The use of renal stents in atherosclerotic renal artery stenosis has been mired in controversy secondary to poorly designed randomized clinical trials which demonstrated minimal benefit over medical management. This publication illustrates the deployment of an isolated renal stent as an ancillary procedure for a patient with a 5.5cm juxtarenal AAA in need of fenestrated endovascular repair.
Methods
Under general anesthesia, the patient was prepped with the left arm tucked. Access via the right common femoral artery over the femoral head was obtained under ultrasound guidance. Using the Seldinger technique, a long sheath (Ansell) was inserted to the level of the infrarenal aorta. A Glidewire (Terumo) was used to enter the right renal ostia with the assistance of an Omniflush (Angiodynamics) catheter after an initial aortogram. A Rosen (Cook) wire was exchanged and the sheath was advanced past the stenosis over the dilator. The balloon mounted iCAST (Atrium) stent was positioned and the sheath pulled back. The stent was deployed and flared using a Flash ostial balloon (Cordis). Completion angiography demonstrated excellent flow through the right renal artery and into the terminal renal branches.
Results
The patient recovered uneventfully overnight with a stable Cr the next morning. Four weeks after his renal intervention, the patient was taken to the operating theatre for a successful 3-vessel fenestrated aortic repair. At the most recent 6-month follow-up, the patient had a stable Cr and residual aortic sac diameter.
Conclusions
While the use of renal stenting in hypertension related to atherosclerotic renal artery disease continues to remain controversial, this intervention can still be performed as an adjunctive procedure in select cases with excellent technical success and low morbidity.
Additional Authors
Raghu L. Motaganahalli
Andres Fajardo
Renal Stenting
At this moment, there is no high-quality evidence supporting the use of renal stenting in uncomplicated hypertension related to renal artery stenosis. However, there may be a role for stenting in the setting of hypertension uncontrolled by medical therapy with evidence of end-organ injury. As illustrated in this publication, the use of renal stenting may also be employed as an adjunctive procedure in aortic interventions.
Renal stenting should be avoided in the anatomic presence of terminal renal artery disease, a short main renal artery, branch artery disease, and pediatric disease. Additionally, it will not benefit the patient in the setting of normal renal function or well-controlled hypertension.
Ideally, general anesthesia in a hybrid operating theatre should be the setting for this procedure. The patient should be placed supine with the left arm tucked with the C-arm positioned on the left side.
At minimum, patients should be evaluated with a CTA which includes the femorals, iliacs, and visceral segment of the abdominal aorta. Renal function testing should be evaluated with a serum creatinine.
Major consideration should be given towards the presence of accessory renal arteries and the location of the renal artery first-order branch as to avoid coverage.
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Procedural complications have been reported as high as 43%. However, contemporary reports suggest minimal and acceptable risk rates with the clear majority related to access, contrast nephropathy, and atheroembolization.
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1. Bax L, Woittiez AJ, Kouwenberg HJ, Mali WP, Buskens E, Beek FJ et al. Stent Placement in Patients with Atherosclerotic Renal Artery Stenosis and Impaired Renal Function: a Randomized Trial. Ann Intern Med 150:840–848, 2009.
2. Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C et al. ASTRAL Investigators. Revascularization Versus Medical Therapy for Renal Artery Stenosis. N Engl J Med 361:1953–1962, 2009.
3. Cooper CJ, Murphy TP, Cutlip DE, Jamerson K, Henrich W, Reid DM et al. CORAL Investigators. Stenting and Medical Therapy for Atherosclerotic Renal Artery Stenosis. N Engl J Med 370:13–22, 2014.
4. Fleming SH, Davis RP, Craven TE, Deonanan JK, Godshall CJ, and Hansen KJ. Accuracy of Duplex Sonography Scans after Renal Artery Stenting. J Vasc Surg Oct;52(4):953-7, 2010.
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