Rev Chil Radiol 2016; 22(1): 13-19. with in renal : our experience

Johanna Marcela Vasquez Veloza*, José Luis Abades Vázquez, José Luis Cordero Castro.

Interventional , San Pedro of La Rioja Hospital, Logrono, Spain.

Abstract In this study we provide the results and effective- ness of angioplasty with stent in patients with stenosis who presented as well with a poorly controlled or refractory and renal failure. Retrospective study including 16 patients treated by angioplasty with stent. and renal function was monitored in the first 24 hr, 6 month and 12 month follow-ups after angioplasty. Reduction of systolic blood pressure from170 mm Hg to 145 mm Figure 2 Selective aortogram and arteriography of left renal Hg was achieved n the first 24 hrs, and to 138 mm artery is performed via the right , with stenosis Hg in the control at 12 months; the diastolic blood approximately 1 cm distal to the ostium being visible. The stenosis causes a reduction of 50% in the diameter of the pressure increased from 95 mm Hg to 77 mm Hg in artery and 75% of the area thereof. the first 24 hrs, and to 70 mm Hg in the control at 12 months. Renal function remained stable. Its prevalence increases with age, especially Keywords: ; Angioplasty; Stent in subjects with morbidity and mortality associated factors, such as diabetes mellitus (DM), the aortoiliac Introduction occlusive disease, arterial hypertension (high blood Renal artery stenosis (RAS) is a disease that in pressure - HBP) or disease. Progression is from 90% of cases is secondary to , affecting 50% in the following 5 years after diagnosis, with oc- the ostium (80-85%) (Figure 1) or the proximal third clusion from 3% to 16% and renal atrophy in 21% of of the renal artery (Figure 2). the patients with stenosis greater than 60%(1). Stenosis of the renal artery can cause chronic renal failure if it affects both renal , or if the hypertension associated with this condition is prolonged or critical. This can be serious in cases where it is accompanied with HBP, and sometimes accelerated or malignant, but often it is indistinguishable from essential HBP(1). As for the diagnosis of renal artery stenosis, Doppler ultrasound is the first screening test(2), as it allows for the identification of subclinical atheromatosis in the different vascular territories, renal disorders and renal artery stenosis(3), allowing for the evaluation of the increase of peak systolic velocity above 180 cm/s, being a good parameter to detect a stenosis greater than 60%(4-11). Another parameter used is the resistance index >0.8, allowing for the identification Figure 1 A selective aortogram and arteriography of the of the patients in whom will not right renal artery was performed via the left femoral artery, improve function, blood pressure or kidney with significant stenosis of the ostium being visible. survival(3,4). But it must be taken into account that it is

Received 5th February 2016; accepted 25th February 2016. Available on internet 5th April 2016. * Author for correspondence. Email address: [email protected] (J.M. Vasquez Veloza). © 2016 SOCHRADI. Published by Elsevier Spain, S.L.U. This is an Open Access article under license CC BY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

13 J.M. Vasquez Veloza et al. Rev Chil Radiol 2016; 22(1): 13-19. operator-dependent, and in some cases can be difficult All of the patients underwent renal arteriography to evaluate, such as in obese patients or those with for correct diagnosis and to assess the degree of abundant intestinal gas, and it also does not allow for stenosis, considered significant when occlusion of the evaluation of the accessory renal arteries(5). vessel lumen was between 50% to 80%, and critical Magnetic resonance angiogram and CT angiogra- when it was greater than 80% (Figure 3). phy are methods with high a sensitivity and specificity (more than 90%), used when the creatinine clearan- ce exceeds 30 ml/min and 60 ml/min, respectively. Their main disadvantages are based on the limited capacity they have to objectify lesions that are not in the ostium, lesions of the accessory arteries and the respiratory or peristaltic artifacts(6). Renal is used in patients with incon- clusive imaging studies, in renovascular hyperten- sion and renal failure due to renal artery stenosis(7). Contraindications are uncorrectable coagulopathy, proven allergy to iodinated contrast and bad . With this technique, data for the severity of the arterial stenosis and commitment of its branches can be obtained, in order to determine the best re- vascularization strategy. Even so, this technique is not without risk and may even worsen renal function, especially in diabetic patients or those who previously had an impaired renal function(8). Treatment of RAS helps to improve or in some cases cure hypertension and regulates renal function. Figure 3 A. Selective aortogram and arteriography of the However, its invasive treatment consists of 2 proce- right renal artery was performed via the left femoral artery, dures: and angioplasty. objectifying critical stenosis of the proximal third with ostium integrity. The left renal artery has early bifurcation with no Surgical repair used primarily in patients who want signs of stenosis. B. After the infusion of 5000 IU heparin the to correct at the same time an aortic , has a 5 × 20 mm metal prosthesis is implanted with a satisfactory preoperative mortality from 2.1% to 6.1% when bypas- angiographic result. ses are implanted, and 4.7% when is performed. Reoperation at 5 years is from 5% to To perform the procedure, all patients received 15% in treated patients, and the survival rate is from hydration protocol such as nephroprotective. It was 65% to 81%(9). performed via the femoral artery under local anaesthe- Percutaneous angioplasty with stenting is a safe sia. Immediately, 5,000 IU of heparin was administered procedure, with low morbidity and high success rate intravenously prior to the start of the intervention. Non- in selected patients, as inpatient mortality is 0.5%, ionic contrast medium was used during angioplasty. but the rate of remains a disadvantage, Subsequently patients received 75 mg of because it presents values between 11% to 23% at for a month and 100 mg acetylsalicylic acid for life. 5 years(7,8). Angiographically diagnosed lesions were classified The aim of this study is to verify the effectiveness of as ostial type lesion, those which are located in the angioplasty with stenting as a treatment for renal artery first 5 mm into the main artery, and as not ostial lesion stenosis using the results obtained in our institution. those found after the first 5 mm of the main artery. Herculink were used in 100% of the cases, Materials and methods most patients with a diameter of 6 mm and longitude Study of retrospective case series, in which all of 20 mm (Table 1). patients diagnosed wit