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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 6  |  Issue : 3  |  Page : 292-295

Renal artery Chronic Total occlusion Angioplasty in a Patient with Bilateral Renal Artery Occlusion and Hypertensive Emergency


1 Department of Cardiology, Aayush Hospital, Vijayawada, Andhra Pradesh, India
2 Department of Nephrology, Aayush Hospital, Vijayawada, Andhra Pradesh, India

Date of Submission23-Mar-2020
Date of Decision26-Mar-2020
Date of Acceptance17-Sep-2020
Date of Web Publication23-Dec-2020

Correspondence Address:
Dr. Raghuram Palaparti
Department of Cardiology, Aayush Hospital, Ramachandra Nagar, Vijayawada - 520 008, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jpcs.jpcs_22_20

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  Abstract 


Atherosclerotic bilateral renal artery chronic total occlusions (CTOs) as a cause of hypertensive emergency is rare, and other causes such as vasculitis should be ruled out before definitive diagnosis. Successful CTO intervention in such a scenario has only been sparsely reported. A 53-year-old-male smoker with severe resistant hypertension required multiple emergency admissions for flash pulmonary edema and aggressive blood pressure control. He was found to have deranged renal parameters with a serum creatinine of 2.4 mg/dL and an estimated glomerular filtration rate of 25 mL/min. His complete blood picture, metabolic panel, and inflammatory markers were within normal limits. Renal Doppler ultrasonography revealed bilateral severe renal artery stenosis and a contracted left kidney. Renal angiography showed total occlusion of both renal arteries with well-collateralized right kidney. He underwent right renal artery CTO angioplasty with stenting. Left renal artery occlusion was managed conservatively because of the contracted kidney size and poor function. He is doing well for the last 30 months with good hypertension control, well-perfusing and preserved right kidney volume, stable renal function, and significantly fewer medications from baseline. Renal artery stenting is lifesaving in patients with bilateral renal artery occlusion and should be expeditiously performed, particularly in patients with and hypertensive emergency or recurrent unexplained heart failure. Kidney size, function, presence of collateralization, and viable renal parenchymal tissue guide in planning the intervention.

Keywords: Bilateral renal artery occlusion, chronic total occlusion, hypertensive emergency, renal artery stenting


How to cite this article:
Chowdary Parvathaneni S S, Palaparti R, Koduru GK, Palaparthi S, Kondru PR, Marri H. Renal artery Chronic Total occlusion Angioplasty in a Patient with Bilateral Renal Artery Occlusion and Hypertensive Emergency. J Pract Cardiovasc Sci 2020;6:292-5

How to cite this URL:
Chowdary Parvathaneni S S, Palaparti R, Koduru GK, Palaparthi S, Kondru PR, Marri H. Renal artery Chronic Total occlusion Angioplasty in a Patient with Bilateral Renal Artery Occlusion and Hypertensive Emergency. J Pract Cardiovasc Sci [serial online] 2020 [cited 2021 Apr 17];6:292-5. Available from: https://www.j-pcs.org/text.asp?2020/6/3/292/304521




  Introduction Top


Atherosclerotic bilateral renal artery chronic total occlusions (CTOs) as a cause of hypertensive emergency is rare, and other causes such as vasculitis should be ruled out before definitive diagnosis. Successful CTO intervention in such a scenario has only been sparsely reported.

