Challenging Case

Dissection by Cutting Balloon Angioplasty

By Duccio Baldari, MD; Cezar S. Staniloae, MD; Khashayar Sehhat, MD; John T. Coppola, MD; and Tak W. Kwan, MD
 

CASE PRESENTATION
A 63-year-old white male was referred for renal angiography for difficult-to-control hypertension. The patient, a cigarette smoker, presented with chronic obstructive pulmonary disease, chronic stable angina, and one functional kidney due to right kidney atresia. He was on angiotensin receptor blockers, beta blockers, and diuretics. Despite increased medication, his blood pressure remained in the 210/105 range. The patient’s BUN was 17 mg/dl, and his creatinine was 1.5 mg/dl.

INITIAL ANGIOGRAPHIC FINDINGS
Noninvasive work-up, including renal ultrasound and a magnetic resonance angiography (MRA) revealed asymmetric kidney size with a shrunken right kidney and stenosis of the left renal artery. A renal angiogram showed 75% ostial right renal artery stenosis and a gradient of 60 mm Hg across the stenotic segment of the right renal artery. The left kidney was small and had rudimentary blood supply.

At this point, the surgical option was considered. The patient’s pulmonary situation and his chronic stable angina, however, would have put him at moderate risk for a major vascular surgery; consequently, the percutaneous approach was preferred.

With the goal of easing the management of the arterial hypertension, and eventual prevention of deterioration of renal function, it was decided to treat the left renal artery stenosis. The patient underwent PTA and stenting of the left renal artery, which yielded a favorable result.

This procedure was considered to be a high-risk intervention in light of the single functional kidney. In fact, in this setting, the occurrence of contrast-induced renal failure or vascular complications can be potentially devastating. Standard follow-up Doppler ultrasonography was planned for 1 week, 1 month, 3 months, and 6 months after the procedure.

Three months later, the follow-up Doppler study showed increased flow velocity, indicating possible restenosis. Notably, no significant change in blood pressure was observed during this period. The antihypertensive regimen remained the same. The patient was then referred for repeat renal angiography.
REPEAT ANGIOGRAPHY AND
ANGIOPLASTY COMPLICATIONS
At this time, the risks of repeat angiography versus those of surgery were considered in view of the presence of a single functioning kidney.

Significant in-stent restenosis was discovered by selective renal angiography of the left renal artery. The artery was engaged using a 7F internal mammary guiding catheter. Two thousand units of unfractionated heparin was given intravenously.

A 4.0-cm X 10-mm cutting balloon (Boston Scientific Corporation, Natick, MA) was inflated inside the stent. The cutting balloon is an over-the-wire or monorail balloon with three or four atherotomes mounted longitudinally around the balloon. The balloon must be inflated with slow increments of pressure, and the rate of burst is only 10 atm. During this inflation, the patient reported back and flank pain. These symptoms could indicate overstretching, perforation, or dissection of the renal artery. Subsequent angiography revealed a severe dissection with dye extravasation distal to the stent (Figure 1).
The angiographic appearance was consistent with a partial rupture with contained dye extravasation. The patient became slightly tachycardic, his blood pressure remained stable, and he did not appear to be diaphoretic or pale.This complication was probably caused by the slippage of the cutting balloon and “watermelon seed” effect with subsequent injury at the bend site of the slightly tortuous renal artery. The slippage of the balloon is a frequent occurrence in restenotic lesions due to their fibroproliferative nature.

HOW WOULD YOU PROCEED?
1. Does emergency surgery become necessary at this point?
2. Are covered stent grafts a viable option?
3. Is prolonged balloon inflation with stenting the best option?

COURSE OF ACTION
This complication was probably caused by the slippage of the cutting balloon and “watermelon seed” effect, with subsequent injury at the bend site of the slightly tortuous renal artery. The slippage of the balloon is a frequent occurrence in restenotic lesions due to their fibroproliferative nature.

Although emergency surgery was considered at this time, the priority now was to restore patency of the renal artery and to seal the dissection. Other options are the use of stent grafts covered with either PTFE or harvested vein, and prolonged balloon inflation. In the case of massive hemorrhage, one may have to face the difficult decision of having to sacrifice the organ with coil or gelfoam embolization. The use of covered stent grafts may represent a challenging task due to the tortuous nature of the vessel. We considered using a PTFE-covered stent was considered, but in light of the lack of data on long-term patency in renal arteries, we decided on a more conventional approach.

We performed prolonged balloon inflation with a 6.0-cm X 20-mm Slalom balloon (Cordis Endovascular, a Johnson & Johnson Company, Miami, FL) for 5 minutes in the dissected area. We then covered this area with an overlapping 6.0-cm X 15-mm Genesis stent (Cordis Endovascular). Finally, the overlap area was inflated with a 6.0-cm X 20-mm balloon and normal flow was reestablished (Figure 2).

