THE JOURNAL OF UROLOGY
Copyright © 1977 by The Williams & Wilkins Co.
IATROGENIC RENAL ARTERY THROMBOSIS JOSEPH N. WARD
AND
RICHARD DIAS
From the Urology Service, St. Luke's Hospital Center, New York, New York
ABSTRACT
Renal calculi were removed from 2 women - in l case by renal bisection and in the other by nephrolithotomy. In each case a small clamp was applied to the renal artery for less than 30 minutes. Both patients suffered renal artery thrombosis necessitating nephrectomy. When the histories of these patients were reviewed the common factor found was oral contraceptives, suggesting that oral contraceptives may predispose to renal artery thrombosis. In young patients clamping the renal artery for less than 30 minutes rarely results in renal artery thrombosis. Baker and associates reported on 51 patients who had split kidney operations for caliceal compression defects or removal of calculi, with no cases of renal artery thrombosis. 1 However, in their surgical technique the vascular pedicle was freed completely but a rubber-shod clamp was applied to the renal artery and vein. Slaughter reported on 80 patients who had undergone renal bisection for calculi, with no cases of renal artery thrombosis.2 In his technique the renal pedicle was thinned down and a curved rubber-shod clamp was applied to the total Marshall and associates had 2 patients in whom renal thrombosis developed in their series of 50 patients who undergone complete longitudinal nephrolithotomy for staghorn calculi. 3 In their surgical technique the renal artery alone was damped with a small bulldog clamp but the circulation was not occluded for more than an hour in any case (30 minutes being the usual clamping period). We describe 2 women who had been on birth control pills before the surgical removal of renal stones. After a routine of clamping the renal artery for a short interval µa,01c,Ja0" suffered renal thrombosis necessitating
good blood flow returned and a nephrostomy tube was placed in position. In the immediate postoperative period there was only a little serosanguineous nephrostomy drainage. It was the considered opinion after 12 hours that there probably was a right kidney shut down (low nephron nephrosis) and the patient was treated expectantly, receiving mannitol intravenously. However, during the following 24 hours there was no return of renal function and the diagnosis of a renal thrombosis was considered. A renal scan was indicative of a right renal artery thrombosis and a selective right renal artery arteriogram confirmed the diagnosis. The right kidney was re-explored jointly with a vascular surgeon. There was no renal artery pulsation and the kidney was pale and soft. Arteriotomy was performed where the renal artery clamp had been applied but there were no visible compression marks on the renal artery. A small thrombus was found and removed from the distal part of the renal artery. A Fogarty catheter was passed distally and proximally but no further clots were obtained and the arteriotomy incision was closed. Since renal blood flow did not return nephrectomy was done. Convales.. cense was uneventful. The pathology report showed necrosis and autolysis of the entire renal architecture. Diagnosis was renal infarction. Case 2. A 20-year-old white woman was first diagnosed in 1971 as having a partial left upper pole staghom calculus. Recently, the patient had been suffering recurring lower urinary tract symptoms, which were characterized by dysurila, urgency and frequency. The woman had been treated previously for thyroid deficiency. She also had been on birth control pills in recent years until the current hospitalization. The patient was small, measuring only 4 feet 9 inches, and had mild tenderness over the left renal area. Urinalysis showed 40 to 50 white blood cells per high power field and 3 plus bacteria. A urine culture was positive for Escherichia coli but negative for tuberculosis. Blood pressure was 120/60 mm, Hg. Blood chemistry studies were within normal range. A cystogram revealed a smooth regular bladder with no reflux. The patient was given appropriate antibiotics for the urinary tract infection and placed on a low calcium diet. Some weeks later the patient was hospitalized because of recurring left renal pain associated with chills and fevers. She was treated again with antibiotics and improved. In October 1971 left nephrolithotomy was performed. The kidney was explored extrapleurally through the bed of the 11th rib. Since it was difficult to define the extent of the renal stone we decided to clamp the renal artery. When the main renal artery was isolated we noted that it divided into an anterior and posterior branch. A small rubber-shod bulldog clamp was applied gently to the main renal artery. The stag-horn calculus then was defined easily and the renal clamp was removed after 3 minutes. However, because of a small intrarenal pelvis we decided to do a nephrolithotomy.
