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From the heart to the kidney: A case report of Wunderlich syndrome following structural valve intervention

Year: 2025

Type: article

Abstract: Wunderlich syndrome (WS) represents spontaneous, nontraumatic renal hemorrhage, a rare yet potentially life-threatening condition most often associated with renal neoplasms, vascular malformations, or coagulopathies. This report describes WS as an uncommon complication following a percutaneous paravalvular leak (PVL) closure attempt after transcatheter aortic valve implantation (TAVI), in a patient receiving procedural anticoagulation, without renal manipulation or prior renal pathology. A 78-year-old hypertensive man, ex-smoker, underwent transfemoral TAVI with an Evolut™ R 34 mm prosthesis for severe symptomatic aortic stenosis. Postprocedural echocardiography revealed moderate-to-severe PVL. A percutaneous closure attempt with 2 Amplatzer™ Vascular Plugs under unfractionated heparinization (maximum ACT 250 s; total dose 8000 IU) failed to resolve the leak. Eighteen hours later, he developed right flank pain. CT (arterial and venous phases; 120 kVp; 1.25 mm slices) revealed a 9.4 × 6.8 cm right perirenal hematoma (52 HU) with retroperitoneal extension and no active extravasation. Despite initial stability, he became hypotensive (88/54 mmHg) with hemoglobin drop (9.0 → 6.0 g/dL). Renal arteriography confirmed no active bleeding. He received 3 units of PRBCs, Hb stabilized at 9.5 g/dL, and creatinine peaked at 1.4 mg/dL before normalization. Conservative management led to full recovery. Follow-up imaging (ultrasound at 6 weeks, CT and angiotomography at 3 months) confirmed hematoma resolution, preserved renal function, and normal blood pressure. This case underscores WS as a rare and atypical complication of structural cardiac intervention under procedural anticoagulation. Vigilant monitoring, multimodal imaging, and multidisciplinary collaboration are vital for successful conservative management and for excluding occult renal lesions.

Source: Radiology Case Reports

DOI: 10.1016/j.radcr.2025.11.002