Renal Artery Stenting

FINAL (2)-150.png
BackTABLEfinal-2tone_edited.png

© 2020 by Backtable. All rights reserved.

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

Overview

Overview content for Renal Artery Stenting is not yet available.

Pre-Procedure

Indications:
Renal artery stenosis with:
• Refractory hypertension and/or declining renal function
• Optimal medical therapy
Renal artery dissection
Hemodynamically significant stenoses:
• 70% stenosis on angiography
• Pressure gradient > 20 mmHg

Contraindications:
• Uncorrectable coagulopathy
• Long segment renal artery occlusion
• Diffuse small branch stenoses
• Renal artery <4 mm
• Small atrophic kidney - suggests nonfunction

Preprocedural evaluation:
H&P - patient selection is critical
• Age of onset of hypertension
• Detailed evaluation of hypertension treatment and current medications
• Comorbidities
Imaging:
• Renal arterial Doppler: > 180 cm/s, tardus parvus waveform
• CTA/MRA
• Captopril renal scan
• Angiogram: reserved for potential planned intervention
Labs: Platelets, INR, GFR

Procedure

Medications:
• Hold antihypertensives day of procedure
• Antibiotic: cefazolin 1 gram IV
• Heparin or bivalirudin

Access:
• May depend on operator comfort and angle of renal artery
• Femoral, brachial and radial
Place 6-Fr guide sheath
• IMA
• Renal standard curve, renal double curve
Place sheath at level of renal artery but directed away from ostium
Advance crossing catheter and 0.014" crossing wire ~ 2 cm outside of guide catheter
Direct guide catheter toward ostium
Identify origin of vessel and degree of stenosis:
• Preprocedural planning
• Inject CO2 or contrast to delineate origin
Pull 0.014" wire into crossing catheter and then pull crossing catheter into sheath
Carefully cross lesion with 0.014" wire and crossing catheter
Average diameter of renal artery is 5-7 mm
Predilate
• Undersize balloon relative to artery
• Fully expand balloon
• Avoid higher pressure if balloon expanded at lower atmosheres
Balloon-expandable stents
• Width 5-7 mm
• Length 10-20 mm
• Cover entire length of stenosis
• Land proximal segment of stent 1-2 mm in the aorta
• Can use stent balloon to flare ostium by reinflating at higher pressure
Remove balloon - completely deflate or balloon could move stent
Final angiogram

Post-Procedure

Complications:
• Renal artery embolization with infarction of renal parenchyma
• Guidewire perforation of renal artery with subcapsular, perirenal or perirenal hematoma
• Rupture of renal artery by balloon or stent
• Misplacement of stent and dislodgement of stent
• Stent restenosis, thrombosis and infection
• Renal artery pseudoaneurysm
• Acute renal failure
• Access site complications
• Major complications < 5%

Postprocedural care
• Bed rest depends on sheath size and potential arterial closure device
• Overnight observation with monitoring of blood pressure, urine output, and follow up creatinine level
• Hypotension following stenting common
• Continue IV fluids
• Aspirin 325 mg PO daily
• Most operators will also initiate plavix 75 mg PO for at least 1 month

Follow-up
• Renal duplex 2 weeks following procedure to establish baseline
• Duplex Q6 months thereafter

Outcomes:
• 66% of HTN patients will see improved BP control and/or reduced antihypertensive medication need
• 75% of renal insufficiency patients will see plateau or improvement in GFR

Related Procedures

No related procedures.

 

References

[1] Prince M, Tafur JD, White CJ. When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis?. JACC Cardiovasc Interv. 2019;12(6):505‐517. doi:10.1016/j.jcin.2018.10.023
[2] Cooper CJ, Murphy TP, Cutlip DE, et al. Stenting and medical therapy for atherosclerotic renal-artery stenosis. N Engl J Med. 2014;370(1):13‐22. doi:10.1056/NEJMoa1310753
[3] Judd E, Calhoun DA. Apparent and true resistant hypertension: definition, prevalence and outcomes. J Hum Hypertens. 2014;28(8):463‐468. doi:10.1038/jhh.2013.140
[4] Stathopoulos JA. Modification of the No-Touch Technique during Renal Artery Stenting. Case Rep Vasc Med. 2013;2013:516267. doi:10.1155/2013/516267
[5] Egan BM, Zhao Y, Axon RN, Brzezinski WA, Ferdinand KC. Uncontrolled and apparent treatment resistant hypertension in the United States, 1988 to 2008. Circulation. 2011;124(9):1046‐1058. doi:10.1161/CIRCULATIONAHA.111.030189
[6] Funaki B. Renal ostial angioplasty and stenting. Part 1: the routine procedure. Semin Intervent Radiol. 2009;26(1):74‐81. doi:10.1055/s-0029-1208385
[7] Funaki B. Renal ostial angioplasty and stenting. Part 2: pitfalls and complications. Semin Intervent Radiol. 2009;26(2):151‐158. doi:10.1055/s-0029-1222460
[8] Rocha-Singh K, Jaff MR, Lynne Kelley E; RENAISSANCE Trial Investigators. Renal artery stenting with noninvasive duplex ultrasound follow-up: 3-year results from the RENAISSANCE renal stent trial. Catheter Cardiovasc Interv. 2008;72(6):853‐862. doi:10.1002/ccd.21749
[9] Goldstein JA, Kolluri R, Rocha-Singh K. Technical Considerations for Renal Artery Stenting. Vascular Disease Management. 2006;3(3)

Join The Discussion

 

Demos

Demos are not yet available for this procedure.

Please check back soon.

CO2 Angiography

Dr. Craig Walker demonstrates CO2 angiography and discusses the advantages of this imaging technique. He then shows the tools and technique to image an iliac artery.

TRA For Addressing Renal Artery Stenosis

Changes in renal artery stenting (RAS) techniques that have established RAS as a safe and effective alternative approach for TFA.

Transradial Approach to Renal Artery Angioplasty and Stenting

At Mount Sinai Hospital in New York City, Interventional Radiologists, Dr. Robert Lookstein and Dr. Vivek Patil perform transradial access for renal artery stenting in a patient with hypertension.

 

Tools

Tools are not yet available for this procedure.

Please check back soon.

 

Literature

Literature is not yet available for this procedure.

Please check back soon.

Seminars in Interventional Radiology (Mar 2009)

Renal Ostial Angioplasty and Stenting. Part 1: The Routine Procedure

This article is the first in a two-part series dedicated to performing the "typical" procedure.

Seminars in Interventional Radiology (Jun 2009)

Renal Ostial Angioplasty and Stenting. Part 2: Pitfalls and Complications

Renal ostial stenting (ROS) is the most common endovascular intervention for treatment of atherosclerotic renal artery stenosis. This article is the second in a two-part series dedicated to pitfalls and complications of renal stenting.

New England Journal of Medicine (Nov 2009)

Revascularization Versus Medical Therapy for Renal Artery Stenosis

Evaluation of the clinical benefit of revascularization in patients with atherosclerotic renovascular disease. Patients in the study underwent revascularization and received medical therapy or received medical therapy alone.

 

Podcasts

Podcasts are not yet available for this procedure.

Please check back soon.

 

Blog Articles

Blog articles are not yet available for this procedure.

Please check back soon.