CASE REPORTS
Case A 30-year-old white woman had a large staghorn calculus in the right kidney. When the woman was first seen in 1969 she complained of severe pain over the right renal area. She had had several urinary tract infections. A recent urinalysis showed packed fields of white blood cells per high power field. A urine culture was positive for Proteus mirabilis and the patient was treated with appropriate antibiotics. A recent excretory urogram (IVP) compared to one taken a few years previously showed increasing destruction of the right renal cortex with marked calicectasis. Blood chemistry studies were normal and the blood pressure was 140/70 mm. Hg. The woman had taken birth control pills until the recent insertion of an intrauterine device. The patient did not know exactly how before she was hospitalized she had stopped taking birth control pills. Because of the continued renal pain and persistent urinary tract infection we decided to remove the """';e:1,mu calculus. kidney was explored extrapleurally through the 11th rib. The renal cortex seemed firm and the was ofrelatively normal size. We decided to do a split and, accordingly, the main renal artery was A small non-traumatic bulldog clamp was applied The kidney was incised along its to the renal border and all were removed. The renal artery ~""""P~~ for 25 minutes. When the clamp was removed Accepted for publication October 15, 1976.
13
14
WARD AND DIAS
The renal artery clamp was reapplied once more for 8 minutes, during which time a nephrolithotomy was performed with ease. When the clamp was removed renal blood flow did not return and there were no signs of arterial wall compression. A vascular consultation was obtained in the operating room and it was the vascular surgeon's opinion that the renal artery was in spasm. An arteriotomy was performed over the site where the arterial clamp had been applied but no thrombi were found, nor was there any sign of damage to the arterial wall. A Fogarty catheter was passed down both branches of the renal artery but no thrombi were discovered. Heparin and papaverine solutions were then injected into both branches of the renal artery and the arteriotomy incision was closed. The kidney was observed on the operating table for 2 hours. Renal blood flow did not return and we decided to do a nephrostomy since it was considered most likely that the renal artery was in spasm. A nephrostomy was done and a small catheter was placed down to the renal artery, so that lidocaine solution could be injected around the renal pedicle postoperatively. During the next 48 hours there was no return of left kidney function although lidocaine solution had been injected intermittently around the renal artery. At this time the patient began to have fevers and a left nephrectomy was done. At the time of re-exploration there was no evidence of return of renal blood flow. The pathology report showed varying degrees of tissue necrosis and there was end-arterial thrombus formation in the interlobular arcuate and intralobular arterial branches. These pathological changes also were seen in the venous channels. Convalescence was uneventful. A recent endocrine examination revealed that the patient is still hypothyroid and she is maintained on a daily dose of thyroid. DISCUSSION
Spontaneous renal artery thrombosis is seen most commonly as a complication of rheumatic heart disease, wherein an embolus originates in a diseased heart valve or forms as a result of cardiac arrhythmia. However, thrombi may originate in the renal artery itself in patients who have atherosclerotic plaques in the arterial wall or a renal artery aneurysm. Less common causes of primary arterial thrombi are periarteritis nodosa or following selective renal arterial catheterization. Perirenal hematomas after trauma may extend around to the renal pedicle with resulting thrombosis of the renal vessels. Typically, a patient with a renal artery thrombosis complains of the sudden onset of pain over the affected kidney. There is usually pyrexia, and the lactic dehydrogenase and serum glutamic oxaloacetic transaminase may be elevated. A urinalysis may be normal. An IVP will show a non-functioning kidney and a renal scan will reveal no arterial blood flow. A selective renal arteriogram