Transradial Renal Artery Angioplasty and Stenting

Percutaneous transluminal angioplasty and stent implantation to treat renal artery stenosis have been proven to be beneficial in atherosclerotic lesions.1,2 The indications for the treatment of renal artery stenosis (RAS) are renovascular hypertension, azotemia secondary to ischemic nephropathy, or renal parenchyma preservation.3–5 The most frequent access site for endovascular treatment of RAS is the common femoral artery. Anatomically, the renal artery courses from the aorta in a caudal direction in most patients. This angle may make access via the femoral approach technically demanding and time consuming. Some operators prefer the axillary or brachial approach because of this advantage; however, only a few operators use the transaxillary approach today due to potential significant complications.6–8 It has been reported that the radial artery approach provides an alternative entry site for coronary angiography and angioplasty as well as for vertebral artery stenting.9–11 The major advantage is a significant reduction in access-site related vascular complications such as the necessity for vascular repair or blood transfusion during coronary intervention.12 Convinced by the value of the transradial artery access technique, we elected to attempt percutaneous transluminal renal artery angioplasty and stenting (PTRAS) via this approach. Case Report. A 69-year-old male patient was admitted to the intensive care unit with severe pulmonary edema and uncontrolled hypertension (230/115 mmHg). Renal function was impaired (serum creatinine, 2.0 mg/dl). Other risk factors for the presence of RAS were significant 3-vessel coronary artery disease (CAD), lower extremity atherosclerosis causing claudication, and refractory hypertension. The other atherosclerotic risk factors were male gender, positive family history, cigarette smoking and dyslipidemia. Based upon the high clinical suspicion for RAS, color-duplex ultrasound was performed. This demonstrated a high-grade stenosis of the right renal artery and high-grade bilateral stenoses of both proximal common iliac arteries. Intravenous nitroglycerin, diuretics, and after-load reduction resolved the heart failure and controlled the blood pressure. Coronary and peripheral angiography was performed. Angiography confirmed the duplex findings with a subtotal stenosis of the right renal artery (Figure 1) and presence of 3-vessel CAD. Due to the sharp aorta-renal angulation, it was decided to use a cranio-caudal approach for this intervention. The left radial artery was chosen for entry because the Allen’s test was abnormal on the right and normal on the left. After superficial local anesthesia, the left radial artery was punctured and a short 6 French (Fr) introducer sheath (Terumo Medical Corporation, Somerset, New Jersey) was inserted. In order to prevent radial spasm, 0.1 mg isosorbite-dinitrate was administrated into the sheath, and 10,000 IU heparin was given intravenously. An Amplatz (AR1; Cordis Corporation, Miami, Florida) diagnostic catheter was used to direct a hydrophilic, soft-type, angled tip 0.035´´ guidewire (Terumo Medical Corporation) from the left subclavian artery into the descending aorta. After advancing the Amplatz catheter as distal as possible, the Terumo wire was exchanged for a J-tip, extra-long wire (Angiodyn™, Braun, Germany). For engagement of the renal ostium, the Amplatz catheter was replaced by an extra-long, 6 Fr, 125 cm Multipurpose Guiding catheter (Cordis Corporation). Baseline angiograms were performed to optimize the working position. Although several steerable 0.014´´ guidewires were used, it was difficult to pass the stenotic lesion. Finally, a hydrophilic guidewire (straight type, platinum tip, 0.014´´ Crosswire™; Terumo Medical Corporation) successfully crossed the stenosis. Along this rail an additional stiffer 0.014´´ guidewire (Spartacore™; Guidant Corporation, Temecula, California) was advanced with the tip into a proximal branch artery (Figure 2). Thereafter, the hydrophilic wire was removed. After crossing the subtotal renal artery stenosis with a low-profile coronary balloon catheter (3.5 x 20 mm Viva™; Boston Scientific/Scimed, Inc., Maple Grove, Minnesota), predilation of the lesion was performed to 6 atmospheres (atm) for 30 seconds. To stabilize the lesion, a pre-mounted balloon-expandable coronary stent (5.0 x 18 mm ACS Multi-Link RX Ultra™; Guidant Corporation) was implanted. A maximum balloon pressure of 12 atm was applied for 20 seconds. Post-deployment there was no residual stenosis or resting pressure gradient (Figure 3). The sheath was removed immediately after the procedure and a single tourniquet was pulled tight over the puncture site. The serum creatinine dropped to 1.1 mg/dl by the 4-week