CASE 525 Published on 05.08.2000

Transbrachial renal artery angioplasty

Section

Interventional radiology

Case Type

Clinical Cases

Authors

D.Vorwerk, F.Poretti

Patient

61 years, male

Categories
No Area of Interest ; Imaging Technique Digital radiography
Clinical History
Stenosis of right renal artery
Imaging Findings
Patient was admitted because of hypertension. Duplex sonography revealed a pathologic Doppler flow curve in the right renal artery with slowed acceleration indicating renal artery stenosis. During cardiac angiography , renal angiography was additionally performed revealing a tight stenosis of the right renal artery close to the orifice. The patient had undergone patchplasty at the right groin and iliofemoral bypass surgery on the left side. Thus, a transbrachial approach was chosen to attempt renal PTA. After retrograde puncture of the left brachial artery, a 6 F sheath was inserted. A 5 F head hunter catheter was guided into the abdominal aorta. Arteriography revealed a tight stenosis of the right renal artery (Fig. 1).
Discussion
The stenosis was passed by use of a hydrophilic guide wire and the headhunter catheter. Once the catheter tip was safely positioned within the renal artery distal to the stenosis, the guidewire was exchanged (Fig. 2 a) for a 0.018 in heavy duty guidewire (Platinum Plus, BSIC). After retrieval of the diagnostic catheter, a 6 mm balloon catheter of a working length of 120 cm (Smash, BSIC) was advanced over the guidewire across the stenosis (Fig. 2 b). Gradual infaltion of the balloon was performed , primarily showing a waist of the balloon at the level of the stenosis (Fig. 2 c) that disappeared with prolonged inflation over 45 seconds (Fig. 2 d). Once the balloon was deflated, it was retrieved into the aorta and angiography was performed through the inner lumen of the catheter by use of a Y-connector and a 5 cc syringe that gave enough power to obtain sufficient imaging quality. The guide wire remained in place to gave reaccess to the renal artery if needed. Angiography showed marked improvement of the lumen with a residual stenosis of 30% (Fig. 3). High flow within the renal artery was, however, present and thus it was decided to terminate the intervention without additional treatment such as stent placement. The next day transrenal duplex sonography was performed showing normalization of the doppler flow signal. Routine access to renal artery stenoses is via the transfemoral route. Transbrachial PTA is performed if a transfemoral route is not recommendable or the anatomy of the renal artery offers a more gentle passage via a transbrachial access. Transbrachial PTRA is technically more advanced because there is a limitation of the access diameter to a 7 F sheath. To avoid use of a long guiding catheter, we used a small diameter guidewire in combination with a routine balloonn catheter to obtain contrast injection through the inner catheter lumen. The problem of diameters becomes of importance if an additional stent placement is necessary. Then, a stent has to be placed either without a protecting sheath or a long sheath has to be advanced from the arm down to the renal artery which may create an unstable situation. In that particular case, there was a residual stenosis present after PTA. It was, however, considered to be not hemodynamically relevant which was proven by duplex sonography. Otherwise, stent insertion would have been mandatory especially due to the fact that the lesion was located close to the orifice.
Differential Diagnosis List
Transbrachial PTA of right renal artery stenosis
Final Diagnosis
Transbrachial PTA of right renal artery stenosis
Case information
URL: https://eurorad.org/case/525
DOI: 10.1594/EURORAD/CASE.525
ISSN: 1563-4086