confirms the diagnosis. An emergency embolectomy must be done within a 6-hour period if the kidney is to be saved. During the years we have followed a standard surgical technique in patients who have undergone split renal procedures for calculi. This technique entails isolating the renal artery and gently applying a small bulldog clamp. The clamp is released intermittently during the procedure, the total period of clamping rarely exceeding 30 minutes. Although our first patient had a large staghorn calculus with some parenchymal destruction it is possible that clamping the renal artery for 30 minutes was sufficient to devitalize the remaining parenchymal tissue. However, the second patient had only a small calculus, no obvious parenchymal de-
struction and the clamping time was only 8 minutes. It would seem unlikely that this technique or clamping time could be a factor in the thrombosis. We are more inclined to postulate that the birth control pills could have had some part in the renal vessel thrombosis in the latter patient. In 1968 Vessey and Doll published the results of their investigation on the relationship between the use of oral contraceptives and thromboembolic disease. 4 They concluded that the risk of venous thromboembolism is about 9 times greater in women who use oral contraceptives than in those who do not. Later, Ask-Upmark and Bickerstaff drew attention to the increased incidence of vertebral artery occlusion in women on oral contraceptives. 5 Laragh has studied the effect of birth control pills in relation to hypertension and toxemias of pregnancy. 6 He observed a dramatic sustained increase in plasma angiotensinogen in all but 1 woman taking birth control pills. He also observed a specific and striking effect of birth control pills on the various components of the renin-angiotensin-aldosterone system. Stern and associates reviewed the cardiovascular risk factors in 986 women using oral contraceptives and found that they had higher plasma triglyceride levels, and systolic and diastolic blood pressures compared to women not using contraceptive pills. 7 Mann and Inman reviewed 219 deaths from myocardial infarction in women less than 50 years old. 8 They found that the use of oral contraceptives during the month before death was significantly greater in the group with infarction than during the corresponding month in the control group. While there is no absolute proof that birth control pills were responsible for the renal vascular accident in our patients it is most unusual to have renal artery thrombosis occur in such young patients when the vascular system appears to be normal. Also, there was no evidence of trauma to the arterial wall, which would have indicated an excessive clamping force. Baker and associates, 1 and Slaughter applied the pedicle clamp to a thinned down pedicle of which the renal artery and vein were clamped. It may be that the skeletonizing of the renal artery is less desirable than having the cushioning effect of the areolar fatty tissue and renal vein included in the pedicle clamp. REFERENCES
1. Baker, R., Maxted, W. C., Kelly, T., Laico, J. and Longfellow, D.: Results of more than ten years experience with renal bivalve for calyceal compression defects and renal calculi. J. Urol., 92: 589, 1964. 2. Slaughter, G. W.: Renal bisection. J. Urol., 68: 17, 1952. 3. Marshall, V. F., Lavengood, R. W., Jr. and Kelly, D.: Complete longitudinal nephrolithotomy and the Shorr regimen in the management of staghorn calculi. Ann. Surg., 162: 366, 1965. 4. Vessey, M. P. and Doll, R.: Investigation ofrelation between use of oral contraception and thromboembolic disease. Brit. Med. J., 2: 199, 1968. 5. Ask-Upmark, E. and Bickerstaff, E. R.: Vertebral artery occlusion and oral contraceptives. Brit. Med. J., 1: 487, 1976. 6. Laragh, J. H.: The pill, hypertension, and the toxemias of pregnancy. Amer. J. Obst. Gynec., 109: 210, 1971. 7. Stern, M. P., Brown, B. W., Jr., Haskell, W. L., Farquhar, J. W., Wehrle, C. L. and Wood, P. D. S.: Cardiovascular risk and use of estrogens or estrogen-progestagen combination. Stanford three-community study. J.A.M.A., 235: 811, 1976. 8. Mann, J. I. and Inman, W. H.: Oral contraceptives and death from myocardial infarction. Brit. Med. J., 2: 245, 1975.
