Published in: Iranian Journal of Emergency Medicine
Authors: Abdolghader Pakniyat, et al.
Link: Read

📌 Clinical Summary

A 48-year-old man presented to the Emergency Department with sudden, severe left flank pain radiating to the lower abdominal quadrant. Initial management with intravenous ketorolac and morphine failed to relieve his pain, raising suspicion for an atypical cause of renal colic.

🧪 Key Investigations:

• Bedside color Doppler showed reduced left iliac arterial flow.
• CT angiography documented left-sided renal, iliac and popliteal arterial thrombosis. Echocardiography showed an atrial mass interpreted as left atrial thrombus and severe rheumatic mitral stenosis.

He had known mitral stenosis, previous mitral commissurotomy and ECG-confirmed atrial flutter, without new lower-limb complaints despite extensive arterial thrombosis.

The abstract also mentions right popliteal thrombosis; this summary follows the left-sided findings in the case narrative and figure.

🩺 Diagnosis

Acute renal infarction with renal artery thrombosis, occurring alongside:

• Left atrial thrombus
• Mitral valve disease
• Peripheral arterial thromboses (iliac and popliteal)

💡 Clinical Pearls

Do not use analgesic response as a diagnostic test. Persistent pain prompts reassessment, but improvement cannot establish a stone diagnosis. Check vital-sign trends, abdomen, bilateral femoral and distal pulses, limb temperature, sensation and power. A cold or neurologically impaired limb requires immediate vascular assessment. 2024 ACC/AHA guideline.

Widen the question beyond renal colic. Consider aortic dissection or aneurysm complication with abrupt pain, shock or pulse asymmetry; mesenteric ischemia with disproportionate abdominal pain; and infected urinary obstruction with systemic illness. Renal infarction is particularly plausible with an embolic substrate such as atrial arrhythmia or valve disease. These are discriminating bedside concerns, not diagnoses established by this summary.

POCUS is a clue, not an exclusion test. An iliac flow abnormality does not diagnose renal infarction or establish where a clot originated. Acquisition, Doppler settings and the vascular territory examined matter. Normal conventional Doppler cannot exclude renal perfusion defects; specialist contrast-enhanced ultrasound is a different examination. A retrospective imaging study demonstrated additional infarcts with contrast enhancement, but was not a validation of ED POCUS sensitivity.

Ask CT the right question. When vascular ischemia is suspected, discuss contrast-enhanced CT/CTA with radiology to assess renal enhancement and the relevant arterial anatomy; a stone-focused noncontrast study does not answer the same question. Creatinine, urinalysis and LDH help characterize the presentation but do not independently exclude infarction. ED case-series evidence supports contrast imaging; it does not establish a stand-alone laboratory rule-out pathway.

🛠️ Treatment & Outcome

• Initiated systemic anticoagulation
• Underwent surgical thrombectomy
• Required mitral valve replacement
• Recovered well and was discharged after 14 days in normal sinus rhythm

Initial treatment depends on the threatened organ and mechanism. Obtain urgent vascular and cardiology input, monitor renal function and urine output, and reassess limb perfusion. For diagnosed acute limb ischemia, intravenous unfractionated heparin is recommended unless contraindicated to limit propagation and further embolization; it does not replace urgent revascularization of a threatened salvageable limb. Active bleeding, major bleeding risk, suspected dissection and previous heparin-induced thrombocytopenia change the plan. Imaging must not delay limb-saving intervention. 2024 ACC/AHA guideline.

The reported operations are case-specific. A 13-patient catheter-directed thrombolysis series suggests renal reperfusion is possible, but lacks a comparison group. It cannot establish superiority over anticoagulation, guarantee renal recovery or define a universal treatment window. Discuss renal salvage promptly according to anatomy, duration, remaining perfusion, renal reserve and bleeding risk; do not infer that every renal infarction needs thrombectomy or thrombolysis.

Address the embolic substrate. Severe rheumatic mitral stenosis with atrial thrombus requires a specialist anticoagulation and valve plan. Restoration of sinus rhythm alone does not remove the indication after systemic embolism or atrial thrombus. Current ESC/EACTS guidance supports vitamin K antagonist therapy in the relevant rheumatic mitral-stenosis setting rather than routine DOAC substitution. The INVICTUS trial favored vitamin K antagonists over rivaroxaban in rheumatic heart disease with atrial fibrillation; it did not test this individual patient’s treatment. The prosthesis type and postoperative plan must be checked before specifying long-term therapy.

📚 Reference

Pakniyat AG, et al. Original case report. Iranian Journal of Emergency Medicine.
🔗 Link