Running repairs: renal artery dissection following extreme exertion.

A 43-year-old champion New Zealand athlete presented acutely with the onset of right flank pain. He gave a previous history of ‘exercise-induced’ arrhythmia and vertebral degeneration, which were attributed to a lifetime of sporting activity. Only the day before, he had competed in a gruelling triathlon race consisting of a 11.5 km swim, a 25 km cycle and a 10 km run in summer temperatures reaching at least 32°C (94°F ). On examination, he was normotensive but had moderate renal angle tenderness. Urinalysis showed white cells >107–8/ml but no red cells or casts, and an abdominal ultrasound was unremarkable. He was discharged with simple analgesia but represented 7 days later with increasing abdominal pain and malignant hypertension. A renal isotope scan demonstrated the absence of perfusion of the right kidney. Subsequent Fig. 1. Renal angiogram showing dissection of the right renal artery angiography confirmed the presence of dissection and distal to an abnormal proximal angulation. dilatation of the right renal artery with a segmental accessory artery perfusing the lower pole, as well as the kidney as a whole, via co-lateralization (Figure 1). At surgery, the origin of the right renal artery end-to-end anastomosis to the renal artery stump. appeared to be above the diaphragmatic crus, with a Intra-operative Doppler confirmed flow in the graft. normal proximal centimetre of right renal artery angHe was discharged 10 days later, normotensive and ling downwards. The artery became angulated more with normal renal function, on felodipine 20 mg and horizontally adjacent to the muscular crus of the metoprolol 95 mg daily. He represented 2 weeks later diaphragm that contained a fibrous band. The dilatawith accelerated hypertension. Isotope scanning again tion of the artery medial to the cava was immediately confirmed the absence of right renal perfusion, and anterolateral to the crus and the dissection appeared Doppler flow studies with contrast failed to show flow to be angulating distally from this point. There was in the aorto-renal graft. He was commenced on single thrombus in the vessel extending back to the bifurcaagent captopril 25 mg tds with immediate blood prestion of the renal artery at the hilum. The upper twosure control. Subsequently he has undergone a nephrecthirds of the kidney was dusky in colour but normalized tomy. Gross pathology demonstrated an infarcted following aorto-renal saphenous vein grafting with an kidney with preservation of the lower pole. There was no evidence of dysplasia of the renal artery. Adjacent to areas of frank renal infarction there was striking Correspondence and offprint requests to: Dr Merlin Thomas, juxtaglomerular expansion in areas of preserved glomDepartment of Medicine, University of Otago, Dunedin, New Zealand. eruli, consistent with his hyper-reninaemia (Figure 2).