Cath Lab Digest

by Richard Heuser, MD and Shishir Murarka, MD (Banner Estrella Medical Center)

A 59-year-old African-American female patient presented with malignant hypertension. She had nonischemic cardiomyopathy, an ejection fraction of 34%, and has been followed for her other medical problems including hypertension, sleep apnea, a previous stent in her left renal artery, hyperlipidemia and chronic renal insufficiency. The left renal stent was initially placed on January 18, 2008, with a 5 x 18 mm HercuLink stent (Abbott Vascular, Abbott Park, Illinois), and was dilated on August 31, 2009 due to in-stent restenosis. The patient has been on coumadin to prevent a stroke.

The patient complained of resting chest pain. Coronary angiography was scheduled, and because of severe hypertension with blood pressure of 210/110, she underwent renal angiography as well. The patient had a baseline serum creatinine of 1.7 and was pretreated with a bicarbonate drip and mucomyst. The left ventricular function showed an ejection fraction of 35%, with global hypokinesis. Her central aortic pressure was 210/110. The right coronary artery was normal and the left coronary artery was completely free of disease. The renal arteriogram, on the right side, showed a 20–30% proximal stenosis and a near-total intraparenchymal renal artery occlusion. The vessel was quite large. On the left side, there was an in-stent restenosis of 60–80% of the proximal portion of the renal artery. The patient underwent therapy.

The left renal artery was treated with an RCD-type catheter and we used a 4 cm x 5.0 mm AngioScore (AngioScore, Inc., Fremont, California) balloon inflation with the stenosis going from 70% to approximately 0%. We placed the same guiding catheter into the right side with a Cougar wire (Medtronic, Inc., Minneapolis, Minnesota) in the upper branch and a Miracle 3 wire (Asahi, Abbott Vascular) in the lower branch. We used a 3.0 x 12 mm Xience stent (Abbott Vascular) and deployed it to 12 atmospheres. The 99% stenosis went to 0%, and the patient’s serum creatinine at discharge was 1.3.

This was the second in-stent restenosis on the left side and this was the first time we have seen intraparenchymal stenosis on the right side where the renal arteries were normal on a previous study.

This case shows an example of intervention in a patient with a near-total atherosclerotic renal artery intraparenchymal lesion. We could not find any case reports demonstrating placement of stents to treat atherosclerotic intraparenchymal renal arteries. There is little information in the literature on these distal lesions in atherosclerotic disease. With the ongoing debate over the revascularization of renal artery stenosis,1–6 it would be interesting to evaluate the effects of treatment of distal lesions on renal function and blood pressure response.

References

1. Plouin PF, Chatellier G, Darné B, Raynaud A. Blood pressure outcome of angioplasty in atherosclerotic renal artery stenosis: a randomized trial. Hypertension 1998;31:823–829.

2. Webster J, Marshall F, Abdalla M, et al. Randomised comparison of percutaneous angioplasty vs. continued medical therapy for hypertensive patients with atheromatous renal artery stenosis. J Hum Hypertens 1998;12:329–335.

3. van Jaarsveld BC, Krijnen P, Pieterman H, et al. The effect of balloon angioplasty on hypertension in atherosclerotic renal-artery stenosis. N Engl J Med 2000;342:1007–1014.

4. Bonelli FS, McKusick MA, Textor SC, et al. Renal artery angioplasty: Technical results and clinical outcome in 320 patients. Mayo Clin Proc 1995;70:1041–1052.

5. Textor SC. Revascularization in atherosclerotic renal artery disease. Kidney Int 1998;53:799–811.

6. Wheatley K, Ives N, Gray R, et al. Revascularization versus medical therapy for renal-artery stenosis. ASTRAL Investigators. N Engl J Med 2009;361:1953–1962.

________________________________________________________________

Richard R. Heuser, MD, FACC, FACP, FESC, FSCAI, is an internationally recognized cardiologist, inventor, educator and author. A diplomate of the American Board of Cardiovascular Diseases and the American Board of Interventional Cardiovascular Diseases, Dr. Heuser is one of the early pioneers of angioplasty and is considered one of American’s top cardiologists. Dr. Heuser is currently in practice at the Phoenix Heart Center/Physicians Group of Arizona. He is Director of Cardiology and Chief of Cardiac Catheterization Laboratory at St. Luke’s Hospital and Medical Center, Phoenix, Arizona, and Clinical Professor of Medicine at the University of Arizona College of Medicine, as well as Director of the Interventional Fellowship Program at the University of Arizona College of Medicine, Phoenix Campus.

With 13 patents granted for different catheters stents and other medical devices, Dr. Heuser has served as a principal investigator to research the safety and/or effectiveness of more than 100 medical devices and 50 pharmaceutical products, and has participated in more than 20 research studies. He has authored numerous articles, textbooks and medical manuscripts, and is frequency invited to international medical conferences to present findings of research developed in Phoenix.

Dr. Heuser received his medical degree from the University of Wisconsin School of Medicine in Madison, Wisconsin, and completed his medicine internship and residency, as well as his cardiology fellowship, at the Johns Hopkins Hospital in Baltimore, Maryland.