Abdominal Aortic Aneurysm and Renal Artery Stenosis: Renal Function and Blood Pressure Before and After Endovascular Treatment

Home , Renal artery, Renal artery stenosis

Journal of Human Hypertension (2002) 16, 367–369  2002 Nature Publishing Group All rights reserved 0950-9240/02 $25.00 www.nature.com/jhh CASE REPORT Abdominal aortic aneurysm and renal artery stenosis: renal function and blood pressure before and after endovascular treatment

B Agroyannis, A Chatziioannou, D Mourikis, N Patsakis, K Katsenis, S Kalliafas, P Dimakakos and L Vlachos Department of Nephrology, Radiology and Vascular Surgery, Aretaieon University Hospital, Athens Greece

We describe three patients with abdominal aortic aneur- patient and remained normal in the other two normot- ysm (AAA) and renal artery stenosis (RAS). These ensive patients. In conclusion, simultaneous treatment patients were treated by placement of an aortic endo- of AAA and RAS with aortic endograft placement and graft and angioplasty or stenting of the renal artery. renal artery angioplasty with or without stent, is a safe After the procedure renal function improved or and effective technique for selected high-risk patients. remained stable in two patients and deteriorated slightly Journal of Human Hypertension (2002) 16, 367–369. DOI: in one. Blood pressure was reduced in one hypertensive 10.1038/sj/jhh/1001367

Keywords: abdominal aortic aneurysm; renal artery stenosis; aortic endograft; angioplasty

Introduction with renal artery stenosis of about 80%, blood pressure 135/85 mm Hg and serum creatinine 3.1 mg/dl. Atherosclerotic renovascular disease is an important The left kidney had previously been removed for cause of hypertension and renal dysfunction. The nephrolithiasis. incidence increases with age and usually coexists This patient was simultaneously treated by place- with atherosclerotic disease elsewhere. Several ment of an aortic endograft with a proximal studies have evaluated the prevalence of renal artery uncovered suprarenal stent and by renal artery ang- stenosis (RAS) in patients undergoing angiography ioplasty. Eight months after the procedure he is still for a variety of extrarenal vascular problems includ- well and his blood pressure was 140/80 mm Hg and ing abdominal aortic aneurysms, coronary artery his serum creatinine was 2.7 mg/dl. disease, peripheral vascular disease and aorto- In this patient who had a short proximal neck, we 1–3 occlusive disease. used an endograft with a proximal uncovered supra- We describe three patients with abdominal aortic renal stent. The covered part of the endograft was aneurysm (AAA) and RAS who were treated by placed right below the renal artery and the proximal placement of an aortic endograft and renal artery uncovered suprarenal stent was deployed in front of angioplasty (with or without stent). Figure 1 the renal artery. (angiography and CT) shows the placement of stent and aortic endograft. Case 2 Case report A 77-year-old man had high grade RAS of the left kidney, hypertension (22/110 mm Hg), serum creati- Case 1 nine of 1.98 mg/dl and infrarenal AAA (neck longer A 77-year-old man had an AAA with infrarenal neck than 15 mm). This patient was treated with renal less than 15 mm, single-functioning right kidney artery angioplasty and stenting. Blood pressure was improved (160/90 mm Hg) and antihypertensive medications were reduced, but his serum creatinine Correspondence: B Agroyannis, MD, Department of Nephrology, remained stable (1.96 mg/dl). After 8 months the Vas. Sofias 76, Athens 115 28, Greece. Fax: +301 7231702 AAA was treated by the placement of an infrarenal Received 6 August 2001; revised and accepted 30 October 2001 aortic endograft. In this patient there was sufficient Abdominal aortic aneurysm and RAS B Agroyannis et al 368 with a marked catheter. The length of the proximal aortic neck was defined as the distance between the lowest renal artery and the proximal portion of the aneurysm.

Discussion In this study, we describe three patients with coexisting RAS and abdominal aortic aneurysm. Several autopsy series emphasise the relationship between age and the presence of significant renal artery atherosclerosis. Increasing prevalence of RAS is found among elderly people. In cadaveric studies, the prevalence of serious RAS was 5% in patients younger than 64%, 18% in patients 65–74 years old and 42% in patients older than 74 years.1–3 Several studies evaluated the prevalence of RAS in patients undergoing angiography for a variety of extrarenal problems including AAA, coronary artery disease, peripheral vascular disease and aorto- occlusive disease. From angiographic data, the prevalence of RAS in patients with extrarenal vascular disease, ranges from 11% to 42%. The highest prevalence is among patients with peripheral vascular disease. In patients with AAA the prevalence of RAS is about 22%. If an infrarenal AAA is recog- nised in aortography, a high flush should be con- sidered to examine the renal arteries.1,4 Percu- taneous transluminal renal angioplasty is an accepted method of treatment of hypertension and renal dysfunction resulting from RAS. The role of renal artery stents in percutaneous revascularisation of the kidney is not yet clearly defined. However, available data suggest that renal artery stent placement is particularly helpful in ostial atheromatous lesions. Stent placement following percutaneous transluminal angioplasty (PTA) prevents immediate Figure 1 Angiography (a) and CT (b) show the placement of a recoil, but does not exclude restenosis because the stent in the left renal artery and the stent-graft in the aorta. presence of an intra-arterial foreign body may be the cause for neointima formation. Nevertheless, percutaneous transluminal renal angioplasty may offer a neck length (Ͼ15 mm) and we used an infrarenal favourable outcome in elderly high-risk patients aortic endograft. Three months after endovascular with symptomatic RAS. The decision to perform repair of AAA, he continues to do well, his blood angioplasty in RAS greater than 60% would appear pressure was 140/80 mm Hg, but his renal function reasonable as the occlusion may occur in 5% at 1 was slightly deteriorated (serum creatinine year and 11% at 2 years.1,4–6 2.37 mg/dl). Before 1991, surgery was the treatment of choice for AAA. About a decade ago the endovascular treatment of AAA was first presented. Since then it has Case 3 evolved as a technique for patients who are not can- A 73-year-old man had a 70% RAS of the left kid- didates for open surgery. In high-risk patients with ney, blood pressure 140/80 mm Hg, serum creatin- life-threatening AAA the aortic endografts represent ine 1.2 mg/dl and infrarenal AAA with neck length the only treatment option. Therefore endovascular less than 15 mm. This patient was simultaneously repair of AAA is a new and rapidly expanding tech- treated by placement of a renal artery stent and an nique. The procedure is technically successful and aortic endograft with suprarenal stent. blood flow is excluded completely from the aneur- Four months after intervention he continues to do ysm sac. Initial reports emphasised the need for a well, his serum creatinine was 1.1 mg/dl and his sufficiently sized infrarenal neck for proper place- blood pressure was 140/80 mm Hg. ment of the stent-graft. They suggest that the normal All patients, according to pre-procedural plan- aorta between the orifices of the renal arteries and ning, underwent a spiral CT scan and an angiogram the beginning of AAA must have a length of at least

