Percutaneous intervention of renal artery stenosis improves control of hypertension and to some extent, stemming progressive renal dysfunction. Dual blood supply of a kidney through 2 separate renal arteries occurs in almost 25% of the general population. Proximity of the 2 renal ostia can render endovascular intervention challenging. We report a case of simultaneous intervention of 2 renal arteries supplying the right kidney for uncontrolled hypertension and rapidly progressive renal dysfunction. Kissing balloon angioplasty and tandem stenting with bifemoral approach resulted in successful treatment of the 2 right renal arteries with excellent technical and clinical outcome.
VASCULAR DISEASE MANAGEMENT 2012;9(3):E42–E44
Key words: bifurcation lesion, kissing balloon angioplasty, renal artery stenosis, dual supply
Angioplasty combined with stenting has resulted in most optimal angiographic outcomes for renal artery stenosis as well as improved control of hypertension and to some extent, stemming progressive renal dysfunction.1 Dual blood supply of a kidney through 2 separate renal arteries occurs in almost 25% of the general population.2 Close proximity of ostia of the 2 renal arteries can make percutaneous intervention challenging. We report a case of simultaneous intervention of 2 renal arteries with almost a common ostium, but not quite.
An 87-year-old male patient with long-standing hypertension, chronic kidney disease (stage 2; Glomerular filtration rate [GFR] was 73 mL/min/1.73m2; baseline creatinine 1.2-1.4 mg/dL), and diabetes mellitus, was transferred to our hospital with recent worsening of hypertension control despite taking 4 anti-hypertensive medications, and acute on chronic renal failure with rapid progression to stage 4 (GFR 22 mL/min/1.73m2; serum creatinine 2.87), after starting valsartan 2 weeks ago. He also had a history of peripheral arterial disease (previous left femoral to anterior tibial bypass graft), and coronary artery disease (CAD) (previous percutaneous coronary intervention). He was asymptomatic with no symptoms of congestive heart failure. Hyperkalemia has been treated at the transferring hospital. On admission, blood pressure was 155/76 mm Hg, and heart rate was 78 BPM. Physical examination was unremarkable. There was no jugular venous distension, crackles on chest auscultation, or lower extremity edema. Laboratory values were unremarkable except creatinine, which was elevated to 2.87 mg/dL from a baseline value of 1.2-1.4 mg/dL.
A transthoracic echocardiogram showed left ventricular ejection fraction of 50%, with grade 1 diastolic dysfunction and mild aortic stenosis. Abdominal ultrasound revealed right kidney size was 11.3 cm, and left kidney size was 10.4 cm without hydronephrosis, but slight cortical thinning bilaterally. Based on the fact that renal dysfunction occurred after starting an angiotensin receptor blocker, a renal duplex scan was performed, which revealed a renal to aortic flow velocity ratio less than 3.5, suggestive of possible bilateral severe renal artery stenosis.
Selective renal arteriography revealed a solitary left renal artery with mild stenosis. However, the right kidney had a dual arterial supply, superior and inferior right renal arteries. Ostia of the 2 renal arteries were very close, but selective arteriography could not be performed using one catheter at a time, and each one had to be engaged separately. Both the superior (Figure 1) and inferior (Figure 2) renal arteries had an ostial 95% stenosis, with a pressure gradient of 70 mm Hg. Each artery supplied almost half the kidney, and there was no true “dominant” artery. Interestingly, the 2 ostia were too close to allow for simultaneous engagement even using 2 catheters.
Based on these results, simultaneous percutaneous intervention of both right renal arteries was performed. After obtaining access in both common femoral arteries, two 7 Fr Renal Double Curve guide catheters (Cordis Corporation) were simultaneously engaged into the 2 renal arteries. We gave the patient 7000 units of heparin intravenously, which resulted in an activated clotting time of 276 seconds. We placed 0.014-inch diameter Asahi prowater guidewires (Abbott Vascular) distally and crossed the stenosis in each renal artery. Using two 2.5 mm x 8 mm Quantum Apex non-compliant balloons (Boston Scientific), simultaneous kissing balloon angioplasty of both renal arteries was performed at 12 atm (Figure 3). However, the lesion in the superior renal artery failed to yield, requiring another angioplasty at 20 atm using the same balloon. Subsequently, serial stenting of the 2 renal arteries was performed using 2 Liberté Rx bare metal stents (Boston Scientific): 3.5 mm x 12 mm for the superior and 3 mm x 12 mm for the inferior renal artery. Final angiography revealed well-expanded stents in both renal arteries with <20% residual stenosis in the inferior (Figure 4). There was no residual stenosis in the superior renal artery (Figure 5). There was no distal embolization, and no dissection.
After the procedure, excellent blood pressure control was achieved using only 2 antihypertensive drugs compared to 4 previously. Renal function stabilized without further deterioration for a year (GFR, serum creatinine 2.5 mg/dl). At 1 year, blood pressure continues to be well-controlled, requiring only 2 antihypertensive medications. At 1-year follow-up, he has not had worsening of renal dysfunction and has not had any hospitalization for congestive heart failure.
