A dual wire approach to severe ostial bifurcating renal artery stenosis

Simultaneous Kissing Balloon Stenting Technique in Management of Two Branches of Right Renal Artery Bifurcation: A Case Report

Atherosclerosis and fibromuscular dysplasia are the commonest types of diseases associated with renovascular hypertension, with atherosclerosis accounting for 70%-80% of all cases and the latter accounting for 10% of cases. We report a case of a 65-year-old asian male with stenosis of the right renal artery with early bifurcation treated by percutaneous balloon dilation and simultaneous kissing balloon stenting technique.

Kissing stent management of stenosis of two branches of left renal artery bifurcation: a case report

Background

Secondary hypertension accounts for 5% of all cases of hypertension. Renal artery stenosis is one of the common causes of secondary hypertension. Atherosclerosis and fibromuscular dysplasia are the commonest types of stenosis associated with renal vascular hypertension, with the former accounting for 70–80% of all cases and the latter accounting for 10% of the incidence. The greatest incidence atherosclerosis is in men over the age of 40 years, mostly affecting the proximal part of the renal arteries, whereas fibromuscular dysplasia affects women ranging in age from 30 to 50 years. Currently, possible treatments are medical treatment using blood pressure-lowering drugs, balloon angioplasty with or without stent insertion, and surgery to reconstruct the artery.

Case presentation

We report a case of a 46-year-old Asian woman with stenosis of two branches of renal artery bifurcation treated by percutaneous balloon dilatation and stenting of both branches after referral to our department for a renal angiogram following 8 months of uncontrolled hypertension despite receiving medications. Initially, the patient presented with severe headache and fatigue. She was a known nonsmoker, was not diabetic, and had no history of diabetes in her family. She had no history of atherosclerosis. Apart from high blood pressure, the result of her physical examination was unremarkable. Laboratory investigations revealed normal serum cholesterol, lipid profile, and serum creatinine. She had been attending a hypertension clinic and receiving antihypertensive drugs for the past 8 months on a regular basis under close observation. Despite this treatment and care, her blood pressure remained high at 175/110 mmHg, which the attending doctor concluded to be uncontrolled blood pressure. Initial imaging indicated left renal artery stenosis, and the patient was referred to our department.

Conclusions

For patients with uncontrolled hypertension despite receiving medications, renal Doppler ultrasound should be included in the diagnostic workup for secondary hypertension. Once renal artery stenosis is suspected, renal angiography is highly recommended because the technique is able to accurately diagnose stenosis in the branch arteries, unlike computed tomographic angiography and magnetic resonance angiography. Percutaneous transluminal renal angioplasty is the treatment of choice for renal artery stenosis in patients with renovascular hypertension or renal dysfunction.

The Y-stenting technique for pulmonary artery bifurcation stenosis: Initial results and mid-term outcomes

BACKGROUND

Treatment for main or peripheral PBS is challenging. An interventional approach is generally preferred as surgical angioplasty often results in residual stenosis. However, there is limited data on the mid- and long-term results of the different interventional approaches. The aim of this study is to report on initial and mid-term results of the Y-stenting technique for pulmonary artery bifurcation stenosis (PBS).

METHODS

A single centre retrospective study of all Y-stenting procedures for main or peripheral PBS was conducted. Patient and procedural data as well as mid-term outcomes were analysed.

RESULTS

11 Y-stenting procedures were performed, 9 in the main pulmonary bifurcation and 2 in the PA periphery. In 8 patients the bifurcation stents were connected, in 3 patients there was no connection between the stents. Y-stenting creates a geometry close to the physiological PA bifurcation anatomy with complete alignment to the vessel wall without flow separation. Control angiography showed unrestricted blood flow after all procedures. Median right/left ventricle pressure ratio decreased from 0.9 to 0.5. No immediate or delayed adverse events were seen. During a median follow-up of 33.5 months, 2 patients in the non-connected group and 3 patients in the connected group needed a total of 6 re-interventions. No intima proliferation was seen in patients with connected stents.

CONCLUSIONS

Y-stenting is a safe and effective treatment for PBS. When both bifurcation stents are connected, this may result in lower rates of in-stent intima proliferation in comparison to other PBS stenting techniques.

Impact of aortorenal morphology on renal artery stent procedures: significance of aortic tortuosity and renal artery derivation

PURPOSE

To clarify the impact of aortorenal morphology on renal artery stenting procedures.

METHODS

A retrospective study evaluated 142 consecutive renal artery stenting procedures performed for de novo atherosclerotic renal artery stenosis in 119 patients (62 men; mean age 72±9 years, range 41-93). All procedures were done via a transfemoral approach without distal protection. Aortorenal morphology was classified into 3 types based on the relationship between abdominal aortic tortuosity and renal artery derivation. Using a straight reference line centered on the most angulated point of the inner curve of the infrarenal abdominal aorta, type 1 referred to a renal artery ostium that was more than half of the aortic diameter distance from the reference line in the greater curvature and less than half in the lesser curvature. Type 2 referred to a renal artery ostium that was less than half of the aortic diameter distant from the reference line in the greater curvature and more than half in the lesser curvature. Type 3 referred to a renal artery ostium that was beyond the reference line in the greater curvature or more than one aortic diameter from the reference line in the lesser curvature. The technical success rate, procedure time, final engagement technique, shape of the guide catheter used, and any adverse events were analyzed.

RESULTS

Type 1 aortorenal morphology was observed in 91 cases, type 2 in 30, and type 3 in 21. All cases were successfully treated; there were no technical complications, in-hospital cardiovascular events, or deaths. Procedure time differed significantly (p<0.001) among the 3 types (type 1: 19.6±5.6 minutes, type 2: 23.3±6.8 minutes, and type 3: 32.3±9.6 minutes; p<0.05 for type 1 vs. 2, p<0.001 for type 2 vs. 3, and p<0.001 for type 1 vs. 3). There were also significant differences among types in terms of engagement technique and guide catheter shape.

CONCLUSION

Aortorenal morphology was significantly associated with procedure time and the selection of engagement technique and guide catheter shape.

Stents in renal artery bifurcation stenosis: a case report

A 39-year-old patient presented with poorly controlled hypertension, and she was referred to renal angiogram and potential renal angioplasty. Renal angiogram showed a bifurcation lesion of the right renal artery. A guide wire was used to cross the upper branch, while the lower branch was protected by another same-type guide wire through the same introducer. Two thin monorail balloons were used to dilate the two branches; however, despite balloon dilatation, the stenosis of the vessels persisted. The “kissing balloon” technique was then attempted by simultaneously inflating both branches using the same balloons, but more than a 70% residual stenosis persisted in each branch. Two stents were finally placed in a “kissing” way through the main renal artery. The imaging and clinical results were good, without any procedure-related complications. Three years clinical followup was also good, without any reason for further interventional approach.

Use of kissing embolic protection devices in the treatment of early bifurcation renal artery stenosis: a case report

Renal artery stenosis (RAS) is a progressive disease that may cause hypertension and chronic renal insufficiency. Percutaneous renal artery angioplasty with stent placement is a well-recognized treatment for atherosclerotic RAS. It can infrequently involve the bifurcation, and treatment of this stenosis has been described using bare metal and drug-eluting stents deployed simultaneously in a kissing fashion. Atheroembolism is believed to be caused by the release of microscopic plaque fragments and cholesterol crystals from the RAS or atherosclerotic aorta. Herein, the authors describe the use of a kissing embolic protection device technique during renal artery stent placement.