Endovascular Treatment of Renal Artery Bifurcation Stenoses with Branched Balloon Angioplasty
Article Outline
An 85-year-old man with left sided single kidney presented with end-stage renal failure after an acute intestinal bleeding. A complex bifurcational stenoses distally to a 6 months previously implanted ostial stent in the left renal artery was found on duplex imaging and angiogram. These two de-novo stenoses in the distal main renal artery and the proximal segment of the lower branch were simultaneously treated with a ultra-low profile, monorail bifurcation balloon catheter system (Avion Bifurcation RX2™, Invatec, Italy) that consists of a main vessel balloon (20/3.5
mm) and a side vessel balloon (20/2.75mm). One day and three months postinterventionally, duplex ultrasound demonstrated no recurrent stenoses. Bifurcation balloon catheter systems for complex renal artery stenosis are discussed.
Keywords: Renal artery stenosis, Bifurcation balloon catheters, End-stage renal disease
Introduction
Ostial or proximal main renal artery stenoses are routinely treated by percutaneous transluminal renal angioplasty and stent placement (PRI).1, 2, 3 Balloon dilatation of more distally located lesions involving the renal artery bifurcation is more critical, and can result in occlusion of a segmental branch artery by shifting atherosclerotic material into the non exposed lumen.4, 5 Safe dilatation of bifurcation stenoses using the kissing balloon technique has been described for the terminal aorta, common iliac arteries, coronary arteries and the popliteal artery bifurcation.5, 6, 7, 8 The kissing balloon technique has also been reported for the renal artery with balloons and guide wires directed independently to the bifurcation lesion and by use of large sized guide catheters.9, 10 We here describe the kissing balloon technique using an ultra-low profile, double-balloon system (Avion Bifurcation RX2™) offering safe, fast and easy handling for endovascular treatment of bifurcation renal artery lesions.
Material and Methods
An 85-year-old patient presented with acute renal failure following severe intestinal bleeding. He presented with a history of bilateral renal artery stenosis treated by angioplasty and stenting with improvement of renal function 6 months before. Currently renal failure persisted despite transfusion of blood, and the patient remained dependent on hemodialysis after intestinal bleeding. Renal duplex ultrasound imaging revealed a complex high-grade renal artery stenosis on the left side distally to the stent involving the lower branch and the origin of the upper segmental branch artery. The right renal artery was free of recurrent stenosis, but the kidney was shrunken. Although there was an end stage renal disease situation after a hemorrhagic shock, we intended to improve renal function by a repeat angioplasty.11
PTA technique
Left sided femoral approach was used, a long 6-F renal sheath catheter (Terumo, Tokyo, Japan) was introduced, and unfractionated standard heparin (Liquemine™; 5.000 IU) was given intraarterially. Selective renal angiography confirmed a significant bifurcation renal artery stenosis (Fig. 1a).
Fig. 1
a. Digital subtraction angiography reveals high-grade, complex stenosis at the renal bifurcation (black arrow) and in the lower side branch (white arrow). b. Simultaneous inflation of the double balloons in place (Avion Bifurcation RX2®, Invatec). Main vessel balloon (3.5
mm) placed in the main renal and lower branch renal artery (black arrow); side vessel balloon (2.75mm) positioned in the main and upper side branch renal artery (white arrow). c. Inflation of the double balloon more distally to treat a stenosis in the lower branch (white arrow) with the main vessel balloon (3.5mm). d. Result after withdraw of the balloons with both guide wires remaining in place.
