Congenital renal arteriovenous fistula with giant arterial and venous aneurysms formation

A 39-year-old woman came to the outpatient department with a chief complaint of right back soreness discomfort for 2 months.She denied any history of trauma, biopsy, or abdominal surgery.Physical examination revealed a pansystolic murmur in the right upper quadrant.Laboratory values were all within normal range with the except of hematuria (approximately 30 cells/mL), including normal blood routine and normal renal function with a creatinine of 70.45mLmol/ L.She underwent a computed tomography scan, which revealed vascular tortuosity and aneurysmal dilatation adjacent to the renal hilum.Therefore, a contrast-enhanced computed tomography angiogram was performed, which confirmed a congenital right renal arteriovenous fistula (RAVF) concomitant with giant renal arterial and venous aneurysms formation, with the diameter reaching 45 mm (A/ Cover and B).Cardiac echocardiography showed normal systolic function (left ventricular ejection fraction of 59%) and normally functioning valve.Staged endovascular embolization was planned, but the patient refused further treatment owing to financial difficulties.Regular computed tomography angiogram testing was advised, unfortunately, the patient did not continue follow-up.RAVF is an uncommon malformation of the kidney.The majorities of cases are iatrogenic and occur as a complication of renal biopsy, surgery, nephrostomy, or blunt or penetrating trauma. 1,2Congenital RAVF is even rarer and always underdiagnosed as a clinical condition.The common symptoms and signs of RAVF consist of abdominal bruit, hypertension, cardiomegaly, congestive heart failure, and hematuria. 3Indications for treatment of RAVF are the progressive increase in the size of the fistula or concomitant aneurysms, hematuria, hypertension, and high-output heart failure. 1 Management options for RAVF include the conservative approach, endovascular techniques, or surgical resection.However, in cases concomitant with tortuous and giant aneurysms formation, the treatments are technically challenging.