Teaching Case

Bilateral renal artery stenosis

The patient was admitted because of high blood pressure and deteriorated renal function. Nuclear scan calculated a relative renal function of 28% for the right and 72 % for the left kidney. Aortography revealed bilateral severe renal arterial stenosis (Fig. 1 a).

It was decided to dilate the right renal arterial stenosis first because in case of failure or complication, loss of renal function was considered limited. A 7 F sheath was introduced into the right femoral artery and selective angiography of the right renal artery was performed by use of a 5 F cobra-shaped catheter (Fig. 1 b). The stenotic segment was passed by a hydrophilic guidewire and the catheter was advanced over the stenotic segment into the peripheral renal artery (Fig. 2 b). After exchanging the guidewire for a 0.035 in 200 cm long conventional guidewire with a curved tip, the catheter was exchanged for a 6 F guiding catheter with renal configuration allowing angiography despite the guidewire inside. After the safe position of the guidewire in the renal artery was checked the guiding catheter was exchanged for a 6 mm large 2 cm long balloon catheter and inflation within the stenosis was performed over 60 seconds. The patient felt some dull discomfort in his right flank but no pain. After deflation of the balloon catheter, the 6 F guiding catheter was reinserted after retrieval of the balloon catheter while keeping the guidewire in place. Selective angiography revealed sufficient opening of the renal artery with no signs of deteriorated flow or dissection (Fig. 2 b). Then, after removal of the guiding catheter, the cobra catheter was reinserted for safe removal of the guidewire from the renal artery and the intervention was terminated. Balloon angioplasty of renal arteries is a safe technique to reopen renal artery stenosis. In case of long-time hypertension, clinical success is frequently limited and may be a full success in only one third of patients. In case of renal insufficiency, however, balloon angioplasty may help to improve renal function which was the major indication in that case.