AngioJet TM rheolytic thrombectomy induced intravascular haemolysis leading to Acute Kidney Injury requiring Dialysis

Background: AngioJetTM rheolytic thrombectomy has been used in the treatment of deep vein thrombosis (DVT) to prevent post-thrombotic syndrome. Though not widely appreciated, it has the potential to cause intravascular haemolysis. Report: A 37 year old man with no previous medical history presented to his GP with a three week history of progressive right upper limb swelling. Doppler imaging confi rmed right upper limb DVT and CT scan demonstrated thoracic outlet syndrome. The patient underwent AngioJetTM thrombectomy followed by IV heparin infusion. Successful revascularisation of the occluded vein was achieved. Overnight he developed haematuria, which was initially attributed to IV heparin. Urinalysis however revealed no red cells or casts. Apart from an Hb drop from 134 to 117 his blood profi le and blood fi lm showed no abnormality. He subsequently developed progressive oliguria with marked oedema and acute kidney injury (AKI). His creatinine peaked at 1070umol/l at 96 hours post procedure and he was started on intermittent dialysis. He remained dialysis dependent for 6 days. Ultrasound imaging excluded urinary obstruction. Autoimmune and vasculitic serology were negative. Intravascular haemolysis and haemoglobinuria was confi rmed by raised LDH (1714u/L) and low haptoglobin (<0.1units). Direct Coomb’s test, Cold agglutinin test and paroxysmal nocturnal haemoglobinuria screen were negative. The patient’s renal function normalised over 3 months. Conclusions: The likely cause of this man’s AKI is heme pigment nephropathy from intra-vascular haemolysis. Increased awareness of this condition may allow early identifi cation and intervention to reduce the risk of renal injury from AngioJetTM associated haemolysis. Case Report AngioJetTM rheolytic thrombectomy induced intravascular haemolysis leading to Acute Kidney Injury requiring Dialysis Hultin Sebastian1*, Nguyen Tam2 and Murali Karumathil1 1The Wollongong Hospital, Department of Renal Medicine, Australia 2The Wollongong Hospital, Department of Vascular Surgery, Australia *Address for Correspondence: Sebastian Hultin, The Wollongong Hospital, Department of Renal Medicine, Australia, Email: sebastian.hultin@doctors.org. uk Submitted: 11 July 2018 Approved: 02 August 2018 Published: 03 August 2018 Copyright: 2018 Sebastian H. et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite this article: Sebastian H, Tam N, Karumathil M. AngioJetTM rheolytic thrombectomy induced intravascular haemolysis leading to Acute Kidney Injury requiring Dialysis. J Clini Nephrol. 2018; 2: 025-028. https://doi.org/10.29328/journal.jcn. 1001015 Introduction We report a case of dialysis-requiring acute kidney injury AKI following AngioJetTM rheolytic thrombectomy in a 37 year old mine worker, likely secondary to mechanical haemolysis induced by the procedure. The increasing availability of percutaneous mechanical thrombectomy (PMT) has offered a novel avenue for management of both venous and arterial thromboses. Bene it has been demonstrated in lower limb DVTs particularly in the prevention of post thrombotic syndrome [1]. Although its bene it in upper limb DVT is less clear [2], the presence of a large symptomatic thrombus prompted decision to proceed with thrombolysis and PMT in addition to anticoagulation. Targeted therapy for thrombus dissolution also remains an attractive strategy in patients with signi icant bleeding risk or where systemic thrombolysis is not an option [3]. AngioJetTM, available at our facility, creates a hydrodynamic vortex through retrogradely oriented high speed luid jets allowing selective trapping and dissolving of thrombi [4]. While AngioJetTM thrombectomy is recognised as an effective treatment for DVT, adverse effect data has focused on mortality (0%), thromboembolic events AngioJetTM rheolytic thrombectomy induced intravascular haemolysis leading to Acute Kidney Injury requiring Dialysis Published: August 03, 2018 26/28 (<1%) and requirements for blood transfusion (4.2-14%) despite an insigni icant incidence of major bleeding [5]. A systematic case series review in 2011 concluded that PMT was a feasible treatment for DVT and possibly safe, although the authors concluded that the level of evidence was for adverse events was lacking [5]. A more recent systematic review of percutaneous thrombectomy in pulmonary embolism in 2013 highlighted signi icant cardiovascular risk associated with AngioJetTM with cardiovascular complications reported in 21.1% of all cases with massive embolism and 17.4% of cases with submissive embolism [6]. There was also a signi icant risk of risk of bradyarrhythmia (11.6%) and asystole (1%) in addition to a higher rate of bleeding (14.5%). The same review found an incidence of 11.7% of renal impairment, which may have been signi icantly under reported due to post intervention routine biochemical testing not always taking place. Although PMT induced haemolysis is well described in the literature, there has been historical under-appreciation of the potential for severe AKI largely due to lack of in-vivo trials evaluating renal function as an outcome and lack of reporting on renal function change as a complication [7]. Early studies have demonstrated intravascular haemolysis following procedure with clinically insigni icant drops in Hb concentrations, elevated LDH and low haptoglobin consistent with haemolysis, and less frequently an increase in creatinine [8]. In 2009 [3] reported a presumed irst case of severe AKI requiring dialysis following AngioJetTM PMT in a patient with pulmonary embolus [3]. Prior to this in 2007, however, a prior paediatric case of AKI involving PMT had already been reported in a 16 year old patient with severe clot burden DVT and multiple administration of contrast resulting in severe AKI requiring peritoneal dialysis [9]. More recently in 2016 a further case of AKI requiring dialysis following PMT treatment of an extensive lower limb and IVC DVT [10] was reported. Our case adds to a growing case series of severe AKI requiring short to medium term RRT.