Combined Endovascular and Surgical Treatment in Takayasu's Arteritis-Induced Renal Artery Stenosis (TARAS) Complicated with Vein–Graft Aneurysm of the Aorto-Renal By-pass

Article Outline

• Abstract
• Case study
• Discussion
• Conflict of Interest/Funding
• References
• Copyright

Abstract 

Introduction

We report a case of combined endovascular and surgical treatment in a patient with Takayasu's arteritis-induced bilateral renal artery occlusion.

Report

A 38-year-old women suffering from Takayasu's arteritis-induced renal artery stenosis (TARAS) was referred to our centre. The patient also complained of claudication and of symptoms related to ostial stenosis of superior mesenteric artery. She was treated with a sequence of open and endovascular procedures and is now on a 3-year uneventful follow-up.

Discussion

To our knowledge, this is the first case of combined endovascular and surgical treatment of TARAS performed simultaneously in one operative procedure that has ever been reported in the literature.

Keywords: Takayasu's arteritis, Renal artery angioplasty, Vein–graft aneurysm, Endovascular treatment, Drug-eluting stents

The incidence of Takayasu's arteritis-induced renal artery stenosis (TARAS) among patients varies from 28% to 75%, depending on reports.¹ We present our experience from a successful treatment of Takayasu's disease-related bilateral renal artery occlusion and mid-term follow-up.

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Case study 

A 38-year-old woman suffering from hypertension due to TARAS was referred to our centre. The onset of the patient's symptoms consisted of malaise, arthritis and fatigue, but the patient soon developed symptoms of arterial obstruction in addition to hypertension resistant to combined drug therapy. The patient also suffered from intermittent claudication due to left common iliac artery (LCIA) stenosis. At the time of referral, the patient was in a remission phase of the disease being under combined therapy (immunosuppressive agents and corticosteroids). Digital subtractive angiography (DSA) revealed occlusion of bilateral renal arteries. Both renal arteries were collateralised through lumbar arteries.

Following DSA, we proceeded with an LCIA angioplasty using a self-expandable stent (9×40mm) (LUMINEXX^®, Bard Inc., Tempe, AZ, USA) and also a failed attempt for renal artery recanalisation through the aortic lumen. We then decided to proceed with a scheduled combined (open surgery and endovascular treatment) of both renal arteries. We first performed an aorto-renal by-pass of the left renal artery (LRA) using the saphenous vein as a conduit and then we continued by performing puncture and distal catheterisation of a polar branch of the right renal artery (RRA) and recanalisation of the occluded RRA with angioplasty and stenting using a 4×20mm drug-eluting stent (DES) (Endeavor^®, Medtronic, Minneapolis, MN, USA).

The patient had an uneventful follow-up with significant recess of hypertension and claudication symptoms. A series of computed tomography angiographies (CTAs) (9 and 20 months postoperatively) revealed progressive dilation of the vein–graft conduit (maximum diameter: 15.6mm) and also an increase in the degree of a pre-existing right common iliac artery (RCIA) stenosis (Fig. 1). A decision for endovascular approach was made and so we proceeded with the use of a 5×50mm stent graft (VIABAHN Endoprosthesis, W.L. Gore & Associates Inc., Flagstaff, AZ, USA) which successfully excluded the vein–graft aneurysm (Fig. 2) and also an RCIA angioplasty using again a 9×40mm LUMINEXX^® stent.

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• Figure 1 

  CT angiography: dilation of the vein-graft conduit (maximum diameter: 15,6mm).

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• Figure 2 

  Endovascular treatment successfully excluded the vein-graft aneurysm.

Follow-up CTA (6 months) revealed patent renal arteries and shrinkage of the aneurysm of the pre-existing by-pass, but the patient complained of symptoms of chronic bowel ischaemia (CBI). CTA findings revealed ostial stenosis of superior mesenteric artery (SMA), which was again successfully treated with SMA angioplasty using a 5×20mm balloon.

The patient is now on a 6-month follow-up following the last intervention and nearly 3 years since the first combined procedure, being on a single-agent anti-hypertensive medical therapy and free of any symptoms related to other vascular beds.

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Discussion 

Our experience of endovascular treatment of TARAS is added to an increasing number of reports of a similar approach for Takayasu's arteritis.² However, until now there has been no report of a case of bilateral renal artery occlusion treated simultaneously or of the use of DES in Takayasu's arteritis apart from a few reports concerning coronary vessels.³ There are also some reports of the use of DES in atherosclerotic renal artery stenosis with results similar to those of bare metal stents.⁴

Our choice to perform combined open and endovascular revascularisation of both renal arteries was based upon the need to restore blood circulation in both kidneys and to maintain, if possible, collateral circulation in case of any acute postoperative adverse event. Our aim was to perform angioplasty in both renal arteries, but that proved to be technically unfeasible at least for the left renal. As for the right renal, since we were not able to achieve orthotopic recanalisation through the aortic lumen, we successfully performed retrograde recanalisation. Furthermore, since Takayasu's disease has a history of relapse, we were able to treat the patient each time using endovascular procedures without adding risks related to open surgery.

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Conflict of Interest/Funding 

None.

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References 

1. Johnston SL, Lock RJ, Gompels MM. Takayasu arteritis: a review. J Clin Pathol. 2002 Jul;55(7):481–486
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2. Min PK, Park S, Jung JH, Ko YG, Choi D, Jang Y, et al. Endovascular therapy combined with immunosuppressive treatment for occlusive arterial disease in patients with Takayasu's arteritis. J Endovasc Ther. 2005 Feb;12(1):28–34
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3. Amir O, Kar B, Civitello AB, Palanichamy N, Shakir A, Delgado RM. Unprotected left main stent placement in a patient with Takayasu's arteritis: an unusual solution for an unusual disease. Tex Heart Inst J. 2006;33(2):253–255
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4. Misra S, Thatipelli MR, Howe PW, Hunt C, Mathew V, Barsness GW, et al. Preliminary study of the use of drug-eluting stents in atherosclerotic renal artery stenosis 4mm in diameter or smaller. J Vasc Interv Radiol. 2008 Jun;19(6):Epub 2008 Apr 2008
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