Case Report

A 53-year-old-male smoker (1 pack per day for 30 years) and hypertensive for the last 5 years was on multiple antihypertensive medications which included extended-release prazosin 10 mg twice a day, clonidine 200 μg three times a day, extended-release nifedipine 20 mg three times a day, isosorbide dinitrate/hydralazine fixed-dose combination (20 mg/37.5 mg) three times a day, and torsemide 10 mg once a day. He presented to us with multiple emergency admissions due to flash pulmonary edema and accelerated hypertension (blood pressure >200/110 mmHg) requiring invasive mechanical ventilation and aggressive blood pressure lowering with intravenous nitroglycerine infusion or sodium nitroprusside infusion. On evaluation, he was found to have deranged renal parameters with a serum creatinine of 2.4 mg/dL and blood urea nitrogen of 55 mg/dL. Complete blood picture and the metabolic panel were within normal limits including inflammatory markers, erythrocyte sedimentation rate, and C-reactive protein. His electrocardiogram showed left ventricular hypertrophy with strain pattern and echocardiography identified concentric left ventricular hypertrophy with good ventricular systolic function. A renal Doppler ultrasonography revealed severe bilateral renal artery stenosis, normal-sized right kidney (11.2 cm × 9.8 cm), and contracted left kidney (4.5 cm × 6.2 cm). A nuclear scan revealed critically reduced perfusion of both kidneys, small left kidney, normal intrarenal transit of tracer, no obstruction to outflow, glomerular filtration rate of 25 mL/min, and relative renal function (right kidney vs. left kidney) as 90% versus 10%. Invasive coronary and renal angiogram showed mild coronary artery disease with bilateral renal artery occlusion. The right renal artery is a proximal CTO with a faint filling of the distal vessel from collaterals. The left renal artery is also a subtotal occlusion with faint distal filling [Figure 1]. After informed consent, he underwent revascularization of the right kidney. A 7F sheath (Input, Medtronic, Minneapolis, MN, USA) was placed in the right femoral artery. Using 7F RDC 1 guide catheter (55 cm, Boston Scientific, Massachusetts, USA), the right renal artery was engaged and occlusion was attempted to cross using SION blue wire (0.014”, Asahi Intecc, Aichi, Japan) with balloon support. As the lesion could not be crossed, the wire was upgraded to a HI-Torque Pilot 200 wire (190 cm, Abbott Vascular, Santa Clara, CA, USA) and then to Fielder XT wire (190 cm, Asahi). The Fielder XT wire entered into a false passage. Using a parallel wire technique, leaving the Fielder XT wire in the dissection plane, a HI-Torque Intermediate wire with larger tip load (Abbott Vascular) was used which could cross the lesion with the support of a 2 mm × 10 mm NC Trek balloon (Abbott Vascular). The lesion was predilated with a 2 mm × 10 mm NC balloon at 14 atm followed by a 3.5 mm × 15 mm NC Traveler balloon (Abbott Vascular) at 14 atm. A 4 mm × 12 mm Xience V Everolimus-Eluting Stent (Abbott Vascular) was deployed at 16 atm pressure. The stent was post dilated using a 5.0 mm × 12 mm NC Trek balloon (Abbott Vascular) at 18 atm pressure with a good angiographic result [Figure 2] and [Video 1]. There was a transient rise in creatinine to 4 mg/dL over the next 48 h, however the patient remained nonoliguric without any symptoms. By 1-week postprocedure, serum creatinine decreased to 2.2 mg/dL. He was followed up at 1 month, 3 months, 6 months, and every 6 months thereafter. The number of his antihypertensive medications has been reduced significantly by the first follow-up. His latest follow-up at 30 months showed good hypertension control, well-perfusing right kidney, preserved kidney volume and patent stent on renal Doppler study, stable renal function with a serum creatinine of 2.0 mg/dL, and estimated glomerular filtration rate of 45 mL/min [Figure 3]. He is adherent to lifestyle modifications and his current medications include extended-release nifedipine 20 mg twice a day, clonidine 100 μg twice a day, torsemide 5 mg once a day, aspirin 75 mg, and atorvastatin 20 mg once a day.
Figure 1: (a) Digital subtraction angiography still image showing bilateral renal artery occlusion (two black arrows). (b) Collateral to the right kidney (black arrow). (c) Subtotal occlusion of the left renal artery (black arrow).

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Figure 2: (a) Parallel wire technique, Fielder XT wire in false passage (white arrow). (b) Right renal artery after pre dilatation. (c) Stenting with 4 × 12 mm Xience V stent. (d) Final result after stenting (white arrow).

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Figure 3: (a) Preserved volume of the right kidney at 30-month follow-up. (b) Normal flow velocities across the stent. (c) Color Doppler showing well-perfusing right kidney.

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  Discussion Top


The etiology in our patient appears to be atherosclerotic in origin, given his age, smoking history, hypertension, and normal inflammatory markers. Clinical presentation, the severity of the bilateral stenosis, kidney size, and the relative and residual function of kidneys guided by a technetium 99m-EC diuretic renal study were taken into consideration in deciding the management plan.[1] In major randomized clinical trials, renal-artery stenting, when added to medical therapy in patients with atherosclerotic renal artery stenosis and hypertension or chronic kidney disease, did not confer a significant benefit with regard to the prevention of clinical events.[2],[3] However, current guidelines still recommend renal artery stenting as a reasonable option (Class IIb in ESC, 2017, general recommendations for the management of the patients with peripheral artery diseases) for patients with hemodynamically significant renal artery stenosis and uncontrolled resistant hypertension or recurrent unexplained congestive heart failure or flash pulmonary edema.[4],[5],[6]

In a patient with bilateral renal artery occlusion, the mechanism of resistant hypertension is probably due to the preserved microcirculation allowing juxtaglomerular cell survival, resulting in elevated renin production.[7] We are unable to define accurately the time frame over which bilateral occlusions developed in our patient. Our patient had extensive collateralization of the right kidney, indicating chronic occlusion. Collateralization and thereby excessive renin production by the viable renal parenchyma could be the cause of severe resistant hypertension in our patient. However, we did not measure plasma renin levels in our patient before performing the intervention. We believed that the patient will certainly be benefited from the intervention, given his bilateral occlusion. Good control of hypertension and stabilization of renal function during the follow-up confirmed the same. It was decided to medically treat the left kidney, given a small size and poor relative function on the nuclear scan. A single-patient study showed that the clinical benefit of angioplasty and stenting could still be achieved in a patient with a single atrophic kidney and is predicted by elevated renal vein renin levels.[7] However, current evidence does not support intervention on an atrophic kidney.

