Case presentation

A 71-year-old woman with a history of hypertension, dyslipidemia, and remote tobacco abuse presents with difficult to control blood pressure despite four medications. Diagnosed with essential hypertension many years earlier, her blood pressure had been well-controlled on an angiotensin-receptor blocker (valsartan) and a diuretic (hydrochlorothiazide). Over the past 6 to 8 months, her blood pressure progressively increased with systolic pressures in the 180 mmHg range and diastolic pressures exceeding 90 mmHg despite the addition of adequate doses of beta-blocker (atenolol) and a calcium channel blocker (amlodipine). Her physical examination was notable only for a blood pressure of 160/90 mmHg. Routine laboratory studies, including renal function, were normal, with a creatinine of 1.1 mg/dL. Suspicious of renal artery stenosis, her physician ordered a magnetic resonance angiogram (MRA) of her renal arteries. This revealed a severe stenosis of the left renal artery and she was referred for renal angiography and intervention.

Catheterization

Selective right and left renal angiography was performed using a 6 French, 55 cm long internal mammary guide catheter. Selective right renal angiography uncovered a nonsignificant stenosis of the ostium (Figure 53-1 and Video 53-1). Left renal angiography confirmed the findings on MRA with a very severe eccentric stenosis of the proximal segment of the left renal artery apparent (Figure 53-2 and Video 53-2).

FIGURE 53-1 Selective right renal angiogram demonstrating a mild stenosis of the proximal segment of the right renal artery (arrow).

FIGURE 53-2 Selective left renal angiogram revealing a severe stenosis in the left renal artery (arrow).

The decision was made to perform left renal artery stenting and, after administration of a bolus followed by an infusion of bivalirudin, the operator positioned a 0.014 inch floppy-tipped guidewire in the left renal artery and performed predilatation with a 4.5 mm diameter by 15 mm long rapid exchange balloon (Figures 53-3, 53-4). After balloon predilatation, a 6.0 mm diameter by 15 mm long bare-metal stent on a rapid exchange, a 0.014 inch platform was positioned in the proximal segment of the left renal artery (Figure 53-5). The stent was deployed by inflating the balloon to 10 atmospheres of pressure. An excellent angiographic result was obtained (Figure 53-6 and Video 53-3).

FIGURE 53-3 Balloon inflation in the left renal artery.

FIGURE 53-4 Result after balloon inflation in the left renal artery.

FIGURE 53-5 Position of the stent in the left renal artery.

FIGURE 53-6 Post-stent result in the left renal artery.

Postprocedural course