, we thought that although the patient's symptoms improved with OCPs, there was an increased risk for embolization to the venous system and pulmonary vasculature as previously described 1 , 2 . We believed that as the patient's body position varied throughout the day, moving to prone or leaning forward, the small bowel and mesentery would relax on the retroperitoneum and allow thrombus in the aneurysm sac to embolize to the lungs.…”

“…Although her symptoms improved with medication, the aneurysm caused concern for future embolization to the systemic venous circulation as seen in two other reported renal vein aneurysms 1 , 2 . For this reason, she underwent exploratory laparotomy with complete resection of the left renal vein aneurysm.…”

Incidental finding of circumaortic left renal vein aneurysm on imaging

“…The RVA and malformation were resected; pathology showed thrombus in the malformation to which the PE was attributed. 16 The patient presented here is an asymptomatic 59 year old male with left circumaortic RVA found incidentally on imaging. This appears to be only the second published incidence of such finding.…”

“…3 Abdominal pain was the presenting symptom in six cases [7][8][9][10][11] and hematuria in four patients. 7,[12][13][14] Etiology was unknown for most cases 2,4,6,7,11,14 ; however, five were thought to be related to arteriovenous fistula or other vascular malformation, 5,8,13,15,16 two were thought to be related to malignancy, 3,12 and one attributed to nutcracker syndrome. 10 Complications ranged from none to thrombosis, pulmonary thromboembolism, and rupture.…”

“…6,12 There were two cases complicated by PE in this series. 16,17 Rios et al attributed recurrent pulmonary embolism to a left RVA due to a large lymphatic malformation overlying the left renal vein. Özyüksel et al similarly described a RVA J o u r n a l P r e -p r o o f associated with a vascular malformation which was felt to be the source of the PE as the rest of the workup was negative.…”