Renal Artery Aneurysm Rupture as a Dangerous Mimic of Ovarian Cyst Rupture: A Case Report

Introduction Renal artery aneurysm rupture is a rare but morbid diagnosis, often requiring emergency surgery and nephrectomy. Clinical presentation can mimic more common pathology in non-pregnant women such as ruptured ovarian cyst. Case Report We present a case of a woman with a prior history of ovarian cyst presenting with a ruptured renal artery aneurysm. Prompt computed tomography (CT) imaging revealed a left renal artery aneurysm rupture with hemoperitoneum and renal infarct. She underwent emergency laparotomy and nephrectomy and was ultimately discharged in good condition. Conclusion While ovarian cyst rupture is the most common cause of spontaneous hemoperitoneum in non-pregnant women of childbearing age, renal artery aneurysm rupture should be considered and prompt CT imaging obtained, particularly in cases of hemodynamic instability, to ensure prompt treatment.


INTRODUCTION
Renal artery aneurysm (RAA) is a rare diagnosis, estimated to occur in 0.09% of the general population. 5upture is a rare but morbid complication, often requiring emergent surgery and nephrectomy.In contrast, ovarian cyst rupture is the most common cause of spontaneous hemoperitoneum in non-pregnant women of reproductive age and is usually managed conservatively in the absence of hemodynamic compromise or associated torsion. 1,2We report a case of spontaneous ruptured RAA as a dangerous mimic of ovarian cyst rupture.

CASE REPORT
A 52-year-old woman with a past medical history of ovarian cysts was brought in by emergency medical services (EMS) to our emergency department (ED) for acute onset of atraumatic left lower quadrant pain.Her symptoms started abruptly while at work, which she stated felt like symptoms one year prior when she was found to have ovarian cysts and likely an ovarian cyst rupture.She endorsed lightheadedness, but she denied any shortness of breath, chest pain, cough, fevers, chills, or changes in urination.
Emergent computed tomography of the abdomen and pelvis revealed a large left retroperitoneal and peritoneal hematoma secondary to left RAA rupture, as well as concern for developing splenic infarcts in the left lower renal pole (Image).The patient was taken emergently to the operating room (OR) for exploratory laparotomy within two hours of ED arrival.She underwent suprarenal cross-clamping with repair of the left renal artery and ligation of renal vessels.She returned to the OR two days later for left nephrectomy and abdominal closure.She was extubated and transferred to the floor.She was discharged home two days later in good condition.

DISCUSSION
Although the incidence of RAA is rare, ranging from 0.01-0.09% of the population, this case report illustrates the importance of timely diagnosis. 3,4Contemporary rupture rates are estimated at approximately 3%. 5 They are most commonly found in women >60 years with risk factors including hypertension, fibrodysplasia, and connective tissue disorders causing arterial medial wall degeneration.Patients notably lack traditional cardiovascular risk factors such as cigarette use and diabetes. 6,7Aneurysms are usually asymptomatic and found incidentally on screening imaging, although patients can present with symptoms such as hypertension, flank pain, hematuria, and abdominal pain. 5 the presentation of a ruptured RAA can be identical to the more common ruptured ovarian cyst, consideration of rare serious surgical pathology should be maintained for patients with acute abdominal pain and free fluid on exam.Bradycardia in the setting of hemoperitoneum is a well described phenomenon particularly in ruptured ectopic pregnancy and can indicate hemorrhagic shock, both of which were considerations in the case reported here. 8,9Other emergent complications of RAA include thrombosis, embolism, and obstructive uropathy.
For non-ruptured RAA, surgical or endovascular intervention is recommended for aneurysms with a diameter exceeding two centimeters, patients with uncontrolled symptoms (ie.pain or refractory hypertension), or in women of childbearing age (as there are higher rates of rupture and mortality in pregnancy and puerperium than in the general population). 3,6These guidelines remain somewhat controversial given the increased incidence of aneurysms uncovered by widespread use of imaging combined with a knowledge gap of the natural progression of disease. 2,4ndovascular intervention through stenting or angioembolization is a safe and effective alternative to open repair, with studies suggesting a trend toward shorter

Population Health Research Capsule
What do we already know about this clinical entity?Renal artery aneurysm (RAA) rupture is a rare but morbid diagnosis that can lead to emergency surgery and nephrectomy.

What makes this presentation of disease reportable?
We report a case of spontaneous ruptured RAA presenting as a dangerous mimic of ovarian cyst rupture, a more common pathology in non-pregnant women.
What is the major learning point?Emergency physicians should maintain an index of suspicion for emergent vascular pathology in non-pregnant women of childbearing age with spontaneous hemoperitoneum.

How might this improve emergency medicine practice?
Maintaining an index of suspicion for rare disease processes such as RAA rupture will ensure prompt recognition and treatment in the ED.
Image.Cross-sectional image of abdominal computed tomography showing hematoma with extravasation of contrast (arrow) as a result of ruptured left renal artery aneurysm.
hospital stays and fewer complications. 10In cases of hemodynamic compromise, exploratory laparotomy and nephrectomy are often indicated. 2,3,4

CONCLUSION
This is a case of spontaneous rupture of a left renal artery aneurysm as a dangerous mimic of ovarian cyst rupture.While ovarian cyst rupture remains the most common cause of spontaneous hemoperitoneum in non-pregnant women of childbearing age, RAA should be considered with confirmation via computed tomography, particularly in cases of hemodynamic instability to ensure prompt treatment of a disease with potentially high morbidity and mortality.