Reparación laparoscópica de fístula de arteria renal derecha a vena cava, posnefrectomía radical derecha

ResumenAntecedentesLa fístula arteriovenosa posnefrectomía es poco frecuente a pesar del número de nefrectomías que se realizan en el mundo, y ocurren más a menudo en el lado derecho, como el caso que presentamos.Presentación del casoMujer de 66 años de edad. En enero 2005 se realizó nefrectomía radical derecha. En mayo 2015 se presenta a la consulta de cardiología en anasarca y con un soplo abdominal, se realiza tomografía de abdomen, se diagnostica fístula de arteria renal derecha a cava. Hemodinamista descarta tratamiento endovascular, es enviada a nuestro servicio de urología.Por laparoscopia, en decúbito lateral derecho se extraen 2 l de ascitis y se diseca el nacimiento de la «arteria renal derecha» y se aplican 2 grapas de Hem-o-lok de 10 mm. El primer día de postoperatorio: mínimo dolor abdominal, toleró vía oral, canalizó gases y signos vitales normales, sin embargo, se sigue escuchando soplo abdominal (30 h de postoperatorio); se hace tomografía de abdomen. La fístula arteriovenosa sin cambio y doble grapa Hem-o-lok en la arteria mesentérica superior, pero con flujo a pesar de las 2 grapas (obstrucción parcial). Hicimos laparoscopia de urgencia, se retiran grapas de la arteria mesentérica superior, se localiza la arteria renal derecha, doble grapa Hem-o-lok, desaparece el soplo. Postoperatorio excelente. Tomografía de control, sin fístula arteriovenosa y arteria mesentérica superior normal sin grapas.ConclusionesCaso complejo, poco común, que se resolvió con técnica laparoscópica. Quizá una placa de ateroma evitó la obstrucción completa de la arteria mesentérica superior. La posición del paciente fue un factor importante para encontrar la arteria renal derecha.

BackgroundPost-nephrectomy arteriovenous fistula is rare in relation to the number of nephrectomies performed worldwide and they are more frequent on the right side, as was true for the case presented herein.Case reportA 66-year-old woman underwent right radical nephrectomy in January 2005. In May 2015 she came to a cardiology consultation presenting with anasarca and an abdominal murmur. An abdominal tomography scan was done and an arteriovenous fistula involving the right renal artery and the vena cava was diagnosed. The hemodynamics specialist ruled out endovascular treatment and the patient was referred to our urology service.Through laparoscopy performed with the patient in the right lateral decubitus position, 2 L of ascites were extracted and the origin of the right renal artery was dissected. Two 10 mm Hem-o-Lok staples were applied. On the first postoperative day the patient had minimal abdominal pain, tolerated a liquid diet, passed gases, and had normal vital signs, but the abdominal murmur continued to be heard. At 30 h after the procedure, an abdominal tomography scan was carried out that revealed no change in the arteriovenous fistula. The double Hem-o-Lok staples were observed in the superior mesenteric artery, but there was flow despite the 2 staples (partial obstruction). Emergency laparoscopy was performed, removing the staples from the superior mesenteric artery. The right renal artery was located and 2 Hem-o-Lok staples were placed. The murmur ceased. The patient had excellent postoperative progression. The control tomography scan showed there was no arteriovenous fistula and the superior mesenteric artery was normal with no staples.ConclusionsThis was an unusual and complex case that was resolved through laparoscopy. Perhaps an atheroma prevented complete superior mesenteric artery obstruction. The position of the patient was an important factor in locating the right renal artery.