Reno-caval fistula – a rare cause of secondary hypertension and heart failure: A case report and review of the literature

Abdulhak A Sadalla; Mohamed A Elrishi

doi:10.4103/LJMS.LJMS_3_20

CASE REPORT

Year : 2020 | Volume : 4 | Issue : 1 | Page : 38-40

Reno-caval fistula – a rare cause of secondary hypertension and heart failure: A case report and review of the literature

Abdulhak A Sadalla¹, Mohamed A Elrishi²
¹ Department of Medicine, Al-Emadi Hospital, Doha, Qatar
² Department of Diabetes and Endocrinology, Al-Ahli Hospital, Doha, Qatar

Date of Submission	24-Jan-2020
Date of Acceptance	12-Feb-2020
Date of Web Publication	12-Mar-2020

Correspondence Address:
Dr. Abdulhak A Sadalla
Al-Emadi Hospital, P. O. Box 50000, Doha
Qatar

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/LJMS.LJMS_3_20

Abstract

A 15-year boy presented with features of high-output heart failure. He was managed successfully with heart failure treatment for 1 year, and then, he sustained refractory hypertension. A reno-caval fistula was discovered which is caused by previous bullet injury. His hypertension was cured by nephrectomy.

Keywords: Heart failure, reno-caval fistula, secondary hypertension

How to cite this article:
Sadalla AA, Elrishi MA. Reno-caval fistula – a rare cause of secondary hypertension and heart failure: A case report and review of the literature. Libyan J Med Sci 2020;4:38-40

How to cite this URL:
Sadalla AA, Elrishi MA. Reno-caval fistula – a rare cause of secondary hypertension and heart failure: A case report and review of the literature. Libyan J Med Sci [serial online] 2020 [cited 2023 Mar 30];4:38-40. Available from: https://www.ljmsonline.com/text.asp?2020/4/1/38/280561

Introduction

Renal arteriovenous fistula (RAVF) is a rare condition in which there is one or more connection between renal arterial and venous systems; it could be congenital, idiopathic, or acquired, following trauma or surgery. Acquired RAVF is the most common type, and it is a reported complication secondary to nephrectomy and laparoscopic cholecystectomy;^[1],[2],[3] the incidence has increasingly recognized due to the increasing number of kidney biopsies.^[4] Secondary hypertension was observed for many decades when the renal artery is connected to the inferior vena cava in an experimental fistula.^[5] It is attributed to renal hypoperfusion, ischemia, and high renin–angiotensin release.^[6],[7]

High-output heart failure is a rare consequence of RAVF due to the significant diversion of blood flow.^{[8],[9],[10],[11]} Clinical findings of RAVF include abdominal bruit, impairment of kidney function, and hematuria.^[12],[13] Heart failure and hypertension caused by RAVF are potentially reversible after fistula closure by embolization or surgical obliteration or by doing nephrectomy.^{[7],[12],[13],[14],[15],[16]} We report a young male patient presented with features of high-output heart failure followed by sustained refractory hypertension. A reno-caval fistula was discovered which is caused by previous bullet injury. His hypertension was cured by nephrectomy.

Case Report

A 15-year-old boy presented with a 10-day history of fever, breathlessness, and leg swelling. On examination his pulse rate was 110 bpm, blood pressure 125/80 mmHg, with bilateral pitting leg edema, The chest examination showed bilateral basal crackles. Cardiovascular examination was unremarkable. The echocardiogram showed an ejection fraction of 25%, dilated ventricles, and functional mitral regurgitation. The diagnosis at that time was heart failure secondary to myocarditis. Accordingly, the patient was treated with diuretic, vasodilator, and digoxin. He responded well, with gradual improvement of symptoms over 2 weeks, and was discharged home in a stable condition. His ejection fraction increased gradually up to 50% after 1 year of initial presentation; thereafter, the patient reported recurrent headaches and his BP was found repeatedly high (systolic BP range between 170 and 190 mmHg and diastolic BP between 110 and 115 mmHg in different days) in spite of the fact that he was already on a vasodilator (losartan), diuretic (furosemide), and beta-blocker (carvedilol). Physical examination at the time revealed a palpable thrill and a continuous murmur in the lower abdomen which raises the possibility of intra-abdominal arteriovenous fistula. On further reviewing his past medical history, the patient had sustained a high-velocity bullet injury to the abdomen few months earlier to his initial presentation with heart failure. Exploratory laparotomy was done at that time, a limited retroperitoneal hematoma was found which was managed conservatively, and the bullet was left in situ.

In the work-up as a newly diagnosed hypertensive patient, urine examination showed microscopic hematuria, and renal function tests and electrolyte tests were normal. The right kidney was smaller than the left by ultrasound with a hypoechoic mass related to its hilum. Doppler study of the renal artery reported a high systolic flow velocity of 350 cm/s. (The normal peak flow is <150 cm/s.) Kidney, ureter, and bladder X-ray showed a 6 cm × 4 cm faint rounded rim of calcification near the right kidney hilum and a bullet shadow overlapping the right transverse process of the L5 vertebra. Intravenous urography showed a smaller right kidney in the nephrogram stage with sac shadow impressing calyces and pushing the right kidney downward and laterally [Figure 1] and [Figure 2]. Right renal angiography revealed a connection sac draining into the inferior vena cava [Figure 3] and [Figure 4], which confirms the diagnosis of secondary hypertension due to underlying traumatic RAVF. The patient was operated by urologist and vascular surgeon; nephrectomy was done with closure of reno-caval connection and repair of caval defect. The early postoperative period was smooth with normalization of BP. Antihypertensive medications were stopped after the surgery.

