CASE REPORT

‘‘Transcollateral’’ Renal Angioplasty for a Completely OccludedRenal Artery

Subash Chandra • Davinder S. Chadha •

Ajay Swamy

Received: 7 March 2010 / Accepted: 6 May 2010 / Published online: 29 May 2010

� Springer Science+Business Media, LLC and the Cardiovascular and Interventional Radiological Society of Europe (CIRSE) 2010

Abstract Percutaneous transluminal renal angioplasty

with stenting has been effective in the control of hyper-

tension, renal function, and pulmonary edema caused by

atherosclerotic renal artery stenosis. However, the role of

the procedure has not been fully established in the context

of chronic total occlusion of renal artery. We report the

successful use of this procedure in 57-year-old male patient

who reported for evaluation of a recent episode of accel-

erated hypertension. A renal angiogram in this patient

showed ostial stenosis of the right renal artery, which was

filling by way of the collateral artery. Renal angioplasty for

chronic total occlusion of right renal artery was success-

fully performed in a retrograde fashion through a collateral

artery, thereby leading to improvement of renal function

and blood pressure control.

Keywords Renal artery stensois � Chronic total

occlusion � Collaterals � Angioplasty

Introduction

It has been estimated that 1% to 5% of individuals with

hypertension have renal artery stenosis (RAS) [1]. RAS is a

progressive disease, and natural-history studies have doc-

umented progression to total occlusion in B16% of patients

with RAS [2]. Renal angioplasty represents an attractive

option that could address multiple mechanisms that worsen

renal and cardiovascular risk [3]. We report a patient with

total occlusion of the right renal artery who underwent

angioplasty of his right renal artery through a collateral

artery.

Case Report

A 57-year-old man, with known hypertensive for the pre-

ceding 7 years and on treatment with three drugs̄optimal

dose of angiotensin-converting enzyme (ACE) inhibitor,

a diuretic, and a beta blocker—with good compliance

presented with recent worsening of hypertension and an

episode of accelerated hypertension requiring hospital

admission. Evaluation showed normal-sized kidneys on

both sides on ultrasound (right kidney 9.8 cm, left kidney

10.2 cm) with an inconclusive renal Doppler ultrasound.

His blood urea level was 21 mg%, and his serum creatinine

level was 0.9 mg%. A diethyelene triamine pentaacetic acid

(DTPA) scan showed a glomerular filtration rate (GFR) of

20 ml/min on the right side and 44 ml/min on the left side.

Other workup for secondary hypertension was negative.

He underwent renal angiogram by way of the right

femoral route. A nonselective injection of the abdominal

aorta (Fig. 1) showed bilateral dual renal arteries. Renal

arteries on the left side were normal except for ostial pla-

quing of the left renal artery supplying the lower pole. On

selective hooking the small artery supplying the lower pole

of the right kidney (Fig. 2) was normal, but the artery

supplying the upper pole could not be selectively cannu-

lated. On considered review of the nonselective angiogram,

S. Chandra

Department of Cardiology, Wockhardt Hospital,

Bangalore, India

e-mail: sindhu06v@yahoo.co.in

D. S. Chadha (&) � A. Swamy

Department of Cardiology, Command Hospital,

Bangalore, India

e-mail: agiamu@gmail.com

A. Swamy

e-mail: ajayswamy@rediffmail.com

123

Cardiovasc Intervent Radiol (2011) 34:S64–S66

DOI 10.1007/s00270-010-9903-1

the upper pole of the right kidney was seen to be filling by

way of a collateral artery from a lumbar artery that was

subsequently selectively imaged using a 5F Cobra catheter

(Cordis, Miami Lakes, FL) (Fig. 3). The collateral artery

was hooked with a 6F renal double curve (RDC) renal

guide catheter (Medtronic, Minneapolis, MN), and a

hydrophilic coronary wire (0.014’’ FC Fielder wire; AS-

AHI INTECC, Japan) was negotiated from the collateral

artery into the renal artery and further into the descending

aorta. Sequential dilatations were performed over this wire

across the ostium of the renal artery with a Sprinter

(Medtronic, Minneapolis, United States) coronary balloon

dilatation catheter (2 mm 9 10 mm and 3 mm 9 10 mm)

(Fig. 4). Contralateral femoral access was subsequently

obtained, and 6F renal guide was positioned at the ostium

of the right renal artery by way of the left femoral route.

Another coronary wire (0.014’’ Cougar; Medtronic) was

passed antegrade across the right renal ostial stenosis. The

retrograde wire was removed, and a cobalt chromium stent

(Racer [6.0 9 12 mm]; Medtronic) was deployed across

the lesion at 8 atm with a good result (Figs. 5, 6). DTPA

Fig. 1 Nonselective injection of the abdominal aorta showing

bilateral dual renal arteries

Fig. 2 Selective injection into the accessory right renal artery

supplying the lower pole of the kidney

Fig. 3 Selective injection into the collateral artery showing opacifi-

cation of the right renal artery

Fig. 4 Retrograde right renal ostial dilatation using coronary balloon

dilatation catheter over the coronary wire, which was negotiated

through a collateral artery

Fig. 5 Stent deployment across the ostium of the right renal artery

S. Chandra et al.: Retrograde Renal Angioplasty Through Collateral S65

123

scan performed 3 weeks after the procedure showed

improvement in GFR from 20 to 32 ml/min on the right

side. Blood urea and creatinine levels checked after

4 weeks was recorded to be normal. The patient now

required only two antihypertensive medications (ACE

inhibitor and diuretic) and was taken off the beta blocker.

Discussion

Renal artery disease is associated with an adverse prog-

nosis regardless of coexisting coronary artery disease [4].

Renal angioplasty with stenting represents an attractive

treatment option in these patients, especially those with

flash pulmonary oedema and recent worsening azotemia.

Renal artery stenting for renal salvage in the setting of

ischemic nephropathy and preserved renal size is a strong

indication for renal revascularization as was performed in

the present case [5, 6].

The beneficial effect of dilating completely occluded

renal arteries has not been not well established. Previous

experience from a single surgical study of aortic throm-

boendarterectomy in revascularization of chronic total

renal artery occlusions in 52 patients resulted in improved

renal function and decreased of blood pressure but was

associated with a 5.7% mortality rate [5]. However,

revascularization using percutaneous techniques has made

the procedure substantially safer and more widely appli-

cable. There are anecdotal case reports in which benefit has

been documented after opening a completely occluded

renal arteries after stenting [6, 7]. The failure of demon-

strable clinical benefits after renal angioplasty has often

been attributed to its performance late in the natural history

of the disease when there is substantial loss of functioning

renal tissue from ischemic nephropathy or from emboli-

sation of material during angioplasty [3]. In this regard,

chronic total occlusion in a patient with a normal-size

kidney and some preserved renal function would intuitively

represent an interesting case offering insights into natural

history of RAS after angioplasty. As was seen in the

present case, renal size and function was partially pre-

served on the right side due to the presence of a collateral

blood supply and a small accessory renal artery. Angio-

plasty restored normal blood supply with subsequent

improvement in renal function (as demonstrated by

improvement in GFR from 20 to 32 ml/min) and optimi-

sation of blood pressure control (decreased number of

antihypertensive medications). The improvement noted in

renal function was maintained at 6-month follow-up, and

long term follow-up is planned.

There are several case reports of coronary and peripheral

angioplasty performed through collateral arteries [8, 9]. In

this case, a new approach to recanalize a chronic total

occlusion of a renal artery performed retrogradely through

a collateral artery has been described.

References

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Fig. 6 Final result after stenting of the right renal artery ostium

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