Recurrent Right Renal Artery Stenosis

A 65-year old woman who has previously undergone right renal artery stenting presented to her physician with increased recurrent arterial velocities within the proximal right renal artery duplex ultrasound survey.

Documented Diagnosis: Recurrent Right Renal Artery Stenosis.

Documented Procedure: Angiographic Assessment with Flush Aortogram.

Other Documentation of the Encounter:

Upon an initial assessment the patient was advised to undergo an angiographic assessment to treat potentially severe recurrent right renal artery stenosis. The patient was counseled as to the risks of the procedure to include access site bleeding, hematoma, or aneurysm formation, contrast-related nephropathy or allergy, or arterial injury. She elected to proceed with the procedure.

The patient was taken to the procedure room and properly identified. She was monitored continually with electrocardiogram, pulse oxygen monitor, and blood pressure cuff. During the procedure, she received conscious sedation consisting of Versed 3 mg and Fentanyl 100 mcg IV in divided doses. She also received Kefzol 1 gram IV for antibiotic prophylaxis, Heparin 3000 units IV for anticoagulation prior to balloon angioplasty and at the end partial heparin reversal with Protamine 20 mg IV.

Both groins were prepped and draped in a sterile fashion. The skin and subcutaneous tissues overlying the right femoral artery were injected with 1% Xylocaine local anesthetic. Access needle was advanced into the right femoral artery with prompt pulsatile arterial return. An 035 J-wire was advanced through the needle and directed into the abdominal aorta under fluoroscopic guidance. The needle was exchanged for a 5-French sheath. A 5-French pigtail catheter was then advanced along over the J-wire and positioned in the abdominal aorta and a flush aortogram was performed.

Additional oblique views of the abdominal aorta revealed a patent left and right renal artery with proximal recurrent right renal artery stenosis and otherwise patent right renal artery stent. The stenosis appeared to occur proximal to the stent and within the origin of the stent as well. The right renal artery was accessed using C2 catheter and glidewire. The glidewire was replaced with 035 Rosen wire and the right femoral sheath exchanged for a 5-French Ansel sheath. Further angiographic assessment was carried out through sheath injections confirming the location and extent of the stenosis again noted to be at the origin of the artery. The Rosen wire was exchanged for a 018 Thruway wire and over this wire the 5 mm x 2 cm Sterling balloon was inflated. Following angioplasty, angiographic assessment showed resolution of the previously noted stenosis with widely patent right renal artery to include the stented portion.

Prior to removing the sheath, the right and left iliac arteries were visualized revealing widely patent right common, internal, and external iliac arteries. Of note, there was a beaded appearance to the proximal right external iliac artery possibly suggesting a fibromuscular dysplastic change. The long Ansel sheath was then re-exchanged over a guidewire for the short right femoral sheath to allow a Mynx closure upon completion of the procedure. The right femoral sheath was removed and a V-pad was placed Elysium.

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