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Título

WHEN TWO IS BETTER THAN ONE: COMBINED TECHNIC TO CORRECT A HIGH-FLUX ARTERIOVENOUS FISTULA IN PEDIATRIC KIDNEY TRANSPLANT

Relato do Caso

INTRODUCTION
Arteriovenous fistula (AVF) after percutaneous allograft biopsy in kidney transplant recipients is a rare, and in most cases of spontaneous resolution, complication. Worsening of graft function is the major and most severe outcome, sometimes leading to graft loss. Endovascular treatment, when necessary, is the first option. We describe the successful embolization of a post-biopsy AVF by a combined technic.

CASE REPORT
Female, 11 years old kidney, chronic kidney disease after cortical necrosis post septic-shock, received a kidney from a 8 years old deceased donor. Because of an allograft disfunction – increase of basal serum creatinine level (Cr) from 1.7ml/dL to 2.5mg/dL, was performed a percutaneous fine-needle biopsy. The following day to the procedure she presented with intense abdominal pain, gross hematuria with blood clots and the necessity of blood transfusion, and elevation of Cr to 8.9mg/dL. In the doppler ultrasound was identified a AVF in the superior lobar artery. Seriated ultrasounds were performed, and an increase in the AVF to an estimated flow of 832mL/min with repercussion on the main renal vein debit lead to a angiographic exam. A high debit fistula between the upper and medium poles of the allograft was confirmed, with an almost simultaneous highlight of the renal artery and vein. Two Interlock coils (VoetX 2mm x 4mm x 4.1mm) were positioned in the nidus of the AVF, but a residual arterio-venous flow was perceived. The OnyxTM34 was directly injected in the nidus of the AVF. Complete occlusion of the AVF and an estimated loss of the renal parenchyma of 10-20% were shown in the final nephogram. The Cr started to decrease in the next day, reaching a Cr of 2.6mg/dL.

DISCUSSION
Compared with coils, a complementary liquid polymer increases the efficacy of the procedure while minimizing the loss of renal parenchyma, a common complication. The use of liquid agents to correction of AVF in other fields is well stablished, but their use to treat renal complications is not well disseminated. There is a risk of systemic venous embolization, but it is minimized using coils as an anchorage mechanism. We described the successful embolization of AVF using a combined technic of coils and a liquid embolic system, allowing a superselective approach, with complete occlusion of the FAV, showing itself a secure, fast and effective option of treatment.

Palavras Chave

Arteriovenous fistula; kidney transplant; pediatric transplant; angioplasty; embolization;