Copyright © 1977 by The Williams & Wilkins Co.
IATROGENIC RENAL ARTERY THROMBOSIS JOSEPH N. WARD
AND
RICHARD DIAS
From the Urology Service, St. Luke's Hospital Center, New York, New York
ABSTRACT
Renal calculi were removed from 2 women - in l case by renal bisection and in the other by nephrolithotomy. In each case a small clamp was applied to the renal artery for less than 30 minutes. Both patients suffered renal artery thrombosis necessitating nephrectomy. When the histories of these patients were reviewed the common factor found was oral contraceptives, suggesting that oral contraceptives may predispose to renal artery thrombosis. In young patients clamping the renal artery for less than 30 minutes rarely results in renal artery thrombosis. Baker and associates reported on 51 patients who had split kidney operations for caliceal compression defects or removal of calculi, with no cases of renal artery thrombosis. 1 However, in their surgical technique the vascular pedicle was freed completely but a rubber-shod clamp was applied to the renal artery and vein. Slaughter reported on 80 patients who had undergone renal bisection for calculi, with no cases of renal artery thrombosis.2 In his technique the renal pedicle was thinned down and a curved rubber-shod clamp was applied to the total Marshall and associates had 2 patients in whom renal thrombosis developed in their series of 50 patients who undergone complete longitudinal nephrolithotomy for staghorn calculi. 3 In their surgical technique the renal artery alone was damped with a small bulldog clamp but the circulation was not occluded for more than an hour in any case (30 minutes being the usual clamping period). We describe 2 women who had been on birth control pills before the surgical removal of renal stones. After a routine of clamping the renal artery for a short interval µa,01c,Ja0" suffered renal thrombosis necessitating
good blood flow returned and a nephrostomy tube was placed in position. In the immediate postoperative period there was only a little serosanguineous nephrostomy drainage. It was the considered opinion after 12 hours that there probably was a right kidney shut down (low nephron nephrosis) and the patient was treated expectantly, receiving mannitol intravenously. However, during the following 24 hours there was no return of renal function and the diagnosis of a renal thrombosis was considered. A renal scan was indicative of a right renal artery thrombosis and a selective right renal artery arteriogram confirmed the diagnosis. The right kidney was re-explored jointly with a vascular surgeon. There was no renal artery pulsation and the kidney was pale and soft. Arteriotomy was performed where the renal artery clamp had been applied but there were no visible compression marks on the renal artery. A small thrombus was found and removed from the distal part of the renal artery. A Fogarty catheter was passed distally and proximally but no further clots were obtained and the arteriotomy incision was closed. Since renal blood flow did not return nephrectomy was done. Convales.. cense was uneventful. The pathology report showed necrosis and autolysis of the entire renal architecture. Diagnosis was renal infarction. Case 2. A 20-year-old white woman was first diagnosed in 1971 as having a partial left upper pole staghom calculus. Recently, the patient had been suffering recurring lower urinary tract symptoms, which were characterized by dysurila, urgency and frequency. The woman had been treated previously for thyroid deficiency. She also had been on birth control pills in recent years until the current hospitalization. The patient was small, measuring only 4 feet 9 inches, and had mild tenderness over the left renal area. Urinalysis showed 40 to 50 white blood cells per high power field and 3 plus bacteria. A urine culture was positive for Escherichia coli but negative for tuberculosis. Blood pressure was 120/60 mm, Hg. Blood chemistry studies were within normal range. A cystogram revealed a smooth regular bladder with no reflux. The patient was given appropriate antibiotics for the urinary tract infection and placed on a low calcium diet. Some weeks later the patient was hospitalized because of recurring left renal pain associated with chills and fevers. She was treated again with antibiotics and improved. In October 1971 left nephrolithotomy was performed. The kidney was explored extrapleurally through the bed of the 11th rib. Since it was difficult to define the extent of the renal stone we decided to clamp the renal artery. When the main renal artery was isolated we noted that it divided into an anterior and posterior branch. A small rubber-shod bulldog clamp was applied gently to the main renal artery. The stag-horn calculus then was defined easily and the renal clamp was removed after 3 minutes. However, because of a small intrarenal pelvis we decided to do a nephrolithotomy.
