Renal arteriovenous malformations (AVMs) are abnormal communications between the intrarenal arterial and venous systems. These malformations are either congenital or acquired (often by iatrogenic means). Renal arteriovenous malformations (AVMs) are usually identified during the evaluation of gross hematuria. Treatment can be tailored to the individual patient. Options for therapy range from observation to embolization to nephrectomy.
Gross hematuria is the primary reason for evaluation of patients with renal arteriovenous malformations (AVMs). The diagnostic evaluation of patients with microscopic hematuria also may lead to the discovery of an arteriovenous malformation (AVM). Flank pain may lead to the diagnosis of arteriovenous malformation (AVM), although this is unusual without the presence of hematuria. Several case reports describe the incidental discovery of arteriovenous malformations (AVMs) on images from studies performed for other indications.
The initial means of treating renal malformation is usually arteriographically guided embolization. One indication for the treatment of renal arteriovenous malformations (AVMs) is pain. The pain from renal arteriovenous malformations (AVMs) results from either obstruction of the collecting system by clots or from the expansion of the renal capsule due to intrarenal hemorrhage. Persistent gross hematuria, especially in patients with anemia, may prompt treatment.
Hypertension is an important indication for treatment. Attempts have been made to preoperatively determine whether the malformation is responsible for the hypertension. However, selective renal vein renin levels have not been successful in helping discriminate which patients' hypertension will respond to either embolization or nephrectomy. Congestive hear failure (CHF) is an unusual yet compelling indication for treatment.
Indications for surgical therapy have become more restricted as the ability to treat renal arteriovenous malformations (AVMs) with angiographic embolization has improved. Arteriovenous malformations (AVMs) due to malignancy usually require surgical extirpation. Significant metastatic disease and poor performance status may limit the use of nephrectomy, in which embolization may be palliative. Symptomatic hematuria refractory to embolization is definitively treated by nephrectomy. In most cases, hypertension is cured by nephrectomy. Finally, pain refractory to less-invasive attempts may respond to nephrectomy.
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