LAUSR

Index Case A 69-year-old man with a history of rheumatoid arthritis and pulmonary fibrosis presented with an incidentally discovered 11.5 cm left renal mass with a level 3 inferior vena cava (IVC) tumor thrombus, including involvement of the left adrenal and lumbar veins. The thrombus was highly vascularized as shown in Figure 1A-C. Preoperative evaluation was negative for metastatic disease and the serum creatinine (SCr) level was 1.55 mg/dL, correlating with an estimated glomerular filtration rate (eGFR) of 46 mL/min/1.73m. The patient was taken to the operating room for left radical nephrectomy, adrenalectomy, IVC thrombectomy, and retroperitoneal lymphadenectomy. In the recovery room, the patient was hemodynamically stable but was found to be anuric despite adequate fluid resuscitation. Renal ultrasound demonstrated no arterial flow in the right renal artery and flow to the parenchyma was also not observed. The patient was then taken for angiography which revealed complete occlusion of the main right renal artery approximately 2 cm distal to its origin, posterior to the IVC. Distal arterial flow beyond this region was not observed and attempts to advance a wire were unsuccessful (Fig. 1D). Aortogram did not demonstrate an accessory right renal artery and no arterial flow to the kidney were observed via collateral channels.