Successful Angioplasty of Tripolar Renal Arteries in a Single Setting: A Case Report

Renal artery stenosis (RAS) can result in renovascular hypertension and nephrosclerosis and accounts for 1–2% of all cases of hypertension.1 Treatment includes medical therapy, balloon angioplasty and surgical bypass of the renal artery. Percutaneous transluminal renal angioplasty, first introduced by Gruentzig in 1978,2 has assumed a prominent role in the treatment of renovascular hypertension.3 Recently, several series reported the successful use of endovascular stents for treating suboptimal angioplasty results4,5 and as a primary intervention in hypertensive patients with atherosclerotic lesions.6 The procedural success in these studies was excellent (98–100%) with a long-term angiographic stent patency rate of 86–92%. We describe here the first case report of successful angioplasty with stent implantation for treating the stenoses of bilateral multiple renal arteries in a single setting. Case Report.A 78-year-old male was referred for renal angiogram following renal echo Doppler examination, which revealed > 70% stenosis in the right renal artery. This patient had a long history of hypertension and had been treated with beta blockers, Ca channel blockers and diuretics for five years. Despite this triple therapy, his BP was not controlled properly and remained in the range of 150/80 mmHg. Due to the presence of coronary artery disease, this patient had undergone CABG four years earlier. He had no history of diabetes. His serum creatinine was 2.1 mg/dl and serum potassium was 4.6 meq/l. Prior to performing renal angiogram, written informed consent was also obtained for potential angioplasty and stenting. His renal angiogram showed 70% ostial stenosis of the right renal artery, 70% proximal stenosis of the superior polar and 80% ostial stenosis of the left inferior polar renal artery. Percutaneous transluminal angioplasty of all three lesions was performed in a single setting and a bolus of 7,000 IU heparin was administered. The right renal artery was engaged with a 7 French RDC renal guiding catheter (Cook, Bloomington, Indiana) and the lesion was crossed with a 0.014´´ Spartacore guidewire (Guidant Corporation, Santa Clara, California). A 4.5 mm x 18 mm Ultra stent (ACS Multilink) was directly deployed at 20 atm without residual stenosis. Then the left superior polar artery was engaged using the same guiding catheter and the lesion was crossed with the same guidewire. A 5 x 18 mm Tetra stent was directly deployed at 16 atm without residual stenosis. Angioplasty of the inferior polar renal artery was also performed in the same setting using the same guiding catheter and guidewire. The lesion was predilated with a 2.5 x 20 mm Viva balloon (Boston Scientific, Maple Grove, Minnesota) at 18 atm and then a 3 x 13 mm Ultra stent (ACS Multilink) was deployed at 20 atm with excellent results. A total of 80 ml of non-ionic contrast was utilized during the procedure. On the day after the procedure, creatinine was 1.5 mg/dl and BP was 150/70 mmHg. The patient had an uneventful recovery and was discharged on the day after the procedure on 160 mg of aspirin and 75 mg of clopidogrel per day for 4 weeks. He was prescribed only beta blockers and antihypertenise medication and his BP control improved. At 1- and 6-month follow-up, his serum creatinine was 1.2 mg/dl and BP was 150/70 mmHg. Discussion. Atherosclerotic renal artery involvement is a major cause of renovascular hypertension2,7 and concomitant atherosclerotic coronary artery involvement is common. Angioplasty is an effective and established mode of treatment for both of these conditions. The benefit of angioplasty for renal artery stenosis includes complete cure, or at least easier management of hypertension in addition to preservation of renal function.8 Von Knoring et al.9 reported a benefit in 89% of patients treated with PTRA and a very low rate of complications. In addition, PTRA has certain advantages over surgical revascularization in so far as it obviates the need for general anesthesia and is associated with shorter hospital stay and lower costs. Krishna Rocha Singh et al. also reported a 97.3% procedural success rate with PTRA and a 1.3% rate of major in-hospital complications.10 In addition, they have identified two clinical predictors of beneficial long-term blood pressure control, namely, preprocedural mean arterial pressure > 110 mmHg and bilateral stenosis. Among the patients in whom these two predictors were observed, 83% experienced improved blood pressure at 13-month follow-up. Compared to patients with unilateral disease, patients with bilateral lesions are at an increased risk for progressive ischemic atrophy and deterioration of renal function.11 Our patient was an elderly male with concomitant coronary artery disease, bilateral, ostial and proximal renal stenoses and moderate renal impairment (serum creatinine 2.1 mg/dl) of atherosclerotic origin. To the best of our knowledge, there is only one report of PTRA of multiple renal arteries in a single setting, in which the superior and middle polar artery of only the left kidney was stented with half (disarticulated) Palmaz Schatz coronary stent.12 In the instance reported here, we performed PTRA of bilateral multiple renal arteries (two left polar and one right renal artery) in a single setting with excellent results. Post PTRA, the patient had an uneventful recovery with significant improvement in BP and renal function. Both predictors of beneficial long-term BP control, as underlined by Singh et al., were documented in this patient, and PTRA was deemed the best treatment option. The direct stenting strategy for coronary artery disease significantly reduces the risk of periprocedural complications such as no reflow, slow flow and distal embolization. The significant improvement in renal function seen in our patient may be related to direct stenting. Improvement in renal function is important because untreated stenosis may progress in severity, resulting in renal artery occlusion, loss of renal mass, and subsequent decrease in kidney function.14,15 Technical success rate of PTRA with stent implantation is similar to that of surgical revascularization. The latter, however, is associated with a 2–7% perioperative mortality rate, a 17–31% morbidity and deterioration in renal function in 11–31% of patients with reocclusion or restenosis in 3–4%.15,16 We conclude that since PTRA is now the established mode of treatment in atherosclerotic RAS with uncontrolled hypertension and impaired renal function, it can be safely extended to multiple uni- or bilateral stenoses in a single setting by experienced operators with comparable results.

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