Figure 1: Intravenous urogram: Sac shadow impressing right renal calyces and displacing kidney laterally

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Figure 2: Connection sac with a rim of calcification

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Figure 3: Right renal angiography: Right kidney is displaced laterally by a sac

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Figure 4: Sac connection to Inferior vena-cava

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Discussion

Two different clinical presentations for this patient with traumatic RAVF were as follows: initially, he was admitted with congestive heart failure, responded well to therapy, and remained stable for 1 year, and then, he sustained refractory hypertension although he was on diuretic, vasodilator, and beta-blocker as antifailure treatment.

The early pathophysiology is presumed to be a significant arteriovenous diversion of blood and high-output heart failure; thereafter and when renal ischemia and hyperreninemia predominated, it resulted in refractory hypertension. In addition, our patient sustained microscopic hematuria, but his renal function remained intact. Interestingly, there was a rapid normalization of BP soon after the obliteration of RAVF and nephrectomy, and no more medications were required later on.

A similar observation of delayed appearance of hypertension was reported 8 years following traumatic RAVF.^[15] Heart failure has been reported to appear up to 50 years after traumatic RAVF following nephrectomy.^[2],[16] To our knowledge, this is the third case in the literature in which traumatic RAVF presented with both heart failure and hypertension in the same patient.^[4],[12]

Although the outcome was satisfactory; however, detailed history taking and physical examination could help to reach the diagnosis earlier. We stress on considering even remote history of surgery or trauma in assessing patients with hypertension and heart failure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Di Stasi C, Pedicelli A, Manfredi R, Sallustio G. Renocaval arteriovenous fistula as a complication of laparoscopic cholecystectomy. AJR Am J Roentgenol 2001;176:261-2.
2.	El-Rassi I, Jebara I, Khoury A, Kassab R, Tabet G. Cardiac failure caused by renal arteriovenous fistula fifty years after nephrectomy. A new case and review of the literature]. Arch Mal Coeur Vaiss 1997;90:1427-30.
3.	Jose CS, Luiz FF, Marcos JC, Marcos JV, Andre LC. Post nephrectomy arteriovenous fistula. Sao Paulo Medical Journal 1997;115:1444-7.
4.	Rezende LS, Ortiz MR, Paula SC. Idiopathic renal arteriovenous fistula causing renovascular hypertension and cardiac failure. Braz. J Nephrol 2002;24:110-4.
5.	Jhunjhunwala J, Desai A, Kropp KA. Side-to-side right renal artery-vena caval fistula. A new model for experimental hypertension. Invest Urol 1975;13:236-40.
6.	Michel JB, Alhenc-Gelas F, Auzan C, Corvol P, Menard J. Renal arteriovenous fistula: A model for renovascular hypertension in rat. J Urol 1983;129:1270-2.
7.	An HS, Kang TG, Yun HJ, Kim MJ, Jung JA, Yoo JH, et al. Hypertension caused by renal arteriovenous fistula. Korean Circ J 2009;39:548-50.
8.	Nagahara A, Nishimura K, Okuyama A. A giant idiopathic renal arteriovenous fistula associated with high-output heart failure. Int J Urol 2009;16:648-9.
9.	Yared K, Baggish AL, Wood MJ. High-output heart failure resulting from a remote traumatic arteriovenous fistula. Can J Cardiol 2009;25:e143-4.
10.	Rochlani YM, Pai VB, Lataifeh AR, Bartter T. Thinking outside the box: A middle-aged man with new-onset dyspnoea on exertion and pedal oedema.BMJCaseRep 2015;2015. pii:bcr2015209724. doi:10.1136/bcr-2015-209724.
11.	Maldonado JE, Sheps SG, Bernatz PE, Deweerd JH, Harrison EG Jr., Renal arteriovenous fistula. A reversible cause of hypertension and heart failure. Am J Med 1964;37:499-513.
12.	Melo NC, Mundim JS, Costalonga EC, Lucon AM, Santello JL, Praxedes JN. Three cases of hypertension and renal arteriovenous fistula with a de novo fistula. Arq Bras Cardiol 2009;92:e63-5.
13.	Smaldone MC, Stein RJ, Cho JS, Leng WW. Giant idiopathic renal arteriovenous fistula requiring urgent nephrectomy. Urology 2007;69:576.e1-3.
14.	Boijsen E, Kohler R. Renal arteriovenous fistulae. Acta Radiol 1962;57:433-45.
15.	Bozer AY, Böke E, Gnay I, Caǧlar S, Besim A, Turgan C, et al. Hypertension because of an arteriovenous fistula between the right renal artery and the inferior vena cava secondary to a gunshot wound: A case report. Angiology 1981;32:648-52.
16.	Robinson H, Shams J, Kirk J, Sorrentino N, Deitch J. Percutaneous treatment of a traumatic renal-caval arteriovenous fistula presenting as high output cardiac failure. Ann Vasc Surg 2009;23:256.e9-12.