Renal angioplasty is a safe and effective technique, with favorable short- and long-term clinical outcomes. Younger patients and those with truncal rather than ostial stenosis; patients with a rapid deterioration of renal function; those with flash pulmonary edema; and posttransplant renal artery stenosis patients benefit the most from the procedure. Hence, the therapy should be individualized depending on the patient's profile. In some patients, renal artery stenting remains the only viable option for hypertension control. To the best of our knowledge, the data are sparse concerning chronic bilateral renal artery occlusions due to atherosclerosis, who have been treated with renal artery stenting barring a few case reports.[8],[9],[10]


  Conclusion Top


Despite equivocal evidence, guidelines still advocate renal artery stenting in certain high-risk patients and therapy should be individualized. Renal artery stenting is lifesaving in patients with bilateral renal artery occlusion and should be expeditiously performed, particularly in patients with and flash pulmonary edema or unexplained recurrent congestive heart failure. Kidney size, function, presence of collateralization, and presence of viable renal parenchymal tissue guide in planning the intervention.

Declaration of patient consent

The authors certify that appropriate patient consent has been obtained from the patient. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initial will not be published, and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.

Ethics clearance

Ethical clearance in the form of informed written and verbal consent has been obtained from the patient. Ethical committee approval is not required for the case report.

Acknowledgments

We are very thankful to Aayush Hospital management for the support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Hephzibah J. Role of nuclear medicine in evaluation of renal system. Curr Med Issues 2018;16:148.  Back to cited text no. 1
  [Full text]  
2.
Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med 2014;370:13-22.  Back to cited text no. 2
    
3.
Bavry AA, Kapadia SR, Bhatt DL, Kumbhani DJ. Renal artery revascularization: Updated meta-analysis with the CORAL trial. JAMA Intern Med 2014;174:1849-51.  Back to cited text no. 3
    
4.
Aboyans V, Ricco JB, Bartelink MEL, Björck M, Brodmann M, Cohnert T, et al. 2017 ESC guidelines on the diagnosis and treatment of peripheral arterial diseases, in collaboration with the European society for vascular surgery (ESVS): Document covering atherosclerotic disease of extracranial carotid and vertebral, mesenteric, renal, upper and lower extremity arteries Endorsed by: The European stroke organization (ESO) The Task force for the diagnosis and treatment of peripheral arterial diseases of the European society of cardiology (ESC) and of the European society for vascular surgery (ESVS). Eur Heart J 2018;39:763-816.  Back to cited text no. 4
    
5.
Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv 2014;84:1163-71.  Back to cited text no. 5
    
6.
Prince M, Tafur JD, White CJ. When and how should we revascularize patients with atherosclerotic renal artery stenosis? JACC Cardiovasc Interv 2019;12:505-17.  Back to cited text no. 6
    
7.
Maruyama K, Chinda J, Kabara M, Nakagawa N, Fujino T, Takeuchi T, et al. Successful percutaneous transluminal angioplasty for the treatment of renovascular hypertension with an atrophic kidney. Heart Vessels 2015;30:274-9.  Back to cited text no. 7
    
8.
Petrov I, Tasheva I, Garvanski I, Simova I, Marzyanov M, Adam G. Role of endovascular recanalization and stenting of total occlusions of the renal arteries for blood pressure control in resistant to treatment hypertension. J Cardiol Cardiovasc Ther 2017;2:555591.  Back to cited text no. 8
    
9.
Sezer M, Nisanci Y, Ozsaruhan O, Olcay A, Ecder T. Stenting for bilateral renal artery occlusion: A report of two cases. Nephrol Dial Transplant 2003;18:2663-4.  Back to cited text no. 9
    
10.
Yang M, Lin L, Niu G, Yan Z, Zhang B, Tong X, et al. Successful endovascular treatment of chronic renal artery occlusion: A preliminary retrospective case series including 15 patients. Int Urol Nephrol 2019;51:285-91.  Back to cited text no. 10
    


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  [Figure 1], [Figure 2], [Figure 3]



 

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