Reparación laparoscópica de fístula de arteria renal derecha a vena cava, posnefrectomía radical derecha

Background

Post-nephrectomy arteriovenous fistula is rare in relation to the number of nephrectomies performed worldwide and they are more frequent on the right side, as was true for the case presented herein.

Case report

A 66-year-old woman underwent right radical nephrectomy in January 2005. In May 2015 she came to a cardiology consultation presenting with anasarca and an abdominal murmur. An abdominal tomography scan was done and an arteriovenous fistula involving the right renal artery and the vena cava was diagnosed. The hemodynamics specialist ruled out endovascular treatment and the patient was referred to our urology service.

Through laparoscopy performed with the patient in the right lateral decubitus position, 2 L of ascites were extracted and the origin of the right renal artery was dissected. Two 10 mm Hem-o-Lok staples were applied. On the first postoperative day the patient had minimal abdominal pain, tolerated a liquid diet, passed gases, and had normal vital signs, but the abdominal murmur continued to be heard. At 30 h after the procedure, an abdominal tomography scan was carried out that revealed no change in the arteriovenous fistula. The double Hem-o-Lok staples were observed in the superior mesenteric artery, but there was flow despite the 2 staples (partial obstruction). Emergency laparoscopy was performed, removing the staples from the superior mesenteric artery. The right renal artery was located and 2 Hem-o-Lok staples were placed. The murmur ceased. The patient had excellent postoperative progression. The control tomography scan showed there was no arteriovenous fistula and the superior mesenteric artery was normal with no staples.

Conclusions

This was an unusual and complex case that was resolved through laparoscopy. Perhaps an atheroma prevented complete superior mesenteric artery obstruction. The position of the patient was an important factor in locating the right renal artery.