CASE 18507 Published on 27.03.2024

Staged angioplasty and stenting for post-transplant renal artery stenosis

Section

Interventional radiology

Case Type

Clinical Case

Authors

A. L. Periyakaruppan, Ramesh M., Mohamed Rafi Kathar Hussain

Department of Imaging Science and Interventional Radiology, Tamil Nadu Government Multi Super Speciality Hospital, Chennai, India

Patient

40 years, female

Categories
Area of Interest Interventional vascular, Kidney ; No Imaging Technique
Clinical History

A 40-year-old female, a known case of chronic kidney disease stage IV, post-1-year renal transplant, came with complaints of fever on and off, breathlessness, and a productive cough for the past 1 week. Serum creatinine increased from 1.8 to 2.2. Doppler USG of the transplanted kidney is abnormal and diagnosed as graft dysfunction.

Imaging Findings

The renal angiogram was done, showing the main and accessory transplant renal arteries arising from the right external iliac artery. Both arteries show features of renal artery stenosis in the proximal post-anastomotic segment (Figure 1). Ballon dilatation of both arteries was done (Figures 2 to 5) using a 3x15mm non-compliant balloon. Patients continue the further management with the nephrologist. After two months, the patient came with worsening symptoms. The right CFA was punctured using the retrograde Seldinger technique, a 6F sheath was placed, and the right external iliac angiogram showed focal short segment significant stenosis involving the main transplant renal artery (Figure 6). 0.014 tram-track wire is passed distal to the stenosis (Figure 7). 4x16mm size balloon-mounted metallic stent is placed at the site of stenosis (Figures 8 and 9). The post-procedure angiogram shows good opposition of stent and good contrast flow to the renal graft (Figure 10). The sheath was removed with manual compression.

Discussion

Transplant renal artery stenosis (TRAS) is a dreadful complication after renal transplant, seen in 1% to 23% of renal transplant recipients [1]. More common in cadaveric transplants, with a reported incidence of 4.1% to 6.5%, compared to live donor transplants (0.3% to 1.7%) [2–4]. It can occur at any time during the immediate post-operative or in the follow-up. Early stenosis is due to traumatic injury, arterial kinking, or manipulation during vessel harvesting [5]. Late diffuse stenosis is due to immune-related endothelial damage or the progression of underlying atherosclerosis [6]. TRAS can occur proximal to the stenosis (called pre-anastomotic), or occur within the donor artery (called post-anastomotic stenosis) [7]. TRAS can be evaluated by invasive and non-invasive methods. Non-invasive methods are colour Doppler ultrasonogram and MR angiography. Colour Doppler features are peak systolic velocity of more than 2 m/sec, gradient velocity ratio between stenotic and pre-stenotic segments of more than 2:1, resistive index <0.5, and marked spectral broadening with turbulent flow distal to the stenosis [8–11]. The disadvantages of colour Doppler USG are operator-dependent and sometimes challenging due to bowel gas and patient body habitus. MRA is 100% sensitive and 7598% specific for greater than 50% TRAS [12–14]. MRA in addition to the evaluation of arterial anastomosis, also helps to evaluate iliac arteries and renal veins [7]. Disadvantages of MRI include a long waiting list and cost. Invasive methods are catheter-directed angiography and intravascular USG (IVUS). Catheter-directed angiography is the “gold standard” for evaluating TRAS. The intra-arterial pressure gradient can be measured across the stenotic segments. IVUS will show a significant luminal reduction at the level of stenosis. Regarding the treatment, revision surgery is considered when there is an unsuccessful angioplasty or severe complicated stenosis, but the associated risks are ureteral injury and graft loss (15% to 20%) [15]. Endovascular management is the best treatment of choice, with a technical success rate ranging from 89% to 100% [6,8,16,17] and a very minimal complication rate ranging from 0 to 5.5% [6,15–17]. Restenosis is the main complication in endovascular treatment, which is about 10% to 56% in the case of balloon angioplasty and significantly reduced in the case of the stent by about 5.5% to 20% [2,4,18]. The graft survival rate after TRAS treated with angioplasty with or without stenting is similar to TRAS-free transplant patients [17,19,20]. There is a significant decline in blood pressure, a reduction of a number of anti-hypertensive drugs, and a drop in creatinine value is seen in TRAS patients after endovascular procedure [21].

Differential Diagnosis List
Post-transplant renal artery stent
Renal vein stenting
Renal foreign body
External iliac artery stenting
External iliac vein stenting
Final Diagnosis
Post-transplant renal artery stent
Case information
URL: https://eurorad.org/case/18507
DOI: 10.35100/eurorad/case.18507
ISSN: 1563-4086
License