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Year : 2000  |  Volume : 10  |  Issue : 1  |  Page : 35-36
Large arteriovenous malformation in kidney mimicking cyst


Dept of Radiology, The Gujarat Cancer and Research Institute, Ahmedabad, India

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Keywords: Renal AVM, grey-scale sonography, color Doppler

How to cite this article:
Shah SR, Momin AM, Talati AR, Shah RV, Gosami KG, Panchal SY. Large arteriovenous malformation in kidney mimicking cyst. Indian J Radiol Imaging 2000;10:35-6

How to cite this URL:
Shah SR, Momin AM, Talati AR, Shah RV, Gosami KG, Panchal SY. Large arteriovenous malformation in kidney mimicking cyst. Indian J Radiol Imaging [serial online] 2000 [cited 2019 Sep 20];10:35-6. Available from: http://www.ijri.org/text.asp?2000/10/1/35/30631
Renal arteriovenous malformations (AVM) are rare and can be congenital, acquired or idiopathic [1]. Congenital and idiopathic varieties are less common and are usually located in the medullary region [2]. Acquired AVMS may result from trauma, surgery, biopsy, malignancy and inflammation. Frequent symptoms are hematuria and hypertension. Large- flow arteriovenous fistulae may lead to an increasing cardiac load [2]. Grey scale sonography is not only inadequate but also misleading in the diagnosis of AVMs. Any inadvertent interventional procedures or surgery performed on these patients may not only be detrimental but may prove catastrophic. Color Doppler Imaging (CDI) remains the only noninvasive diagnostic modality of choice for AVMs. We report a patient of large AVM entirely confined to the renal pelvis, detected incidentally on CDI.


   Case report Top


A 38-years old man presented with colicky pain in right lumbar region. Routine urine examination showed microhematuria. Hemogram showed hypochromic microcytic anemia with a hemoglobin of 8gm%. A plain radiograph of the abdomen revealed multiple calculi in the right renal region. Grey scale us examination [Figure - 1] showed multiple calculi the in right kidney with minimal dilatation of the calyceal system in the lower pole of the right kidney.

It also showed a multilocular cyst in the upper pole, which appeared to extend into the renal pelvis. The patient was then subjected to a laparotomy. On exploration, a bruit was noted in the region of the renal pelvis and surgery was abandoned. Repeat us examination with cdi was requested. Cdi [Figure - 2] showed flow signals in the cystic lesion in the renal pelvis.

The flow showed mixing of lighter colors and the presence of coarse, mosaic like vibrational artifacts suggestive of an avm. No flow was seen in the upper pole cyst. Power doppler imaging [Figure - 3] showed vascularity in the renal pelvic lesion and confirmed the findings at cdi.

Spectral doppler [Figure - 4] showed high velocity erratic excursions with complete loss of the cyclic systolic and diastolic pattern. Selective right renal angiography [Figure - 5]showed grossly dilated and tortuous vessels in the renal pelvis, with a feeding right main renal artery and a draining renal vein.


   Discussion Top


Renal AVMs are rare and are of three types: congenital, acquired and idiopathic [1]. Acquired renal AVMs are commonest and account for 70% of cases [3] and may develop following trauma, surgery, biopsy, malignancy and inflammation. AVMs developing after percutaneous biopsy are usually asymptomatic and close spontaneously whereas post-traumatic AVMs are more likely to be symptomatic. Congenital renal AVMs account for 27% of cases [3] and can be described under two categories: classic and aneurysmal. Classic congenital renal AVMs appear as cirsoid intrarenal malformations and present with gross hematuria. Aneurysmal congenital renal AVMs more commonly present with an abdominal bruit, hypertension or high output cardiac failure.

Idiopathic renal AVMs are rare and account for about 3% of cases. Radiologically, they can be described as acquired fistulae with an artery communicating directly with one or more veins with no obvious cause [4].

Renal AVMs on grey scale US simulate hydronephrosis and cysts. In these patients, CDI is an important noninvasive modality that can help differentiate a cystic neoplasm from an AVM. On CDI, AVMs show coarse, mosaic like vibrational artifacts or modulation of the Doppler signal from the artery and vein [2]. They may also be seen as focal areas of flow, portrayed as a mixing of lighter colors. These were reflected by a rapid flow rate and marked tortuosity of the vessels [5]. CDI yielded neither false positive or false negative results in AVMs when they were diagnosed on the basis of a focal area of flow manifested by mixing of lighter colors [5]. Spectral Doppler study shows large peak systolic and end diastolic frequency shifts with a smaller resistive index (RI) than those of a normal intrarenal artery. However no correlation can be established between RI and degree of A-V shunting [5].

Awareness of the fact that AVMs may mimic conditions such as hydronephrosis, parapelvic or other cystic lesions on grey scale US is very important particularly if percutaneous interventions or surgery are to be contemplated.

 
   References Top

1.Peter Gordan Kember, Robert James Peck. Renal Arteriovenous Malformations Mimicking Hydronephrosis. J Clin Ultrasound 1998;26:95-97.   Back to cited text no. 1    
2.R. Kubale. Aorta and its Symmetrical Branches. Color Duplex Sonography- Principles and Clinical Applications. Wolf and Fobbe, 1995:137.   Back to cited text no. 2    
3.McAlhany JC, Black HC, Hanback LD, et al . Renal arteriovenous fistula as a cause of hypertension. Am J Surg 1971;122:117.   Back to cited text no. 3    
4.Stanley JC, Rhodes EL, Gewertz BL, et al . Renal artery aneurysms. Significance of macroaneurysms exclusive of dissections and fibrodysplastic mural dilatations. Arch Surg 1975;110:1327.   Back to cited text no. 4    
5.S. Takebayashi, N. Aida, K. Matsui. Arteriovenous Malformations of the Kidneys: Diagnosis and Follow-up with Color Doppler Sonography in Six Patients. AJR November 1991;157:991-995.   Back to cited text no. 5    

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Correspondence Address:
Anishussain M Momin
A-1, Haidary Aprt, B/h Tagore Hall, B/s Riviera Flats, Museum, Ellisbridge, Ahmedabad 380 006
India
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Source of Support: None, Conflict of Interest: None


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    Figures

[Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5]

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