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Renal thrombotic microangiopathy caused by bevacizumab

history presented himself to our emergency department due to progressive development of weakness, numbness, and cramps of lower extremities for 3 days. The findings of physical examination showed that he had bilateral cold feet, impalpable bilateral dorsalis pedis and posterior tibial arteries. The computed tomography (CT) angiography showed a total thrombotic occlusion of abdominal aorta and bilateral iliac artery (Fig. 1a red arrow). Abdominal blood flow was stopped at the aortoiliac region (Fig. 1b red arrow). The patient received emergent endarterectomy and thrombectomy. The patient had normal serum protein C and protein S levels, but low anti-thrombin III level (47.9 %, normal: 79 % to 119%). The patient had passed 22 g of protein in the urine per day and had elevated levels of both cholesterol and triglyceride, 364 mg/dL and 376 mg/dL respectively. Specimens of a renal biopsy showed minimal change disease. The patient is currently in remission of nephrotic syndrome after a course of oral steroid treatment. Both of his lower limbs are salvaged without long-term sequela. Venous thrombosis is well-documented as one complication of nephrotic syndrome. But acute aortoiliac thrombosis complicated with minimal change disease has rarely been reported. As described in our patient, hypercoagulable status may be related to anti-thrombin III deficiency that may be one possible pathogenesis. In summary, we presented a case with initial presentation of acute ischaemia limb and aortoiliac thrombosis caused by minimal change disease. In addition to venous complication, clinicians should still keep a high suspicion of possible arterial involvement in patients with nephrotic syndrome and signs of limb ischaemia.