Renal Artery Thrombectomy Causing Functional and Symptomatic Recovery after 50-Hour Delay in Reperfusion of Acute Main Renal Artery Thrombosis

Acute renal artery thrombosis is rare and even rarer in the thrombus occluding the main renal artery and compromising the entire kidney. We report on a 46-year-old female smoker with no past medical history and no hypercoagulability who developed sudden severe left flank pain, hematuria, acute renal failure, and severe hypertension. A CT angiogram showed totally occluded renal artery at the ostium with a thrombus and severely hypoperfused left kidney with multiple infarcts. Initial course of treatment was with intravenous heparin but with no improvement after 50 hours since symptom onset; angiography was done. This revealed totally occluded renal artery at ostium with no vessels or kidney blush seen. After aspiration thrombectomy, blush was seen in kidney parenchyma along with flow in the arcuate renal arteries although with some distal embolic events. The ostial lesion was treated with a drug eluting stent with excellent result angiographically. However, 8 months later, severe restenosis occurred. This time, the patient did not flank pain or renal failure but had progressive hypertension. The patient was treated this time with rheolytic thrombectomy followed by intravascular ultrasound-guided drug-eluting stenting. The patient has been followed for a year and a half since and recent CT scan revealed widely patent renal arteries bilaterally with normal kidney function, BP, and good perfusion to the left kidney with only tiny areas of infarct. Ultrasound of the kidneys also showed the size of the left kidney as within normal range now, and she has good distal flow velocities in the branch renal arteries. Our case report shows that even delayed reperfusion of complete renal artery occlusion with jeopardized arterial flow to the entire kidney could result in restoration of function to most of the kidney.