OUTCOME
The patient was kept on 0.1 mcg/kg per minute of fenoldopam (Corlopam; Neurex Corporation, Menlo Park, CA) for 6 hours. He was sent home the next day and was prescribed 325 mg PO gD aspirin and 75 mg PO gD clopidogrel (Plavix; Sanofi/Bristol Myers Squibb, Inc., New York, NY). His prescribed antihypertensive regimen included a diuretic, beta-blockers, and an angiotensin receptor blocker. At discharge, the patient’s blood pressure was restored to 170/80.

DISCUSSION
Complications during percutaneous transluminal renal angioplasty (PTRA) are not uncommon, and they can be potentially lethal. These complications include renal artery rupture, aortic dissection at the renal artery level, flow-limiting renal artery dissection, and renal artery embolism. The rate of complication during PTRA varies among published reports. In a series of 1,118 patients who underwent PTRA, Kidney et al reported a 2% need of reparative renal surgery.

Two large series2,3 and two large metanalysis4,5 including 2,994 procedures, revealed a complication rate that varied from 12%4 to 36%.2 In these papers, the combined incidence of complications requiring renal salvage surgery was 1%; in individual series, however, the incidence was as high as 2.5%.

The most commonly reported complication was groin hematoma. Short-term morbidity and mortality was related to renal artery perforation, acute renal failure, and cholesterol embolization.

PTRA is the preferred treatment of renal artery stenosis. Despite initial success rates as high as 99%,6 the long-term effect is limited by a significant restenosis rate. Data on the treatment of in-stent restenosis are scarce.

The use of cutting balloons in this setting seems appealing, but one should be aware of potential complications. Moreover, this device was originally developed for use in coronary arteries and has not yet been extensively studied for use in renal arteries.

The cutting balloon has been extensively studied for coronary applications in which the incidence of dissection or perforation seems to be acceptably low. It is possible that due to the different anatomical configuration of the renal arteries, as opposed to the coronary arteries, this device might not be suitable to the peripheral vascular district.

Duccio Baldari, MD, is a cardiology fellow at St. Vincent Catholic Medical Center in New York City and an Instructor of Medicine at New York Medical College. He does not hold a financial interest in any of the products or companies mentioned herein. Dr. Baldari may be reached at (212) 604-2235; ducciob@aol.com.

Cezar S. Staniloae, MD, is a cardiology fellow at St. Vincent Catholic Medical Center, New York. He does not hold a financial interest in any of the products or companies mentioned herein. Dr. Staniloae may be reached at (212) 604-2235; cstaniloae@aol.com.

Khashayar Sehhat, MD, is a cardiology fellow at St. Vincent Catholic Medical Center in New York City and an Instructor in Medicine at New York Medical College. He does not hold a financial interest in any of the products or companies mentioned herein. Dr. Sehhat may be reached at (212) 604-2235.

John T. Coppola, MD, is Chief of the Cardiac Catheterization Laboratory at Saint Vincent Catholic Medical Center, New York City and Associate Professor of Medicine at New York Medical College. He does not hold a financial interest in any of the products or companies mentioned herein. Dr. Coppola may be reached at (212) 604-2235.

Tak W. Kwan, MD, is Attending Cardiologist at St. Vincent Catholic Medical Center in New York City and Associate Professor of Medicine at the State University of New York, Downstate Medical Center, New York City. He does not hold a financial interest in any of the products or companies mentioned herein. Dr. Kwan may be reached at (212) 334-8463; kwancardio@aol.com.

1. Kidney DD, Deutsch LS. The indications and results of percutaneous transluminal angioplasty and stenting in renal artery stenosis. Semin Vasc Surg. 1996;9:188-97.
2. Beek FJ, Kaatee R, Beutler JJ, et al. Complications during renal artery stent placement for atherosclerotic ostial stenosis. Cardiovasc Intervent Radiol. 1997;20:184-190.
3. Bakker J, Goffette PP, Henry M, et al. The Erasme study: a multicenter study on the safety and technical results of the Palmaz stent used for the treatment of atherosclerotic ostial renal artery stenosis. Cardiovasc Intervent Radiol. 1999;22:468-474.
4. Leertouwer TC, Gussenhoven EJ, Bosch JL, et al. Stent placement for renal arterial stenosis: where do we stand? A meta-analysis. Radiology. 2000;216:78-85.
5. Martin LG. Renal revascularization using percutaneous balloon angioplasty for fibromuscular dysplasia and atherosclerotic disease. In: Calligaro KD, Dougherty MJ, eds. Modern Management of Renovascular Hypertension and Renal Salvage 1st ed. Baltimore MD: Williams and Wilkins, 1996:125-144.
6. Ivanovic V, McKusick MA, Johnson CM, et al. Renal artery stent placement: complications at a single tertiary care center. J Vasc Interv Radiol. 2003;14:217-225.

 

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