Bilateral Renal Vein Thrombosis Treated with Percutaneous Thrombolysis and Mechanical Thrombectomy

Background
Renal vein thrombosis is a rare phenomenon with significant morbidity. Management usually consists of systemic anticoagulation, yet with the evolution of endovascular technology, more novel treatment options have been described. We report a case illustrating our approach.
Methods
A 34 year old previously healthy Caucasian male presented to the emergency department with gradual onset of bilateral flank abdominal pain and anuria. Initial evaluation revealed only proteinuria but, prior to the initiation of hemodialysis, he underwent an abdominal/pelvic CT. This demonstrated an extensive thrombus involving both renal veins and extending proximally into the juxtarenal IVC. After the initiation of heparin, the patient underwent suprarenal IVC filter placement via a transjugular approach. This was followed by IVC venography through a femoral approach, confirming the aforementioned results (figure), and selective bilateral renal venography starting first with the right renal vein. Pulse spray thrombolysis using 1.5 mg of tPA was performed followed by mechanical thrombectomy with the AngioJet catheter. Repeat renal venography demonstrated patency. Pulse spray thrombolysis was repeated in a similar fashion for the IVC (3.5 mg tPA) and left renal system (2 mg tPA) with subsequent AngioJet thrombectomy. The final venogram revealed residual clot burden in both renal veins, and, therefore, separate catheters were selectively placed in both renal veins and treated with continuous tPA infusion at 0.5 mg/hour (total of 1 mg/hour) for 12 hours in addition to systemic heparinization.
Results
Venography performed 12 hours postprocedure demonstrated excellent flow through both renal systems and the IVC. The patient was kept on heparin which was eventually converted to oral anticoagulation. He maintained excellent urine output and his creatinine trended back towards baseline. In addition, his glomerular filtration rate dramatically improved throughout his hospitalization. Prior to discharge, a renal duplex was performed which again demonstrated excellent flow through both renal venous systems and IVC. His renal function remained stable almost a year after the event and has remained dialysis free.
Conclusions
Percutaneous mechanical thrombectomy and thrombolysis is an alternative therapeutic option for renal vein thrombosis which can be performed with good technical success and, in this patient, provided successful renal salvage and excellent early clinical outcomes.