Journal of Human Hypertension Abdominal aortic aneurysm and RAS B Agroyannis et al 369 15 mm to ensure secure anchoring of the stent-graft. infrarenal deployment of aortic endografts. Recent However, suprarenal placement of stent-grafts in reports include endografts with a proximal some patients with infrarenal neck less than 15 mm uncovered suprarenal stent. So far the presence of (3–14 mm) was recently performed. No statistically the suprarenal stent does not appear to impair kid- significant differences in laboratory values and ney function.2,8 Complications of the endovascular arterial blood pressure were found between patients repair of AAA include graft migration and endoleak. with suprarenal and infrarenal placement of stent Probably improved graft design will secure long- grafts. Renal function and perfusion remain unaffec- term durability of this procedure.9,10 ted in suprarenal placement of stent-grafts.7–9 In conclusion, coexistence of RAS and AAA may In our study there were two patients with AAA be treated simultaneously by placement of an aortic and unilateral RAS and one patient with AAA and endograft and renal artery angioplasty with or with- solitary-functioning kidney with RAS. out stent. This combined treatment may prevent Out of the three patients, one had hypertension renal function deterioration and AAA rupture in and two had renal dysfunction. These patients were elderly and high-risk patients. treated by placement of aortic endograft and renal artery angioplasty with or without stent placement References (Figure 1). 1 Scoble JE. Is the ‘wait and see’ approach justified in The two procedures were performed simul- atherosclerotic renal artery stenosis? Nephrol Dial taneously in two patients without any adverse Transplant 1995; 10: 588–589. effect. Renal artery angioplasty and stenting can be 2 Greco BA, Breyer JA. Atherosclerotic ischemic renal performed at the same time with aortic endograft disease. Am J Kid Dis 1997; 29: 167–187. placement in the majority of patients, eliminating 3 Hirschberg B et al. Prolonged renal dysfunction sec- the need for a second procedure. ondary to renal artery stenosis in the elderly – it is Aortic endografts are made out of a series of stents never too late. Nephrol Dial Transplant 1998; 13: 982–984. which are covered by a graft. Some of them have 4 Erdoes LS, Berman SS, Hunter GC, Mills JL. Compara- proximal uncovered stents which are deployed in tive analysis of percutaneous transluminal angioplasty front of the renal arteries. The covered stents are and operation for renal revascularization. Am J Kid Dis deployed below the renal arteries. In our patients we 1996; 27: 496–503. did not alter our usual technique of renal artery stent 5 Shanon HM, Gillespie IN, Moss JG. Salvage of the soli- placement which includes that a short part of the tary kidney by insertion of a renal artery stent. AJR stent should protrude for a few millimetres into 1998; 171: 217–222. the aorta. 6 Zuccala A, Zucchelli P. Atherosclerotic renal artery During a short follow-up ranging from 3 to 8 stenosis – when is intervention by PTA or surgery justified? Nephrol Dial Transplant 1995; 10: 585–587. months, renal function in two patients with renal 7 Duda SH et al. Abdominal aortic aneurysms: treatment dysfunction showed slight deterioration in one and with juxtarenal placement of covered stent-grafts. improvement in the other (patient with solitary Radiology 1998; 206: 195–198. kidney), while it remained stable within normal 8 Macferewicz J et al. Vascular Surgical Society of Great values in the third patient. In one hypertensive Britain and Ireland: perioperative renal function fol- patient blood pressure improved and medications lowing endovascular repair of abdominal aortic aneur- were reduced and in the other two normotensive ysm with suprarenal and infrarenal stents. Br J Surg patients their blood pressure remained within nor- 1999; 86: 696. mal limits. It is suggested by some reports that renal 9 Resch T et al. Distal migration of stent-grafts after endovascular repair of abdominal aortic aneurysms. artery atherosclerotic disease is common even JVIR 1999; 10: 257–264. among normotensive patients, especially in elderly 10 Baum R, Cope C, Fairman RM, Carpenter JP. Translu- 2 people. minal embolization of Type 1 endoleaks after endovas- Endovascular repair of AAA is a new and effective cular repair of abdominal aortic aneurysms. J Vasc method of treatment. Initial reports included only Interv Radiol 2001; 12: 111–116.

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