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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Part XXVIII
Renal Artery Stenting
Renal Artery Stenting forRenal
Vascular Hypertension inaPatient
withSolitary Kidney
History andPhysical Examination
A 52-year-old male was referred by his nephrologist in October 2014 for possible renal artery
stenting for uncontrolled hypertension. Patient
has history of hypertension for the past 10years
and had undergone laparoscopic nephrectomy in
2012 for atrophic kidney secondary to renal
artery occlusive disease. He was on four blood
pressure medications (amlodipine, metoprolol,
hydrochlorothiazide, and clonidine). Patient
underwent MRA in 2002 which showed occlusion of the right renal artery (Fig.98.1). Patient
underwent renal duplex study which showed
normal- size left kidney with greater than 70%
stenosis of the left renal artery in September
2014.
98
Procedure
Patient underwent abdominal and renal arteriogram in October 25, 2014, via right femoral
artery approach using micropuncture technique
with insertion of a 5F sheath. Using Omniush
catheter (AngioDynamics, Latham, NY) over an
angle stiff GLIDEWIRE® (Terumo, Tokyo,
Japan), 180-cm-long 035mm aortogram showed
slight aneurysmal dilatation of the abdominal
aorta and 80% stenosis at the origin of the left
renal artery (Fig.98.2). A 5F sheath was replaced
with a 6 F 45 cm angled Pinnacle sheath
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_98
Fig. 98.1 MRA showing right renal artery occlusion
(Terumo). Using SOS Omni catheter
(AngioDynamics) and a soft Glidewire 0.35
180cm was advanced into the upper pole branch
of the left renal artery. Glidewire was exchanged
for 180-cm-long 035 Magic Torque wire, and
long sheath was advanced near the origin of the
left renal artery. A 6×19mm Omnilink (Abbott,
Abbott Park, IL) balloon expandable stent was
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450
98 Renal Artery Stenting forRenal Vascular Hypertension inaPatient withSolitary Kidney
advanced through the sheath. The sheath was
retracted, and the stent was deployed with 2mm
of the stent projecting into the lumen of the aorta.
14 atmospheric pressure was used for ination of
the balloon so that the nal diameter of the stent
was 6.4cm (Fig.98.3). Patient was followed for
1.5 years with no evidence of recurrent stenosis
Fig. 98.2 Abdominal aortogram showing greater than
80% left renal artery stenosis
with better control of blood pressure. Follow-up
duplex imaging of renal artery showed satisfactory peak velocity in November 2014 and in June
2015.
However, in June 2016, renal artery duplex
imaging showed greater than 70% left renal
artery stenosis with elevation of serum creatinine
from 0.9 to 1.2 mg/dL. Patient underwent left
renal artery angioplasty for in-stent restenosis
(greater than 70%) via percutaneous left brachial
artery approach using exchange length glidewire
260-cm-long 035 and using a 6 F 90-cm-long
sheath. A 6mm × 2-cm-long balloon was used
(Fig. 98.4). The procedure was performed on
July 6, 2006. During the later part of the procedure, patient developed left ank pain associated
with nausea and became diaphoretic. Patient
underwent CT scan of the abdomen which
showed large subcapsular hematoma of the left
kidney with small retroperitoneal hemorrhage
(Fig. 98.5). Patient was treated conservatively,
and his symptoms resolved in 6 hours, and he
was discharged after a 24hour stay from the hospital. Patient was last seen in December 2019
with a serum creatinine of 1.2mg/dL with a normal left renal duplex scan and better control of
blood pressure.
Fig. 98.3 Aortogram following renal artery stenting
Discussion
Fig. 98.4 Renal angioplasty via a brachial approach for in-stent restenosis
hypertension, and ischemic nephropathy and
unresponsive to medical therapy are most
likely to benet from renal artery revascularization [1].
The result of CORAL (Cardiovascular
Outcomes in Renal Atherosclerotic Lesions)
trial has signicantly decreased the indication
for renal angioplasty (stenting) for atherosclerotic renal artery stenosis. The CORAL trial did
not show a statistically signicant reduction in
blood pressure following renal angioplasty/
stenting when compared with best medical management. Studies evaluating the use of renal
angioplasty/stenting for preservation of the
renal function have been even less promising
Fig. 98.5 CTA showing left renal subcapsular
hematoma
with no advantage for renal intervention but
with a possibility of access-related complication
[1]. Subgroup analysis of CORAL trial failed to
identify severity of blood pressure as good pre-
Discussion
dictors of response to stent treatment. The one
baseline variable that appears promising for pre-
Atherosclerotic renal artery stenosis accounts
for greater than 90% cases of renal artery stenosis and most often presents in patients
greater than 65years of age [1]. It may be an
independent predictor of death in patients for
coronary artery disease [1]. Patients with cardiac destabilization syndromes, renal vascular
dicting a favorable response to stent intervention is the urine albumin to creatinine ratio with
a low UACR (urine albumin-to-creatinine ratio)
portending a favorable response [2]. In this
patient with uncontrolled blood pressure with
severe renal artery stenosis in a solitary kidney,
it was nephrologist’s opinion that renal stenting
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98 Renal Artery Stenting forRenal Vascular Hypertension inaPatient withSolitary Kidney
should be performed. Patient did develop complication of periprocedural renal subcapsular
hematoma. Therefore, the benets of renal
stenting with renal vascular hypertension and
preservation of renal function must be weighed
against the complications of intervention. At
present, renal artery stenting should be infrequently performed [3]. However, renal artery
stenting may need to be performed during or
following endovascular aneurysm repair in
select group of patients [3]. In contemporary
practice there are few indications of renal artery
stenting, and patient should be very carefully
selected with close consultation with nephrologist. Primary patency of renal artery stenting
exceeds 80% at 5years, and surveillance for in-
stent restenosis should be done with renal
duplex imaging on a yearly basis [1].
