CASE 18507 Published on 27.03.2024

Teaching Case

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 ;

Procedure Angioplasty, Stents ; No Special Focus ;

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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.

Differential Diagnosis List

Post-transplant renal artery stent

Renal vein stenting

Renal foreign body

External iliac artery stenting

External iliac vein stenting

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 75–98% 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].

References

[1] Fervenza FC, Lafayette RA, Alfrey EJ, Petersen J (1998) Renal artery stenosis in kidney transplants. Am J Kidney Dis 31(1):142-8. doi: 10.1053/ajkd.1998.v31.pm9428466. (PMID: 9428466)

[2] Patel NH, Jindal RM, Wilkin T, Rose S, Johnson MS, Shah H, Namyslowski J, Moresco KP, Trerotola SO (2001) Renal arterial stenosis in renal allografts: retrospective study of predisposing factors and outcome after percutaneous transluminal angioplasty. Radiology 219(3):663-7. doi: 10.1148/radiology.219.3.r01jn30663. (PMID: 11376251)

[3] Rengel M, Gomes-Da-Silva G, Incháustegui L, Lampreave JL, Robledo R, Echenagusia A, Vallejo JL, Valderrábano F (1998) Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach. Kidney Int Suppl 68:S99-106. doi: 10.1038/sj.ki.4490573. (PMID: 9839292)

[4] Sankari BR, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick AC (1996) Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control. J Urol 155(6):1860-4. doi: 10.1016/s0022-5347(01)66030-0. (PMID: 8618274)

[5] Becker BN, Odorico JS, Becker YT, Leverson G, McDermott JC, Grist T, Sproat I, Heisey DM, Collins BH, D'Alessandro AM, Knechtle SJ, Pirsch JD, Sollinger HW (1999) Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease. Clin Transplant 13(4):349-55. doi: 10.1034/j.1399-0012.1999.130412.x. (PMID: 10485378)

[6] Pappas P, Zavos G, Kaza S, Leonardou P, Theodoropoulou E, Bokos J, Boletis J, Kostakis A (2008) Angioplasty and stenting of arterial stenosis affecting renal transplant function. Transplant Proc 40(5):1391-6. doi: 10.1016/j.transproceed.2008.04.016. (PMID: 18589114)

[7] Rajan DK, Stavropoulos SW, Shlansky-Goldberg RD (2004) Management of transplant renal artery stenosis. Semin Intervent Radiol 21(4):259-69. doi: 10.1055/s-2004-861560. (PMID: 21331137)

[8] Marini M, Fernandez-Rivera C, Cao I, Gulias D, Alonso A, Lopez-Muñiz A, Gómez-Martínez P (2011) Treatment of transplant renal artery stenosis by percutaneous transluminal angioplasty and/or stenting: study in 63 patients in a single institution. Transplant Proc 43(6):2205-7. doi: 10.1016/j.transproceed.2011.06.049. Erratum in: Transplant Proc 44(1):309. (PMID: 21839234)

[9] Sharma S, Potdar A, Kulkarni A (2011) Percutaneous transluminal renal stenting for transplant renal artery stenosis. Catheter Cardiovasc Interv 77(2):287-93. doi: 10.1002/ccd.22758. (PMID: 20824760)

[10] Taylor KJ, Morse SS, Rigsby CM, Bia M, Schiff M (1987) Vascular complications in renal allografts: detection with duplex Doppler US. Radiology 162(1Pt1):31-8. doi: 10.1148/radiology.162.1.3538150. (PMID: 3538150)

[11] Snider JF, Hunter DW, Moradian GP, Castaneda-Zuniga WR, Letourneau JG (1989) Transplant renal artery stenosis: evaluation with duplex sonography. Radiology 172(3Pt2):1027-30. doi: 10.1148/172.3.1027. (PMID: 2672101)

[12] Luk SH, Chan JH, Kwan TH, Tsui WC, Cheung YK, Yuen MK (1999) Breath-hold 3D gadolinium-enhanced subtraction MRA in the detection of transplant renal artery stenosis. Clin Radiol 54(10):651-4. doi: 10.1016/s0009-9260(99)91085-1. (PMID: 10541389)

[13] Ferreiros J, Mendez R, Jorquera M, Gallego J, Lezana A, Prats D, Pedrosa CS (1999) Using gadolinium-enhanced three-dimensional MR angiography to assess arterial inflow stenosis after kidney transplantation. AJR Am J Roentgenol 172(3):751-7. doi: 10.2214/ajr.172.3.10063875. (PMID: 10063875)

[14] Chan YL, Leung CB, Yu SC, Yeung DK, Li PK (2001) Comparison of non-breath-hold high resolution gadolinium-enhanced MRA with digital subtraction angiography in the evaluation on allograft renal artery stenosis. Clin Radiol 56(2):127-32. doi: 10.1053/crad.2000.0590. (PMID: 11222071)

[15] Merkus JW, Huysmans FT, Hoitsma AJ, Buskens FG, Skotnicki SH, Koene RA (1993) Renal allograft artery stenosis: results of medical treatment and intervention. A retrospective analysis. Transpl Int 6(2):111-5. doi: 10.1007/BF00336655. (PMID: 8447924)

[16] Beecroft JR, Rajan DK, Clark TW, Robinette M, Stavropoulos SW (2004) Transplant renal artery stenosis: outcome after percutaneous intervention. J Vasc Interv Radiol 15(12):1407-13. doi: 10.1097/01.RVI.0000141338.62574.F4. (PMID: 15590798)

[17] Su CH, Lian JD, Chang HR, Wu SW, Chen SC, Tsai CF, Kao PF, Ueng KC (2012) Long-term outcomes of patients treated with primary stenting for transplant renal artery stenosis: a 10-year case cohort study. World J Surg 36(1):222-8. doi: 10.1007/s00268-011-1312-3. (PMID: 22045446)

[18] Hurst FP, Abbott KC, Neff RT, Elster EA, Falta EM, Lentine KL, Agodoa LY, Jindal RM (2009) Incidence, predictors and outcomes of transplant renal artery stenosis after kidney transplantation: analysis of USRDS. Am J Nephrol 30(5):459-67. doi: 10.1159/000242431. (PMID: 19776559)

[19] Valpreda S, Messina M, Rabbia C (2008) Stenting of transplant renal artery stenosis: outcome in a single center study. J Cardiovasc Surg (Torino) 49(5):565-70. (PMID: 18670375)

[20] Salvadori M, Di Maria L, Rosati A, Larti A, Piperno R, Becherelli P, Bandini S, Biagini M, Filocamo MT, Gallo M, Bertoni E (2005) Efficacy and safety of Palmaz stent implantation in the treatment of renal artery stenosis in renal transplantation. Transplant Proc 37(2):1047-8. doi: 10.1016/j.transproceed.2004.12.229. (PMID: 15848618)

[21] Touma J, Costanzo A, Boura B, Alomran F, Combes M (2014) Endovascular management of transplant renal artery stenosis. J Vasc Surg 59(4):1058-65. doi: 10.1016/j.jvs.2013.10.072. (PMID: 24365122)

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