Management conundrum in a case of renal cell cancer (RCC) on dual antiplatelet therapy (DAPT) for recently placed coronary drug-eluting stent (DES)

Abstract

A man in his 50s presented in an emergency with breathlessness and chest discomfort. On evaluation, he was diagnosed with coronary artery disease, with more than 80% narrowing of the right coronary and left circumflex arteries. The patient underwent percutaneous coronary intervention and was started on dual antiplatelet (DAPT) therapy. After starting DAPT, the patient developed gross haematuria with a drop in haematocrit. Further evaluation revealed a left renal mass with urinary bladder clots. Because of the risk of stent thrombosis on stopping DAPT, radical nephrectomy was deferred, and the patient underwent left renal artery angioembolisation and bladder clot evacuation. On the follow-up, the patient was stable with a gradual decrease in renal mass size, and after a year, the patient underwent definitive surgery. The patient is doing well in 4 years of follow-up with no metastasis.

Background

Dual antiplatelet (DAPT) medication is necessary for 12 months after inserting a coronary drug-eluting stent (DES) to prevent stent thrombosis. During this phase, clinicians are more likely to encounter unexpected and urgent non-cardiac surgery cases. The best way to handle such a unique situation in the immediate aftermath of DES implantation must be better understood. In this background, we describe the management of a patient who developed haematuria and was diagnosed with a renal mass just after starting DAPT following DES placement. The patient was successfully treated by renal artery angioembolisation with regular follow-up and radical nephrectomy done later. There is a dearth of information on optimally managing haematuria with renal mass, particularly in the initial stages after DES insertion. Consequently, our experience may provide helpful and safe information for managing such complicated cases.

Case presentation

A man in his 50s was admitted to the emergency room having breathlessness and severe chest discomfort. He was a known smoker with no comorbidity. On evaluation, he was found to have coronary artery disease with right coronary artery and left circumflex artery narrowing by more than 80%. The patient underwent percutaneous coronary intervention (PCI) with DES placement. He was then started on DAPT therapy (DAPT) which composed of clopidogrel and aspirin. After 1 day, the patient developed gross haematuria with a drop in haematocrit and bladder clot retention. On further evaluation, he was found to have a left renal mass with the bladder filled with clots. Due to significant gross haematuria, the patient’s haemoglobin dropped from 116 g/L to 86 g/L. Packed red blood cells were transfused to optimise haemoglobin. The patient was catheterised, and bladder irrigation was started. The patient was haemodynamically stable, but there was ongoing haematuria. Despite our concerns about possible renal cell cancer (RCC) metastases, we could not do an early surgical removal due to the significant risk of stent thrombosis on stopping DAPT. A decision was made for left main renal artery angioembolisation, followed by cystoscopy and bladder clot removal to stop the ongoing blood loss. After angioembolisation and bladder clot removal, the patient improved gradually and had no further episodes of haematuria. After day 5 of angioembolisation, the patient was discharged and planned to continue DAPT with definitive surgery later. The patient was kept under regular follow-up with imaging and clinical evaluation, and (serial) follow-up CT urography (done at regular intervals) showed a decrease in renal mass size with a reduction in contrast enhancement as well.

Investigations

For the evaluation of haematuria, contrast-enhanced computed tomography (CECT) abdomen was done which showed a heterogeneously enhancing renal mass of size 58×55×48 mm arising from the interpolar region of the left kidney (figure 1). After 6 months following angioembolisation, follow-up CT urography showed a non-enhancing renal mass with a reduction in the size to 46×41×36 mm with another nodule of size of 26×24×22 mm and no contrast excretion in left kidney. The right kidney was normal (figure 2). Follow-up CT after 1 year showed a well-lobulated non-enhancing renal mass of size 31×28×31 mm arising from the interpolar region of the left kidney with maintained fat planes (figure 3).

Figure 1.

CECT abdomen showing heterogeneously enhancing exophytic mass (white arrow) of size 58×55×48 mm arising from the interpolar region of left kidney. CECT- contrast-enhanced computed tomography.

Figure 2.

Follow-up CECT (axial and coronal film) after 6 months showing heterogeneous non-enhancing exophytic mass (white arrows) of size 46×41×36 mm with nodule size of 26×24×22 mm and no contrast excretion in left kidney. The right kidney was normal. CECT- contrast-enhanced computed tomography.

Figure 3.

Follow-up CECT (axial and coronal film) after 1 year showing well-lobulated mass lesion (white arrows) 31×28×31 mm arising from the interpolar region of left kidney and bulging into perirenal fat with maintained fat planes. CECT- contrast-enhanced computed tomography. CECT- contrast-enhanced computed tomography.

Differential diagnosis

1. Renal cell carcinoma.

2. Upper tract urothelial carcinoma.

Treatment

Because of the risk of stent thrombosis, the left radical nephrectomy plan was deferred. In view of the large renal mass, we decided to perform main renal artery embolisation (RAE) than selective angioembolisation. With the help of interventional radiologist, the left main RAE was done using gel foam as embolisation agent and complete occlusion of the main renal artery as the target endpoint.

The patient underwent cystoscopy with clot removal for bladder clot retention. The patient improved gradually with no further episodes of haematuria. The patient had left flank pain and fever in the postangioembolisation period. The patient required narcotics for flank pain, which improved by day 3 of the angioembolisation period, and the fever subsided after 48 hours. The patient had raised BP in the postangioembolisation period, controlled by 24 hours. Follow-up renal function was stable. DAPT was continued for a year, and the patient was kept under regular follow-up with clinical examination, contrast CT scan and routine lab investigations. After a year, laparoscopic left radical nephrectomy was planned.

