The Clots That Traveled Far and Distal

Today we discussed a case of an elderly gentleman who presented for AKI 5 weeks after a FEVAR with bilateral renal artery stent placement for a 6.5cm juxtarenal AAA.

We first reviewed the major risk factors for AAA:

  • elderly age, male
  • smokers
  • connective tissue disease

We then reviewed the USPSTF recommendation for AAA screening, which is one-time screening of all male patients 65-75 with any smoking history

We discussed indications for AAA repair

  • Ruptured -> emergent repair (endovascular management is a possibility)
    • Severe pain, hypotension and pulsatile abdominal mass in 50% of patients
    • Often misdiagnosed as renal colic, diverticulitis, GI hemorrhage, ischemic bowel
  • Symptomatic of any size or configuration who do not have a prohibitive surgical risk for repair should be urgent AAA repair
    • Abdominal pain, flank pain, limb ischemia, systemic manifestations such as fever or malaise
  • Asymptomatic infrarenal AAA <5.5cm = conservative
  • Asymptomatic AAA >5.5cm OR rapid expansion OR co-existing PAD OR female gender = elective repair
  • Asymptomatic AAA > 5.5cm with life expectancy <2 years, no repair

We then started reviewing the case, and quickly found out that this patient’s prior hospitalization was notable for livedo reticularis, blue toe syndrome and ischemic colitis. His discharge Cr was roughly stable and it was only 3 weeks later that he started having a significant rise in the Cr. His urine revealed no RBCs, a single eosinophil and no casts. A CT abdomen/pelvis without contrast revealed no stent migration or kinks and a renal duplex US revealed patent flow.

Nephrology reviewed all the data and were confident in their diagnosis: renal atheroemboli. Here’s what you need to know:

  • Vast majority will be iatrogenic, so look for a precipitating event such as angiography, lytic therapy or cardiovascular surgery
  • Look for subacute kidney injury (peaking 3-8 weeks after the event) and signs of extrarenal embolization (GI bleeding, focal neurologic deficits, blue toe syndrome, livedo reticularis
  • Eosinophilia, Eosinophiluria and Hypocomplementemia may all suggest atheroemboly
  • No proven effective medical therapy in patients with atheroembolic renal disease and management is supportive as well as considering how to prevent further embolization
  • Prognosis is generally poor, as many will have a stepwise decline in their renal function due to scarring as well as new embolic events and up to 1/3 may require renal replacement therapy


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