References
1. Tafur JP, White CJ. Renal artery stenosis went
to revascularize in 2017. Curr Probl Cardiol.
2017;122:110–35.
2. Gupta R, Assiri S, Cooper CJ. Renal artery stenosis
ndings from the CORAL trial. Curr Cardiol Rep.
2017;19(9):75.
3. Alexander JQ, Green D, Sullivan TM.Endovascular
intervention for renal artery occlusive disease. In:
Hans SS, Shephard AD, Weaver MR, Bove PG, Long
GW, editors. Endovascular and open vascular recon-
struction: a practical approach. Boca Raton: CRC
Press; 2018. p.19–25.
Part XXIX
Subclavian Artery Stenting
Subclavian Artery Stenting
forIschemic Left Index Finger
99
Physical Examination andHistory
A 48-year-old female was admitted to the hospital
in October 2018 with pain and cyanotic discoloration of the ngers of the left hand more marked
in the left index nger. There was associated coolness and paresthesia of the hand. The symptoms
started 2weeks prior to admission (Fig.99.1). She
Fig. 99.1 Cyanotic discoloration of the left index nger
had history of nicotine abuse (60 pack years). On
examination, left axillary brachial and radial
pulses were absent. Upper extremity arterial
Doppler study showed a wrist brachial index of
1.0 on the right and 0.68 on the left. CTA of the
upper extremities showed near occlusion of the
left subclavian artery 1.5cm from its origin with
reconstitution of the artery beyond the stenosis.
Left vertebral artery was smaller in caliber as
compared to the right.
Procedure
Patient underwent left subclavian artery stenting
on October 10, 2018, via left brachial artery cutdown. Using a small transverse incision, brachial
artery was looped with a silastic loop, and a 5F
sheath was inserted into the small diameter brachial artery (Fig. 99.2). An Omniush
(AngioDynamics, Latham, NY) marker catheter
was advanced over 180-cm-long angle stiff
GLIDEWIRE
subclavian arteriogram was obtained which
showed severe stenosis of the left subclavian artery
1.5cm from its origin (Fig.99.3). A 5F sheath was
exchanged for a 6 F sheath and 45-cm- long
Pinnacle sheath (Terumo), and pre- angioplasty
with a 6 mm × 2-cm-long Armada® balloon
(Abbott, Abbott Park, IL) was performed followed
by deployment of an 8×17mm balloon expandable stent (Fig. 99.3). Completion run showed
®
(Terumo, Tokyo, Japan), and a left
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_99
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99 Subclavian Artery Stenting forIschemic Left Index Finger
Fig. 99.2 Aortogram via left brachial approach showing
severe stenosis of the left subclavian artery
Fig. 99.3 Post-stent angioplasty of the left subclavian
artery stenosis
excellent result (Fig. 99.4). Brachial artery was
sutured with interrupted 7-0 cardiovascular polypropylene suture (Ethicon Inc., Somerville, NJ).
Patient had marked improvement in her symptoms, and ischemic changes in the nger resolved
during subsequent 6weeks (Fig.99.5). Patient had
easily palpable left brachial and radial pulse. Wrist
brachial index was normal on both sides (1). She
was seen at follow- up on March 2019 without any
symptoms in her left hand.
Fig. 99.4 Completion run with minimal residual stenosis
with robust lling of the left vertebral artery
Fig. 99.5 Complete resolution of cyanotic discoloration
of the hand (nger)
Discussion
The subclavian artery is the most frequent intervened on in the brachial cephalic distribution.
Open surgical bypass has excellent outcomes but
carries signicant morbidity and even mortality
[1]. Therefore, endovascular therapy has become
the rst-line consideration for treatment of subclavian artery lesions especially as patency rates
have continued to improve and are reported to be
Reference
457
>90% secondary patency at 1 and 5 years [1].
Although femoral access is the preferred
approach to subclavian artery lesions, brachial
access is an important access site to subclavian
artery interventions. Brachial artery approach is
preferable for crossing the occlusions involving
the origin of the subclavian artery as introduction
of the catheter into the origin of the subclavian
artery from the aortic arch in these situations may
not be always feasible. One other consideration
regardless of the vessels involved from the aortic
arch branches is the relative location of other vessel origins. In patients with major branch origins
located very close to one another, expose the
other vessels for risk during intervention, especially in a heavily calcied lesion [1]. In these
circumstances, disruption of the calcium during
the intervention can result in shift of the calcied
lesion leading to compromise of the lumen of the
adjacent vessel. This should be evaluated with
preoperative CTA or an evaluation performed
during the performance of arch aortogram [1]. In
order to protect the adjacent vessel origin, a balloon can be inated during the intervention [1].
This may require cannulation through an ancillary access or placement of a buddy wire via
femoral access [1]. The protective balloon should
be slightly undersized to the vessel diameter in
order to avoid vessel trauma during ination [1].
Reference
1. Sullivan TM, Titus JM.Stenting for occlusive disease
to the aortic arch branches. In: Hans SS, Shephard
AD, Weaver MR, Bove PG, Long GW, editors.
Endovascular and open vascular reconstruction: a
practical approach. Boca Raton: CRC Press; 2018.
p.9–18.
Part XXX
Acquired Arteriovenous Fistula