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DOI:10.2214/AJR.05.0766
AJR 2007; 189:W111-W112
© American Roentgen Ray Society

Case Report

MR Angiography of Renal-Hepatic Arteriovenous Malformation

Josephine Pressacco1, Gilles Hudon1, Jean-Francois Tanguay2 and Patricia Ugolini1

1 Department of Radiology, Montreal Heart Institute, 5000 Belanger St., Montreal, QC, Canada HIT 1C8.
2 Department of Cardiology, Montreal Heart Institute, Montreal, QC, Canada.

Received May 4, 2005; accepted after revision August 8, 2005.

 
Address correspondence to J. Pressacco.

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This is a Web exclusive article.

Keywords: arteriovenous malformation • cardiovascular imaging • MR angiography


Introduction
Top
 Introduction
Case Report
 Discussion
 References
 
Arteriovenous fistulas secondary to arteriovenous malformations, iatrogenic intervention, and blunt and penetrating trauma have been described as a cause of hyperkinetic heart failure [1]. Cardiac chamber enlargement, systolic-diastolic murmurs, and varicose veins may be the earliest findings. Late complications include thrombosis and pseudoaneurysm. We describe a rare and, to our knowledge, previously unreported arteriovenous malformation arising from the right renal artery, draining into the right hepatic vein, and causing right atrial enlargement.


Figure 1
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  		Fig. 1A —47-year-old man with renal-hepatic arteriovenous malformation. Posteroanterior chest radiograph shows prominent right-border cardiac silhouette (arrows).

 


Figure 2
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  		Fig. 1B —47-year-old man with renal-hepatic arteriovenous malformation. Digital subtraction angiogram of aorta shows abnormal vessel (arrows) possibly arising from right renal artery (arrowhead) and extending cephalad to right upper quadrant toward liver.

 

Case Report
Top
 Introduction
 Case Report
Discussion
 References
 
A 47-year-old man undergoing follow-up for familial dyslipidemia presented with suspected right atrial enlargement initially seen on a chest radiograph 10 years previously (Fig. 1A). Angiography performed to evaluate the extent of atherosclerotic disease in the distal part of the a bdominal aorta and lower limbs incidentally revealed an abnormal vessel arising from the right renal artery and extending in a cephalic direction (Fig. 1B). MR angiography depicted a collateral vessel arising from the right renal artery and entering the right hepatic vein (Fig. 1C). The vessel caused dilatation of the inferior vena cava above the main hepatic vein that measured 3.5 cm in diameter and right atrial enlargement measuring 6 cm from the tricuspid valve to the lateral wall of the atrium (Fig. 1D). The hepatic veins in the right lobe of the liver were dilated, and collateral vessels formed venous-venous connections (Fig. 1C). The patient did not have a history of hepatic cirrhosis or trauma to or instrumentation of the right upper quadrant. These findings support the presence of a right-to-left shunt from a renal-hepatic arteriovenous malformation.


Figure 3
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  		Fig. 1C —47-year-old man with renal-hepatic arteriovenous malformation. Maximum-intensity-projection reconstruction of contrast-enhanced MR angiogram acquired with 25 mL of IV gadoteridol, 5.75 mg of calteridol calcium, and 30.25 mg of tromethamine (ProHance, Bracco Diagnostics) (TR/TE, 5.3/1.5; inversion time, 0 milliseconds; sensitivity encoding; slice thickness, 3.0 mm; gap, 1.5 mm; matrix size, 400 x 253; displayed field of view [DFOV], 35.9 x 35.9 cm; body coil) shows vessel (arrow) arising from right renal artery and entering right hepatic vein. Collateral vessels in right lobe of liver form venous-venous connections. Infrarenal abdominal aorta and iliac arteries are diffusely atherosclerotic. RK = right kidney, LK = left kidney.

 

Figure 4
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  		Fig. 1D —47-year-old man with renal-hepatic arteriovenous malformation. Axial T2-weighted balanced turbo fast-echo image (2.8/1.4; inversion time, 152 milliseconds; sensitivity encoding; slice thickness, 10 mm; no gap; matrix size, 192 x 192; DFOV, 39.8 x 39.8 cm; body coil) shows right atrial enlargement measuring up to 6 cm from tricuspid valve to lateral wall of atrium. Enlargement is secondary to increased blood return from renal-hepatic arteriovenous malformation. RA = right atrium, RV = right ventricle, LV = left ventricle, IVC = inferior vena cava.

 

Discussion
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 Introduction
 Case Report
 Discussion
References
 
The patient in this case had an arteriovenous malformation that has, to our knowledge, not been described in the literature. The malformation caused a right-to-left shunt from the right renal artery to the right hepatic vein. The shunt caused hepatic congestion, increased blood return to the inferior vena cava and right atrium, and right atrial enlargement, an early sign of hyperkinetic heart failure [2]. MR angiography, which has become a powerful technique for imaging the vascular system, clearly showed vascular abnormalities in a noninvasive and nonnephrotoxic manner [3]. The resolution of conventional angiography remains superior to that of MRI. Technical developments, however, should lead to faster MR image acquisition and to contrast agents that improve the quality and resolution of MR images [4].


References
Top
 Introduction
 Case Report
 Discussion
 References
 

  1. Durakoglugil ME, Kaya MG, Boyaci B, Cengel A. High output heart failure 8 months after an acquired arteriovenous fistula. Jpn Heart J 2003; 44:805 -809[CrossRef][Medline]
  2. Hirai S, Hamanaka Y, Mitsui N, Kumagai H, Nakamae N. High-output heart failure caused by a huge renal arteriovenous fistula after nephrectomy: report of a case. Surg Today 2001;31 : 468-470[CrossRef][Medline]
  3. Insko EK, Carpenter JP. Magnetic resonance angiography. Semin Vasc Surg 2004;17 : 83-101[CrossRef][Medline]
  4. Tatli S, Lipton MF, Davison BD, Skorstad RB, Yucel EK. From the RSNA refresher courses: MR imaging of aortic and peripheral vascular disease. RadioGraphics 2003;23 : S59-S78[Abstract/Free Full Text]

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