Outcome and follow-up

The patient underwent laparoscopic left radical nephrectomy. Intraoperatively, there was a small left kidney with a left renal mass of size 3×3.5 cm exophytic in lateral surface originating from mid-pole, and there was another mass 2×2 cm arising from mid-pole with abundant perinephric fat (figure 4A,B). Histopathology report came as clear cell RCC with renal sinus fat involvement pT3a pN0 and all surgical margins free of tumour. The postoperative period was uneventful. The patient was discharged on POD 3. On follow-up of 4 years, the patient is doing well with no metastasis.

Figure 4.

Specimen of left radical nephrectomy (A): gross specimen; (B): cut specimen.

Discussion

The most common malignant kidney tumour is the RCC, which is predominantly made of encapsulated, highly vascular clear cells.¹ RCC is known for its angioinvasion behaviour and can invade the renal sinus, the renal vein and the inferior vena cava. However, this does not prohibit surgical excision and a complete surgical removal improves the cancer survival. Several treatment options exist to manage localised renal masses, including surgery and interventional ablation. While partial nephrectomy is preferred for small renal mass, radical nephrectomy is performed for larger tumours. Tumour size significantly affects treatment modalities.^{2 3}

Angioembolisation is a viable option for many emergent situations in urological practice. RAE, either selective or super-selective depending on the selective occlusion of blood vessels of the target organ, is used to manage haemorrhagic emergencies. Occasionally, RAE would be done electively in the preoperative setting in a very large renal mass to decrease blood loss and ease surgical dissection.^{1 4} Common indications of RAE in renal mass include palliation for advanced-stage RCC, preoperative embolisation before nephrectomy, treatment for angiomyolipoma and as an adjunctive therapy to ablation for RCC.⁵ In angioembolisation, the accessibility, size and flow pattern of the vessels to be occluded are key factors in the selection of the embolisation material, which is crucial for achieving successful results.⁶ Several studies describe the embolisation of RCC using gel foam, ethiodol and ethanol; however, in recent reports, ethanol has emerged as the main component.^{1 7 8}

In the present case, after the PCI, the patient unexpectedly developed haematuria and was diagnosed with a left renal mass. DAPT is the recommended treatment plan for preventing repeated cardiovascular incidents; however, it carries a high risk of bleeding. Due to the stent thrombosis risk, we could not stop anticoagulation therapy and proceed with radical nephrectomy. We delayed radical nephrectomy because earlier studies showed that abruptly stopping DAPT medications, especially within 4 weeks⁹ following the placement of DES, significantly increased the risk of stent thrombosis. Previous studies have found that DAPT medicines for at least 12 months and deferring elective surgery are typically advised due to the significant risks of DES thrombosis.⁹ Studies have reported 70% myocardial infarction and 20% mortality is associated with stent thrombosis.¹⁰ Early and late stent thrombosis incidence is similar in bare metal and DESs. Still, very late stent thrombosis is more familiar with DESs¹¹ so DAPT is recommended longer in DES. Non-cardiac surgery is the second most common cause of discontinuation of DAPT after percutaneous intervention.¹²

American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guideline (2021) recommends less bleeding with shorter duration of DAPT (3–6 months) and fewer ischaemic events with stent thrombosis with longer duration of DAPT (>12 months).¹³ In selected patients post-PCI, shorter duration of DAPT is reasonable with subsequent transition to P2Y12 inhibitor monotherapy to decrease the risk of bleeding events.^14–16

There is no previously published literature of similar case where haematuria occurs immediately after PCI and diagnosed with a large renal mass with active bleeding. In a published case series, Sartori et al reported management of small renal mass in nine patients with ultrasound guided percutaneous laser ablation due to high bleeding risk and found no recurrence in a median follow-up of 26 months.¹⁷ Previous literature suggested that delayed nephrectomy after RAE may assist high-risk patients by reducing the size and vascularity of the primary tumour prior to nephrectomy.¹⁸ It has been shown that embolisation is not a curative treatment and probably only modifies the natural course of the disease minimally, but it provides palliation of local symptoms associated with advanced renal malignancy and is a safe alternative to radical nephrectomy, with lower morbidity and complication rates and a shorter hospital stay.¹⁹

To conclude, the requirement of DAPT for the recently placed coronary DES precluded the early surgical removal of the renal mass in our case. Further, we needed to weigh the risk of stent thrombosis, surgical bleeding and tumour progression in the overall management of this patient. Angioembolisation of the renal artery and a deferred definitive surgery helped us to overcome this difficult situation. This case exemplifies the role of angioembolisation as a safe and viable option to counter the potential risk of stent thrombosis and RCC progression in such a unique situation.

Patient’s perspective.

I would like to offer my most sincere gratitude for the care that was provided to me that ultimately saved my life. That I was able to get through all of this is nothing short of a miracle. I will be eternally grateful to my doctors for being there for me at this difficult time.

Learning points.

• Stopping dual antiplatelet within 4 weeks of drug-eluting stent placement will increase the risk stent thrombosis and this risk decreases significantly after a year.

• Main renal artery angioembolisation is life-saving in cases of haematuria of renal origin where blood thinners cannot be stopped.

• The present case suggests angioembolisation with deferring the definitive surgery to later date can be a safe and viable option to counter the potential risk of stent thrombosis and renal cell cancer progression in a bleeding renal mass.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).