Renal artery stenosis is most commonly caused by atherosclerotic disease and its incidence. Deleterious effects occur more commonly in patients with CAD.3,4 It also is an under-treated disease, unless it is brought to the fore after initiation of certain medications affecting the renin-angiotensin-aldosterone system, as in our patient.4 Most cases of renal artery stenosis are asymptomatic, and the main problem is high blood pressure that cannot be controlled with medications.
Our case represents a patient who suffered uncontrolled hypertension due to unilateral renal artery stenosis. It was brought to attention only after starting an angiotensin receptor blocker, which is also uncommon, as this clinical situation is fairly commonly related to bilateral instead of unilateral renal artery stenosis.5 Whether the presence of 2 renal arteries supplying the right kidney makes any difference or not is unclear.
Endovascular treatment of renal artery stenosis has evolved from angioplasty to stenting.6 The benefit of treating ostial stenosis has been shown to be even more beneficial, similar to our patient.6 Most of these cases are not technically challenging in experienced hands, with a technical success rate >96%.7 However, presence of bifurcation disease or the presence of dual blood supply can add a certain level of technical difficulty. As opposed to coronary intervention where a single guide catheter is used to tackle bifurcation disease, in renovascular disease, the use of 2 simultaneous guide catheters might be required, albeit very rarely.
Endovascular treatment of renal artery stenosis has been shown to significantly improve hypertension control as well as stabilization or improvement in renal dysfunction.1 In our case, not only was there an improvement in blood pressure control with a lesser number of antihypertensive medications needed, but serum creatinine also stabilized, and has not deteriorated for a year.
Kissing balloon technique has been used previously in bifurcation renal artery lesions.8-12 However, most of these reports have been in a single renal artery, which bifurcates early on, and therefore, requires kissing balloon angioplasty, but can be performed with a single guide catheter.8-12 Using 2 simultaneous guide catheters helped us achieve an excellent technical and clinical success. Importantly, this method eliminates the risk of jailing the other branch. In conclusion, the technique of utilizing 2 guide catheters simultaneously in similar cases would substantially improve technical success.
- Boisclair C, Therasse E, Oliva VL, et al. Treatment of renal angioplasty failure by percutaneous renal artery stenting with Palmaz stents: midterm technical and clinical results. AJR Am J Roentgenol. 1997;168(1):245-251.
- Skandalakis JE, Gray SW. Embryology for Surgeons: the Embryological Basis for the Treatment of Congenital Anomalies. 2nd ed. Baltimore, Md: Williams & Wilkins; 1994:pp.623-625.
- Harding MB, Smith LR, Himmelstein SI, et al. Renal artery stenosis: prevalence and associated risk factors in patients undergoing routine cardiac catheterization. J Am Soc Nephrol. 1992;2(11):1608-1616.
- Stack R. Renal artery stenosis: under-diagnosed and under-treated in the cardiac patient? J Invasive Cardiol. 1999;11(2):103-105;discussion 105-106.
- Ahmed A. Use of angiotensin-converting enzyme inhibitors in patients with heart failure and renal insufficiency: how concerned should we be by the rise in serum creatinine? J Am Geriatr Soc. 2002;50(7):1297-1300.
- White C, Ramee S, Collins T, Jenkins JS, Escobar A, Shaw D. Renal artery stent placement: utility in lesions difficult to treat with balloon angioplasty. J Am Coll Cardiol. 1997;30(6):1445–1450.
- Taylor A, Sheppard D, Macleod MJ, et al. Renal artery stent placement in renal artery stenosis: technical and early clinical results. Clin Radiol. 1997;52(6):451-457.
- Baus S, Radermacher J, Galanski M, Chavan A. Kissing balloon technique for angioplasty of renal artery bifurcation stenoses. J Vasc Interv Radiol. 2003;14(11):1455-1459.
- Ho DS, Chen WH, Woo C. Stenting of a renal artery bifurcation stenosis. Cathet Cardiovasc Diagn. 1998;45(4):445-449.
- Lorin JD, Hirsh DS, Attubato MJ, Sedlis SP. A dual wire approach to severe ostial bifurcating renal artery stenosis. Catheter Cardiovasc Interv. 2006;67(6):956-960.
- Avula S, Dorros G. Juxtaposed "kissing" stents as a technique to preserve both limbs of a bifurcating renal artery. Cathet Cardiovasc Diagn. 1995;36(2):143-145;discussion 146-147.
- Howell MH, Strickman NE. Tandem stenting of crossed renal arteries with ostial stenosis. Tex Heart Inst J. 2000;27(2):166-169.
From the University of Oklahoma, Oklahoma City, Oklahoma.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript submitted September 26, 2011, final version accepted September 28, 2011.
Address for correspondence: Faisal Latif, MD, University of Oklahoma Health Sciences Center: 920 Stanton L. Young Blvd., WP# 3010, Oklahoma City, OK 73104. Email: email@example.com