CASE 2085 Published on 22.07.2003

Renal artery stenting with long-sheath and monorail technique

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Müller-Hülsbeck S, Jahnke T

Patient

62 years, female

Categories
No Area of Interest ; Imaging Technique Digital radiography
Clinical History
Severe hypertension refractory to antihypertensive medication and progression of renal insuficiency.
Imaging Findings
MR-angiography of the kidneys was performed (not shown), to look for renal artery stenoses, in a patient suffering from hypertension refractory to antihypertensive medication and progression of renal insufficiency. The right renal artery was occluded, the kidney was shrunken and without function, the aetiology was unknown. An ostial stenosis of the left renal artery was found on MR imaging, and the patient was considered for renal angioplasty and stent placement.
Serum creatinin levels were elavated to 2.4mg/dl.
Stent placement was performed using a 5F, 45cm long sheath, placed below the renal artery. The stenosis was crossed with a 0.014 inch guide wire, using a Cobra-2-catheter placed at the origin of the renal artery, and then the latter was exchanged for a stent-balloon monorail catheter. Without crossing the lesion with the sheath, the stent (Herculink 6mm by 18mm)was finally advanced towards the renal ostium and placed under fluoroscopic control without predilatation (1). Post-dilatation was performed using a 7mm monorail balloon. Stent deployment and balloon insufflation was controlled either with a manometer. The clinical outcome showed a stable and increased renal function indicated by a decreased but still elevated Serum creatinin level of 1.2mg/dl at 6 months; the blood pressure was stable and easier to control.
Discussion
In cases of hypertension refractory to antihypertensive medication and progression of renal insufficiency, imaging procedures for visualisation of the renal arteries are of utmost importance. MR imaging should be the first choice in cases of supposed stenosis; intra-arterial angiography from a groin approach should follow.
When a calcified ostial stenosis (up to 5mm distant from the origin) is detected, direct stent placement can be the treatment of choice with nowerdays available low profile monorail systems. We do not recommend predilatation, while direct stent implantation is supposed to reduce atheroembolism due to stent protection. The recommendation of predilating the ostium to make the passage of the stent easier and to avoid "snow plough" effects of the stent system with possible cholesterol spray peripheral embolization, seems not necessary any longer due to the crossing profiles of currently available monorail balloon stent devices. In ostial stenoses, patency rates with stenting are significantly better than angioplasty alone (2).
The technique of stenting used in this case is safe and easy to handle. The learning curve using monorail designs is short.
Differential Diagnosis List
Calcified ostial renal artery stenosis
Final Diagnosis
Calcified ostial renal artery stenosis
Case information
URL: https://www.eurorad.org/case/2085
DOI: 10.1594/EURORAD/CASE.2085
ISSN: 1563-4086