follow-up. Arterial hypertension was still present but improved. Renal artery color duplex ultrasound revealed normal flow velocities in the right renal artery with a maintenance of kidney size. Discussion. The common femoral artery is the traditional access site for coronary (PTCA) and peripheral vascular (PTA) interventions because of the ease of arterial cannulation and catheter manipulation. However, severe femoral as well as brachial artery complications were reported to occur in 2–6% of patients undergoing coronary and renal angioplasty.12–14 On the contrary, PTCA via the radial approach is reported to have negligible if any vascular complications that require surgical or interventional repair.12,15 The superficial course of the radial artery facilitates hemostasis by simple application of a pressure bandage over the puncture site. Clinically relevant bleeding is uncommon because subcutaneous tissue dissection is rare and extravasation from the puncture site can be controlled easily by manual pressure. This incidence is even less than in patients having had femoral percutaneous vascular suture.16 The outlined advantages of a radial artery approach over a femoral or brachial approach encouraged us to perform a majority of our coronary interventions via the radial artery. Then the natural extension was into other vascular territories. One concern for the transradial artery approach over other sites is that the “puncture site to target lesion distance” is longer. However, we have not experienced a significant loss of catheter steerability and pushability. Another argument against the radial approach is derived from reports in interventional cardiology where radial artery occlusions were observed in up to 5% of patients after coronary interventions. Of note, in patients with a normal Allen´s test before catheterization, none of the persistent radial artery occlusions had any clinical symptoms.15,17,18 The other issues center on the development and refinement of catheters, stents, and stent-grafts. Special equipment is required due to the long distance from the radial artery to the visceral aorta. We use an extra-long, specially produced, 6 Fr multipurpose guiding catheter with a length of 125 cm (Cordis Corporation). Accordingly, pre-mounted stent delivery systems with a working length of at least 145 cm become necessary. Presently, only coronary systems with the required length are available. Although coronary stents are balloon-expandable, tubular, laser-cut, stainless-steel stents and similar in architecture to peripheral stents, the radial strength may be too low for renal artery stenting. Theoretically, incomplete stent deployment and elastic recoil might occur in highly calcified lesions. Newer miniaturized interventional devices such as low-profile monorail catheter systems with pre-mounted stents requiring smaller sheath size and guiding catheters are now commercially available for peripheral procedures. These new devices may solve the potential problem of elastic recoil following transradial renal artery stenting in the near future. Each interventional procedure also bears the possibility of severe peri-interventional complications such as target vessel dissection or even life-threatening vessel wall rupture requiring immediate stent-graft deployment. Depending on the diameter of the altered vessel, the size of the introducer sheath may become a limiting factor. Since it is generally agreed not to place a sheath larger than 6 Fr into the radial artery, it is not possible to implant a peripheral stent-graft via this access site. According to our experience, the maximum diameter that tracks well through a 6 Fr guiding catheter is a coronary stent-graft designed for vessel stenting up to 5.5 mm in diameter. Therefore, in the case of renal artery rupture we presently suggest the use of a 19-mm long coronary stent-graft (JoStent™ coronary stent-graft; JoMed, Germany) hand-crimped on the bare 5.0 x 18 mm ACS Multi-Link RX Ultra delivery balloon (Guidant Corporation). This balloon can be inflated up to 25 atm, achieving a stent-graft diameter of at least 6.0 mm. Taken together, the present report describes the transradial renal artery stenting technique to treat RAS that is used at our institution. As demonstrated, the radial approach can be applied to complex renal artery stenoses. With refinement of the endovascular equipment to a working length of at least 145 cm and its miniaturization to 6 Fr compatibility, the radial approach could become an attractive alternative entry site for renal artery interventions. This is the first case report using this technique; further investigations have to prove the feasibility and safety of the transradial approach for renal artery stenting.

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