A 55-year-old man with a 40 pack-year smoking history presented with acute onset right flank pain. A CT angiogram of the abdomen and pelvis was obtained following a renal abnormality seen on initial portal venous phase CT. Axial images of the right renal artery and kidney (Figures A and B) demonstrate a dissection flap (arrows), which begins approximately 3 cm from the ostium and extends into the inferior, lateral, and posterior branches. Approximately 20% of the right mid kidney is not perfused (asterisks).
Renal artery dissection is most often secondary to trauma, iatrogenic endovascular injury, or extension of an aortic dissection. Spontaneous renal artery dissection (SRAD) is described when there is no clear inciting event and is often associated with underlying arteriopathies, most notably fibromuscular dysplasia.1,3 Diagnosis of SRAD often proves difficult due to the nonspecific clinical presentation, with flank pain and hematuria mimicking renal colic. The findings of SRAD are often imperceptible on ultrasound, the common first line imaging modality to evaluate such symptoms.2 While angiography is considered the gold standard examination, CT or MR angiography remain the mainstay for noninvasive modalities to reliably establish timely and accurate diagnoses.1,3
Treatment of SRAD is dependent on several factors including extent of the vascular injury, stability of the dissection, and the patient’s baseline and current renal function.2 Goals of therapy are to preserve renal function and to treat renovascular hypertension. Treatment options include observation and medical management (antiplatelet, anticoagulation, and antihypertensive medications), endovascular stenting or coiling, surgical revascularization, and complete nephrectomy in severely damaged kidneys.3
Radcliffe D, Kotecha H. JAOCR at the Viewbox: Spontaneous Renal Artery Dissection. J Am Osteopath Coll Radiol. 2020;9(2):26.