Acute Kidney Failure as a Complication of Acute Aortic Obstruction

Introduction: Acute aortic occlusion (AAO) is a rare condition associated with significant morbidity and mortality. It most commonly occurs due to in-situ aortic thrombosis, though embolism, aortic dissection and aortic aneurysm are also known etiologies. We describe a case of acute renal failure (ARF) requiring hemodialysis (HD) in a patient (Pt) with AAO occluding the renal arteries. Case Description: A 45 year old man with a history of chronic kidney disease (CKD) stage IIIa, pulmonary embolism on apixaban, chronic systolic heart failure, and abdominal aortic aneurysm requiring bifemoral bypass 2 years prior presented with left sided abdominal pain and 2 days of anuria. Initial labs showed a serum creatinine (SCr) of 7.6 mg/dL (baseline of 1.7 mg/dL) as well as a potassium of 6.8 mg/dL. Computed tomography (CT) without contrast of the abdomen was concerning for intramural aortic hematoma. Subsequent CT angiogram of the abdomen confirmed an intramural thrombus of the abdominal aorta with occlusion of the left renal artery, bilateral renal infarcts, and patent axillary-femoral bypass graft. He underwent emergent hemodialysis (HD) to correct hyperkalemia. Continuous heparin infusion was initiated. Workup for hypercoagulable disorder including lupus anticoagulant, Factor V Leiden, and protein C/S was negative. Four days after heparin initiation, HD was discontinued. He was discharged on day 12 after bridging to coumadin. SCr at time of discharge was 4.4 mg/dL. 6 months following discharge the Pt had established a new baseline Cr of 3.6 mg/dL. Discussion: AAO is a rare disorder with devastating sequelae, including ARF. One small case series described ARF in 15 out of 29 Pts who presented with AAO.1 Another case series identified a strong association between HD requirement and in-hospital mortality in Pts with AAO.2 As the majority of AAO is managed operatively it is difficult to attribute the etiology of AKI to AOO versus surgical complications. In the case of this Pt who was managed nonoperatively, propagation of aortic thrombus is the clear precipitant of ARF. 1. Crawford et al. “A modern series of acute aortic occlusion”. Journal of Vascular Surgery. 2014 59(4):1044-50. Doi: 10.1016/j.jvs.2013.10.080. 2. Na et al. “Treatment Outcomes and Risk Factors for IN-Hospital Mortality in Patients with Acute Aortic Occlusion”. Vascular Specialist International. 2018 30;34(2):19-25. Doi: 10.5758/vsi.2018.34.2.19.