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Stent-Assisted Coiling of a Ruptured Renal Artery Aneurysm: an Unusual Cause of Low Back Pain

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Abstract

Renal artery aneurysms are rare, but their reported incidence has increased as a result of the widespread use of imaging techniques. Most aneurysms are asymptomatic and discovered incidentally; however, they can present with refractory hypertension, pain and hematuria. We report the case of a 42 year old normotensive woman who presented with acute lower back pain with unremarkable lumbar x rays, in the setting of acute anemia with hypotension, leading to a high suspicion for internal bleeding. CT scan of the abdomen and pelvis revealed the presence of a ruptured 1.8 cm right renal artery aneurysm. Successful exclusion of the aneurysm was accomplished by stent-assisted coiling. Follow up imaging at one and six month intervals revealed patency of the stent and no deleterious effects on renal function.

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Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments.
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GRADE A RECOMMENDATIONS (based on good-quality patient-oriented evidence): Advise patients to stay active and continue ordinary activity within the limits permitted by pain, avoid bed rest, and return to work early, which is associated with less disability. Consider McKenzie exercises, which are helpful for pain radiating below the knee. Recommend acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) if medication is necessary. COX-2 inhibitors, muscle relaxants, and opiate analgesics have not been shown to be more effective than NSAIDs for acute low back pain. Consider imaging if patients have no improvement after 6 weeks, although diagnostic tests or imaging is not usually required. GRADE B RECOMMENDATIONS (based on inconsistent or limited-quality patient-oriented evidence): Reassure patients that 90% of episodes resolve within 6 weeks-regardless of treatment. Advise patients that minor flares-ups may occur in the subsequent year. Consider a plain lumbosacral spine x-ray if there is suspicion of spinal fracture or compression. Consider a bone scan after 10 days, if fracture is still suspected or the patient has multiple sites of pain. Suspect cauda equina syndrome or severe or progressive neurological deficit if red flags are present. Obtain complete blood count, urinalysis, and sedimentation rate if cancer or infection are possibilities. If still suspicious, consider referral or perform other studies. Remember that a negative plain film x-ray does not rule out disease. GRADE C RECOMMENDATIONS (based on consensus, usual practice, opinion, disease-oriented evidence, or case series): Recommend ice for painful areas and stretching exercises. Discuss the use of proper body mechanics and safe back exercises for injury prevention. Refer for goal-directed manual physical therapy if there is no improvement in 1 to 2 weeks, not modalities such as heat, traction, ultrasound, or transcutaneous electrical nerve stimulation. Do not refer for surgery in the absence of red flags.
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Increasing utilization of diagnostic imaging studies has provided newer insight into our current knowledge of visceral artery aneurysms. Because many are "silent," an appreciation of the true incidence and natural history of these nonaortic arterial aneurysms is only recently being understood. Historical data suggest that renal artery aneurysms (RAAs) occur in approximately 0.1% of the general population. Recognized complications associated with RAAs include renovascular hypertension, renal artery thrombosis, infarction from distal embolization, arteriovenous fistula formation, and, the most dreaded risk, rupture. Unfortunately, there remains continued controversy about the indications for and mode of treating RAAs. This article attempts to shed some light on the contemporary management options in view of advances in percutaneous endoluminal interventions.
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Visceral artery aneurysms (VAAs), which were once considered uncommon, are now being diagnosed with increasing frequency, a fact that reflects the routine use of computed tomography (CT), magnetic resonance imaging, and ultrasonography. Diagnostic radiology plays a major role in the detection and characterization of VAAs. Cross-sectional imaging can help exclude aneurysm rupture, which requires emergent treatment. CT angiography or catheter angiography can clearly depict the aneurysm and help identify other aortic, visceral, or peripheral aneurysms. Most important, radiologic examination can help determine the adequacy of the collateral blood supply to the vascular bed distal to the aneurysm, information that is essential prior to the initiation of endovascular treatment. Advances in endovascular therapy have allowed interventional radiologists to contribute to the management of VAAs. Coil embolization or covered stent placement can now be used to treat patients with aneurysms whose size or location would make a surgical approach problematic, as well as patients in whom surgery is considered to pose considerable risk.
Guideline update: what´s the best approach to acute low back pain? Evaluation and treatment of acute low back pain Aneurysms of the renal artery Renal artery aneurysms Management of a renal artery aneurysm with coil embolization A case of ruptured aneurysm of the renal artery
  • S M Bach
  • K B Holten
  • S Kindade
  • M K Eskandari
  • S A Resnick
  • V Kyle
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