CASE REPORTS
Case A 30-year-old white woman had a large staghorn calculus in the right kidney. When the woman was first seen in 1969 she complained of severe pain over the right renal area. She had had several urinary tract infections. A recent urinalysis showed packed fields of white blood cells per high power field. A urine culture was positive for Proteus mirabilis and the patient was treated with appropriate antibiotics. A recent excretory urogram (IVP) compared to one taken a few years previously showed increasing destruction of the right renal cortex with marked calicectasis. Blood chemistry studies were normal and the blood pressure was 140/70 mm. Hg. The woman had taken birth control pills until the recent insertion of an intrauterine device. The patient did not know exactly how before she was hospitalized she had stopped taking birth control pills. Because of the continued renal pain and persistent urinary tract infection we decided to remove the """';e:1,mu calculus. kidney was explored extrapleurally through the 11th rib. The renal cortex seemed firm and the was ofrelatively normal size. We decided to do a split and, accordingly, the main renal artery was A small non-traumatic bulldog clamp was applied The kidney was incised along its to the renal border and all were removed. The renal artery ~""""P~~ for 25 minutes. When the clamp was removed Accepted for publication October 15, 1976.
13
14
WARD AND DIAS
The renal artery clamp was reapplied once more for 8 minutes, during which time a nephrolithotomy was performed with ease. When the clamp was removed renal blood flow did not return and there were no signs of arterial wall compression. A vascular consultation was obtained in the operating room and it was the vascular surgeon's opinion that the renal artery was in spasm. An arteriotomy was performed over the site where the arterial clamp had been applied but no thrombi were found, nor was there any sign of damage to the arterial wall. A Fogarty catheter was passed down both branches of the renal artery but no thrombi were discovered. Heparin and papaverine solutions were then injected into both branches of the renal artery and the arteriotomy incision was closed. The kidney was observed on the operating table for 2 hours. Renal blood flow did not return and we decided to do a nephrostomy since it was considered most likely that the renal artery was in spasm. A nephrostomy was done and a small catheter was placed down to the renal artery, so that lidocaine solution could be injected around the renal pedicle postoperatively. During the next 48 hours there was no return of left kidney function although lidocaine solution had been injected intermittently around the renal artery. At this time the patient began to have fevers and a left nephrectomy was done. At the time of re-exploration there was no evidence of return of renal blood flow. The pathology report showed varying degrees of tissue necrosis and there was end-arterial thrombus formation in the interlobular arcuate and intralobular arterial branches. These pathological changes also were seen in the venous channels. Convalescence was uneventful. A recent endocrine examination revealed that the patient is still hypothyroid and she is maintained on a daily dose of thyroid. DISCUSSION
Spontaneous renal artery thrombosis is seen most commonly as a complication of rheumatic heart disease, wherein an embolus originates in a diseased heart valve or forms as a result of cardiac arrhythmia. However, thrombi may originate in the renal artery itself in patients who have atherosclerotic plaques in the arterial wall or a renal artery aneurysm. Less common causes of primary arterial thrombi are periarteritis nodosa or following selective renal arterial catheterization. Perirenal hematomas after trauma may extend around to the renal pedicle with resulting thrombosis of the renal vessels. Typically, a patient with a renal artery thrombosis complains of the sudden onset of pain over the affected kidney. There is usually pyrexia, and the lactic dehydrogenase and serum glutamic oxaloacetic transaminase may be elevated. A urinalysis may be normal. An IVP will show a non-functioning kidney and a renal scan will reveal no arterial blood flow. A selective renal arteriogram