A Review of the Prevention and Management of Catastrophic Complications During Renal Artery Stenting

  • Fri, 9/5/08 - 3:36pm
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Author(s): 

Charles T. Burke, MD

Introduction
Since the introduction of percutaneous transluminal renal angioplasty (PTRA) in 1978,1 endovascular management for renovascular disease has become the standard of care with the number of renal artery interventions performed increasing annually.2 Initially, endovascular treatments were limited by high restenosis rates, due to adjacent bulky aortic plaques leading to significant elastic recoil. These early limitations have been overcome with the development of a wide array of balloon expandable and self-expanding stents that are now available. In a meta-analysis by Rees et al,3 the technical success rate of PTRA is 55% for ostial lesions and 70% for nonostial lesions. With the addition of stents, the technical success rate improves to 99%. A randomized, prospective clinical trial comparing PTRA and percutaneous transluminal renal stenting (PTRS) for ostial lesions also demonstrated a significant difference in favor of stenting for immediate success rates without a significant increase in complications.4

The overall complication rate with renal artery stenting is reported to range from 8–36%.5–13 Many of these complications are minor with no clinical consequence; groin hematoma and access site trauma being the most common. Fortunately, catastrophic complications during renal artery stenting are distinctly uncommon. The incidence of secondary nephrectomy is < 1% and 30-day mortality rates are reported up to 3%.3,10,11 Nephrectomy may be required in instances of complete renal artery occlusion from embolization or dissection that cannot be managed with endovascular techniques. Common causes of mortality with renal artery stenting include hemorrhage, acute renal failure, cholesterol embolization, sepsis, and aortic dissection.3

The overall incidence of major complications with renal artery stenting is 6–10%, and major complications may occur at any point in the procedure.5,6,9 Manipulations with the initial catheterization can lead to dissections of the renal artery or segmental branches, which may be a cause for acute renal artery occlusion. Renal artery rupture, renal artery dissection or aortic dissection may follow stent deployment. Cholesterol embolization resulting in renal artery occlusion may occur with either the initial catheterization or the stent deployment. With meticulous technique, many of these complications can be avoided. Prevention and management of these serious complications can mean the difference between procedural success and possible catastrophe.

Renal Artery Dissection
The creation of a renal artery dissection during stenting that results in a change in management of the patient is unusual. In published series, this complication has been reported to occur in 1–18% of cases.6,9 Beek et al report three instances of renal artery dissection, two of which were of no clinical significance, but resulted in loss of the kidney in the third.6 The cause for significant dissection of the renal artery is typically the subintimal passage of the guidewire during the initial catheterization. However, it might also arise from other manipulations, including predilatation prior to stent deployment, over-sizing the stent, or aggressive balloon dilatation of the stent.

Regardless of the cause, dissection of the renal artery occurs more often in heavily calcified lesions. Some dissections that occur after balloon dilatation or stent placement may be beyond the physician’s control. However, technical error may be the cause when the initial guidewire placement takes a subintimal course and goes unrecognized. The resulting subintimal false channels are reported to occur in up to 18% of cases.6 In this situation, it is critical to identify when the wire takes this subintimal path because, if unrecognized, balloon inflation or stenting within the false channel may lead to acute renal artery occlusion or renal artery perforation. Though sometimes unavoidable, there are some techniques that may reduce the incidence of this complication.

Prevention
The key to preventing subintimal guidewire passage rests in understanding the underlying cause. When using a catheter to select the renal artery orifice, the tip of the catheter may wedge into the atherosclerotic plaque that frequently abuts the renal artery orifice. The guidewire, as it is advanced out of the catheter, then dissects underneath this plaque into the subintimal plane of the renal artery. Hydrophilic guidewires are particularly susceptible to this complication, though even “soft-tipped” guidewires may dissect if one is not careful. Some authors recommend using a reversed-curve catheter to help prevent this complication.14 When using a reversed-curve catheter, a “soft-tipped” guidewire is extended approximately one centimeter from the tip of the catheter, and the catheter is advanced cephalad while directed toward the renal ostium. This allows the guidewire to engage the renal artery orifice rather than the tip of the catheter; the catheter may then be advanced over the guidewire, rather than wedging into the plaque. Similarly, a second guidewire may be used to prevent the catheter from abutting the aortic wall, the “no-touch” technique. The renal artery orifice is gently probed with a guidewire without touching the aortic wall with the guiding catheter. This technique is discussed in more detail later in the article.

References: 

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Irishsays: April 23.2011 at 12:19 pm

Real brain power on display. Thnaks for that answer!

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