Transradial Renal Artery Stenting

Case report

A 69-year-old black female with previous history of coronary artery disease, coronary artery bypass surgery, uncontrolled hypertension and hyperlipidemia was evaluated for repeated episodes of congestive heart failure. She had refractory hypertension with very high systolic blood pressure on each of these admissions. Her medicine regimen included carvedilol 25 mg twice daily, losartan 100 mg daily, furosemide 80 mg daily and clonidine 0.2 mg three times daily. Her echocardiogram showed concentric left ventricular hypertrophy with grade III diastolic dysfunction and normal left ventricular systolic function. A stress Myoview imaging test was negative for inducible ischemia. Her serum creatinine was 1.4 mg/dL. She was investigated with magnetic resonance angiogram for renal artery stenosis, which showed a high-grade stenosis of the right renal artery while the left renal artery was occluded and the left kidney was non-functional. She was referred to our hospital for renal angiogram and intervention.

Left radial artery access was achieved with a 6 French sheath. With the sheath insertion partially into the radial artery, she had pain and spasm. After inserting the sheath halfway, intra-arterial vasodilators verapamil 2.5 mg, and nitroglycerine (NTG) 200 mcg were injected. Radial angiogram showed a smaller-size radial artery without evidence of focal spasm (Figure 1; Video 1). 

A 0.014” Kinetix wire (Boston Scientific) was advanced through the radial artery. A balloon-assisted guide advancement technique was used to advance a 6 French Judkins right (JR) 4 guide catheter without any difficulty (Figure 2; Video 2).¹

The JR 4 guide was advanced under fluoroscopy guidance to the descending aorta and subsequently into the abdominal aorta. Selective angiogram of the right renal artery showed severe ostial stenosis (Figure 3; Video 3).

The same Kinetix wire was used to cross the lesion and inserted in the distal artery. A 5.0 mm x 18 mm Express SD (Boston Scientific) stent was positioned with angiographic guidance (Figure 4) and deployed. Aortic stent struts were flared with the stent balloon at high pressure. The lesion was treated successfully, with very good angiographic result (Figure 5; Video 4). The patient was discharged home two hours post-procedure after removing the hemostatic band. Three days later, the serum creatinine remained unchanged. Renal artery revascularization, along with her optimum medical regimen, has now kept this patient out of the hospital for the last 5 months with stable blood pressure control and without any flare of heart failure.

Discussion

Renal artery revascularization has been shown to improve heart failure control and a reduction in heart failure hospitalizations.² In patients with bilateral renal artery stenosis, recurrent pulmonary edema can be prevented by successful stent placement in one or both renal arteries.³ Transradial renal artery angioplasty and stenting is technically feasible and safe.⁴

Working through a small and tortuous radial artery may be challenging because of a higher incidence of local pain and discomfort for the patient due to significant resistance to the movement of a catheter. This is more likely to occur when a larger guide (6 French) is advanced through a smaller radial artery. The technique of balloon-assisted tracking of a guide catheter over a 0.014” percutaneous transluminal coronary angioplasty (PTCA) guide wire helps with easy and nontraumatic negotiation into a small and tortuous radial artery by eliminating the “Razor” effect.⁴

Due to the angle of renal artery origin (Figure 6), a cranio-caudal approach is an attractive alternative in comparison to a retrograde approach into the renal artery via femoral access. A JR 4 or multipurpose guide catheter can be engaged very coaxially into the renal artery via radial approach, which provides sufficient support, reduces chances of guide-induced dissection and allows easy access into the renal ostia to deliver a device. It also makes it technically easy to position (Figure 4) the stent in the aorto-ostial disease and flare the stent struts in the aorta. Left radial access is preferred over right radial access, as it saves 10-15 cm of travelling distance at the arch.  A 110 cm-length guide catheter will reach to the renal ostia from the left radial approach in almost all patients, irrespective of height and tortuosity at the left subclavian region. Most radial arteries will allow a 6 French guide catheter access. Multiple renal stent systems compatible with a 6 French guide catheter and with a shaft length of more than 120 cm are commercially available.

In our opinion, a transradial approach to the renal artery is very attractive for the emerging renal denervation treatment for hypertension. In the SYMPLICITY HTN-1 and 2 trials, the only significant complications were related to the access site (femoral) complications and one renal artery dissection caused by a guide catheter.^5,6 The coaxial entry in the renal artery via a cranio-caudal approach and the safety of radial artery access can reduce these complications. Also, radial access will allow immediate ambulation and discharge after two hours post completion of an uncomplicated procedure.

The authors can be contacted via Dr. Kintur Sanghvi at SanghviK@Deborah.org

References

1. Patel T, Shah S, Pancholy S. Balloon-assisted tracking of a guide catheter through difficult radial anatomy: A technical report. Catheter Cardiovasc Interv. 2012 May 28. doi: 10.1002/ccd.24504. (Published online Nov 14, 2012.) 
2. Kane G, Xu N, Roubicek T, et al. Renal artery revascularization improves heart failure control in patients with atherosclerotic renal artery stenosis. Nephrol Dial Transplant. 2010; 25: 813-819. 
3. Bloch MJ, Trost DW, et al. Prevention of recurrent pulmonary edema in patients with bilateral renovascular disease through renalartery stent placement. Am J Hypertens. 199: 12: 1-7. 
4. Scheinert D, Ludwig J, at el. Transradial approach for renal artery stenting. Catheter Cardiovasc Interv. 2001 Dec; 54(4): 442-448. 
5. Symplicity HTN-1 Investigators. Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. 2011; 57: 911-917. 
6. Symplicity HTN-2 Investigators, Esler MD, Krum H, Sobotka PA, Schlaich MP, Schmieder RE, Böhm M. Renal sympathetic denervation in patients with treatment-resistant hypertension (The Symplicity HTN-2 Trial): a randomised controlled trial. Lancet. 2010; 376: 1903-1909.