Delayed Renal Artery Stump Pseudoaneurysm and Arteriovenous Fistula Following Nephrectomy Complicated by Pulmonary Coil Migration: Successful Laparoscopic Management

Background: Renal arteriovenous fistula (RAVF) and renal artery pseudoaneurysm (RAP) are rare vascular complications that may occur following renal surgery, trauma, or endovascular interventions. Delayed presentation after nephrectomy is exceptionally uncommon. Case Description: We report the case of a 59-year-old woman with a pseudoaneurysm of the left renal artery stump associated with a high-flow renal arteriovenous fistula who was diagnosed three decades after left nephrectomy performed for complicated nephrolithiasis. The patient presented with episodic left flank pain without haematuria. Computed tomography angiography (CTA) and selective angiography confirmed the presence of a pseudoaneurysm and a high-flow arteriovenous fistula. Endovascular coil embolization was initially attempted; however, the coil migrated through the high-flow fistulous tract into the peripheral left pulmonary arterial circulation. Because the patient remained asymptomatic and haemodynamically stable and the coil was located peripherally, the procedural risk of retrieval was considered to outweigh the anticipated benefit. The coil was therefore left in situ under clinical and imaging surveillance. Because substantial arteriovenous shunting persisted after the unsuccessful embolization, definitive laparoscopic ligation of the left renal artery and vein stumps was successfully performed approximately one month later. During the two-year follow-up, two CTA examinations and Doppler ultrasonography confirmed complete occlusion of the fistula and pseudoaneurysm, with no recurrent abdominal symptoms or pulmonary complications related to the migrated coil. Discussion: Although post-nephrectomy arteriovenous fistulas presenting 28 and 45 years after surgery have previously been reported, the combination of a renal artery stump pseudoaneurysm, a high-flow fistula, pulmonary coil migration, persistent arteriovenous shunting, and subsequent successful laparoscopic management is particularly unusual. This case highlights the technical challenges of endovascular treatment in high-flow fistulas and the role of surgical management following unsuccessful embolization. Conclusions: Delayed renal artery stump pseudoaneurysm associated with renal arteriovenous fistula after nephrectomy is an extremely rare condition. Although endovascular embolization remains the preferred first-line treatment, surgical management may be necessary in cases complicated by technical failure or embolization-related complications.