Cath Lab Digest

Case Study
D.T., a 78-year-old, black female, presented electively for a redo right renal percutaneous transluminal angioplasty (PTA) after canceling 3 weeks prior, due to the ravages of Hurricanes Katrina and Rita in Louisiana. She noted vague right back pain that she attributed to prior back surgery and muscle straining while evacuating during the hurricanes. Past medical history included diabetes, hypertension, chronic heart failure (CHF), chronic renal insufficiency (CRI) with a prior baseline serum creatinine (CR) of 1.7–1.9 mg/dl, prior bilateral renal artery (RA), celiac, superior mesenteric arterial (SMA) and aortic stents, and severe PVD with a left femoral to posterior tibial bypass graft, with multiple left common femoral artery endarterectomies with complex patch angioplasties. Further history included a primary advanced adenocarcinoma of the right groin, with a radical groin dissection and post-op radiation treatment three years prior, resulting in a patient with limited femoral artery access. She had undergone bilateral RA PTA/stents in 2002 with subsequent bilateral RA ISR diagnosed by ultrasound in June 2005. In August 2005, a repeat left RA PTA was performed by a left brachial artery (BA) approach without complications, and a right RA PTA had been scheduled just prior to the hurricanes for a 80–90% RA ISR (Figure 1A). The patient had 2 right RA stents placed in 2002 for a small distal dissection. The last serum CR (1–2 months prior) was 1.8 mg/dl. The patient was on no nephrotoxic oral medications, and was maintained on daily Plavix and ASA. The preadmission serum CR was 2.3 mg/dl, with a calculated CR clearance (CRCL) of 35 mL/min and she was instructed to preadmit 24 hours prior to the planned RA PTA for oral N-acetylcysteine (NAC) 600 mg po bid and “gentle” hydration with saline and sodium bicarbonate, due to her history of CHF.

Unfortunately, the patient “missed her ride” to the hospital the day before her planned procedure, but “had a ride” the morning of the procedure, so she was instructed to take nothing by mouth (NPO) and “come on in” for her scheduled procedure. A right renal infarction or renal artery occlusion had not been diagnosed preprocedure, and her right RA was patent with 80–90% ISR one month ago. Targeted renal therapy (TRT) utilizing the Benephit Infusion System (FlowMedica, Inc., Fremont, California) for direct bilateral RA fenoldopam (Corlopam, Abbott Laboratories, Abbott Park, Illinois) infusions was introduced to our cath lab two weeks prior and TRT had been used in several prior cases, including 4 BA approach infusions without complications and with favorable outcomes. Since this patient was at high risk for contrast-induced nephropathy (CIN) and had minimal hydration (total of 150 cc preprocedure) without NAC, a strategy for CIN prophylaxis utilizing TRT with the Benephit catheter and fenoldopam was planned that day utilizing a bilateral BA approach.

Simultaneous percutaneous bilateral BA access was accomplished under local anesthesia utilizing a Cook (Cook, Inc., Bloomington, Indiana) needle and bivalirudin (Angiomax, The Medicines Company, Parsippany, New Jersey) was used for anticoagulation. A 5-Fr introducer sheath was inserted from the left BA and 5-Fr Benephit Introducer Sheath from the right BA. Set-up angiography utilizing 10 cc contrast revealed 100% occlusion of the previous (1 month ago) 80–90% right RA ISR (Figure 1B). The left RA was patent without ISR. A decision was made to cannulate the left RA using a single branch of the bifurcated Benephit PV catheter via the right BA and provide unilateral TRT with a fenoldopam 0.4 mcq/kg/min infusion while attempts were made to revascularize the right kidney via the left BA (Figures 1C and 1D).

A 6–Fr Amplatz right coronary guide catheter (Cordis Corporation, Miami, Florida) was used to engage the ostium of the 100% right RA occlusion with the previously placed bilateral RA stents extending 1–2 mm into the aorta (Figure 1D). A 0.035” Magic torque (Boston Scientific, Maple Grove, Minnesota) 260-cm guidewire crossed the occluded RA and a 6-Fr Vista Brite Tip (Cordis Corporation) 90 cm sheath was exchanged over the guidewire (Figure 1D). PTA was performed using a 5.0 x 4.0 cm Invatec (Roncadelle, Italy, distributed by eV3, Inc., Plymouth, Minnesota) Sailor Plus balloon at 8 atmospheres (Figure 1E). The RA ostium was further dilated with a 6.0 x 2.0 cm Sailor Plus balloon with excellent angiographic results. A total of 80 cc iso-osmolar Iopamidol contrast (Isovue, Bracco Diagnostics, Inc., Princeton, New Jersey) was utilized. A right RA angiogram and nephrogram demonstrated no thrombus, with the right RA filling somewhat slower, and “pruned” versus the left RA (Figure 1F). The right periprocedural nephrogram also appeared somewhat smaller than the left by visual estimation.