A 5 French cobra-shaped catheter (Terumo, Tokyo, Japan) was used to track the upper segmental artery, which branched off close to the stenosis, and a 0.014-inch guide wire was positioned beyond the eccentric stenosis in the distal upper segmental artery. After removal of the cobra catheter, a monorail balloon catheter system (Avion Bifurcation RX2™, Invatec, Italy) that consists of a main vessel balloon (20/3.5mm) and a side vessel balloon (20/2.75mm) (Fig. 2), was introduced over the guide wire. The balloon catheter system was positioned beyond the sheath within the renal artery and a second 0.014-inch guide wire, advanced through the side vessel balloon, was manoeuvred into the lower side branch. The balloons were simultaneously moved forwards to cover the bifurcation. Angioplasty was performed by inflating both balloons simultaneously. Balloons were primarily sized to the diameter of the main renal artery to avoid eccentric stress on the arterial wall caused by positioning two parallel balloons (Fig. 1b and c). The result was evaluated by flush angiography after withdrawing the balloon catheter from the renal artery with the guide wires both remaining in place. Final angiogram showed successful dilation with less than 30% residual stenosis and improved arterial blood flow to the kidney (Fig. 1d). We used 45ml of Iohexol (Accupaque™, GE Healthcare, U.K.) for angiographic imaging.
Fig. 2
Ultra-low profile balloon with 0.017-inch tip entry profile. Main vessel balloon with 2 markers (arrow) and side branch balloon with 3 markers (solid arrow).
Follow-up
Hemodynamic changes assessed by duplex sonography are shown in the Table 1. The diuresis increased after PRI (preinterventional 900ml/day to postinterventional 1500ml/day). Creatinine stabilized at 6.8mg/dl despite reduction of the dialysis from three times to twice per week. Measured creatinine clearance increased from 6ml/min to 11ml/min.
Table 1. Hemodynamic parameters of the left renal artery assessed by Duplex sonography before and after percutaneous renal intervention
| Early Systolic Peak | Reno-aortal Index | Reno-renal Index | Peak Systolic Velocity (m/sec) | End Diastolic Velocity (m/sec) | Resistance Index | |
|---|---|---|---|---|---|---|
| Pre-interventional | no | 4.80 | 2.30 | 3.90 | 0.37 | 0.85 |
| 1 Day Post-interventional | yes | 3.31 | 1.12 | 2.02 | 0.28 | 0.85 |
| 3 Months Post-interventional | yes | 2.02 | 1.43 | 1.74 | 0.50 | 0.71 |
Discussion
The kissing balloon technique has been successfully used in a variety of vascular domains in the past.5, 6, 7, 8, 9, 10 Kissing balloon inflation is defined as the simultaneous inflation of two balloons each positioned in one branch of the bifurcation.6 Using the kissing-balloon technique, atherosclerotic plaque material is trapped and compressed between the two balloons, which are inflated simultaneously. Refinements in balloon catheter technology has not only extended the spectrum of applications in coronary interventions, but also facilitated the use in small sized peripheral arteries.12 The application of low profile catheters allows the use of smaller sheaths, avoiding bleeding complications at the puncture site, patients with peripheral vascular disease are particularly prone for. Low profile of catheters also facilitate re-intervention, enabling passage of previously deployed stents, but also decrease risk of distal embolisation that jeopardizes the benefit of endovascular renal revascularization. In the present case, the indication for re-intervention was based on a functional single kidney situation and renovascular disease. The bifurcation balloon system was very well applicable because of the distal location of the stenosis at the renal artery bifurcation, for which this system shows a adequate sizing.
In patients with end-stage renal disease the need of chronic dialysis can often be delayed by angioplasty.11 Temporary dialysis dependence might be limited when renal arteries are revascularised with subsequent improvement of renal function.11
Although the intervention may not have contributed to the reduction of dialysis, which was rather due to spontaneous recovery, this case demonstrates the technical feasibility of renal bifurcation catheter system. Using a bifurcation balloon system, we only had to pass the ostium of the renal artery once with the catheter system and could potentially reduce the risk of peripheral embolisation. This device offers an extension of low-profile bifurcational systems, which may be of reasonable use in complex renovascular disesase with renal failure.
This ultra-low profile double balloon catheter system has a good crossing profile, and is a useful adjunct to the interventional armamentarium allowing safe treatment of lesions at the bifurcation of the renal artery.
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PII: S1533-3167(06)00069-0
doi:10.1016/j.ejvsextra.2006.07.003
© 2006 Elsevier Ltd. All rights reserved.