confirms the diagnosis. An emergency embolectomy must be done within a 6-hour period if the kidney is to be saved. During the years we have followed a standard surgical technique in patients who have undergone split renal procedures for calculi. This technique entails isolating the renal artery and gently applying a small bulldog clamp. The clamp is released intermittently during the procedure, the total period of clamping rarely exceeding 30 minutes. Although our first patient had a large staghorn calculus with some parenchymal destruction it is possible that clamping the renal artery for 30 minutes was sufficient to devitalize the remaining parenchymal tissue. However, the second patient had only a small calculus, no obvious parenchymal de-
struction and the clamping time was only 8 minutes. It would seem unlikely that this technique or clamping time could be a factor in the thrombosis. We are more inclined to postulate that the birth control pills could have had some part in the renal vessel thrombosis in the latter patient. In 1968 Vessey and Doll published the results of their investigation on the relationship between the use of oral contraceptives and thromboembolic disease. 4 They concluded that the risk of venous thromboembolism is about 9 times greater in women who use oral contraceptives than in those who do not. Later, Ask-Upmark and Bickerstaff drew attention to the increased incidence of vertebral artery occlusion in women on oral contraceptives. 5 Laragh has studied the effect of birth control pills in relation to hypertension and toxemias of pregnancy. 6 He observed a dramatic sustained increase in plasma angiotensinogen in all but 1 woman taking birth control pills. He also observed a specific and striking effect of birth control pills on the various components of the renin-angiotensin-aldosterone system. Stern and associates reviewed the cardiovascular risk factors in 986 women using oral contraceptives and found that they had higher plasma triglyceride levels, and systolic and diastolic blood pressures compared to women not using contraceptive pills. 7 Mann and Inman reviewed 219 deaths from myocardial infarction in women less than 50 years old. 8 They found that the use of oral contraceptives during the month before death was significantly greater in the group with infarction than during the corresponding month in the control group. While there is no absolute proof that birth control pills were responsible for the renal vascular accident in our patients it is most unusual to have renal artery thrombosis occur in such young patients when the vascular system appears to be normal. Also, there was no evidence of trauma to the arterial wall, which would have indicated an excessive clamping force. Baker and associates, 1 and Slaughter applied the pedicle clamp to a thinned down pedicle of which the renal artery and vein were clamped. It may be that the skeletonizing of the renal artery is less desirable than having the cushioning effect of the areolar fatty tissue and renal vein included in the pedicle clamp. REFERENCES
1. Baker, R., Maxted, W. C., Kelly, T., Laico, J. and Longfellow, D.: Results of more than ten years experience with renal bivalve for calyceal compression defects and renal calculi. J. Urol., 92: 589, 1964. 2. Slaughter, G. W.: Renal bisection. J. Urol., 68: 17, 1952. 3. Marshall, V. F., Lavengood, R. W., Jr. and Kelly, D.: Complete longitudinal nephrolithotomy and the Shorr regimen in the management of staghorn calculi. Ann. Surg., 162: 366, 1965. 4. Vessey, M. P. and Doll, R.: Investigation ofrelation between use of oral contraception and thromboembolic disease. Brit. Med. J., 2: 199, 1968. 5. Ask-Upmark, E. and Bickerstaff, E. R.: Vertebral artery occlusion and oral contraceptives. Brit. Med. J., 1: 487, 1976. 6. Laragh, J. H.: The pill, hypertension, and the toxemias of pregnancy. Amer. J. Obst. Gynec., 109: 210, 1971. 7. Stern, M. P., Brown, B. W., Jr., Haskell, W. L., Farquhar, J. W., Wehrle, C. L. and Wood, P. D. S.: Cardiovascular risk and use of estrogens or estrogen-progestagen combination. Stanford three-community study. J.A.M.A., 235: 811, 1976. 8. Mann, J. I. and Inman, W. H.: Oral contraceptives and death from myocardial infarction. Brit. Med. J., 2: 245, 1975.
