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Journal of Radiology Case Reports

Rescue from hemodialysis by late recanalization of renal artery occlusion

Case Report

Kristina Imeen Ringe1*, Michael Galanski1, Herbert Rosenthal1

Radiology Case. 2011 May; 5(5):19-23 :: DOI: 10.3941/jrcr.v5i5.709

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1. Department of Radiology, Hannover Medical School, Hannover, Germany

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  ABSTRACT
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We report on a patient with terminal renal insufficiency undergoing hemodialysis since four months. Imaging studies showed complete renal artery occlusion of a single kidney with collateral perfusion. Interventional recanalization of the renal artery was successful with a drop of serum creatinine from 1138 to 163 mol/l sparing the patient from further hemodialysis.








  CASE REPORT
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We report on a 49-year-old female patient with a single kidney undergoing hemodialysis since four months due to terminal renal failure that occurred in the course of gastroenteritis. The left pelvic kidney had been removed six years earlier in the course of a caesarean section. Blood pressure was approximately 160/95 mmHg under double antihypertensive medication (Amlodipin and Carvedilol). Prior ultrasound guided biopsy of the right kidney was unobtrusive.

Initially, a CT-angiography was performed for assessment of renal perfusion and evaluation of potential renal artery recanalization, depicting total renal artery occlusion with collateral perfusion of the kidney (Fig. 1 Preview this figure

Figure 1: Computed Tomography
49-year-old female patient with diagnosis of FMD. CTA (arterial phase; 120 kV, 1247 mAs) after injection of 120ml Ultravist (Bayer HealthCare, Leverkusen): On axial (a) and coronal (b) reformations no right renal artery is seen in terms of total vessel occlusion (red arrows). Parenchymal contrast is reduced with proper differentiation of renal medulla and cortex. Status post nephrectomy on the left side (red asterisk).
and Fig. 2 Preview this figure
Figure 2: Computed Tomography
49-year-old female patient with diagnosis of FMD. Coronal maximum intensity projection (MIP, a) and 3D volume rendered image (VR, b): Complete occlusion of the right renal artery (red arrow) with refilling of the segmental arteries via lumbar collaterals (white arrow) can be appreciated.
). Interventional recanalization was considered as feasible and the patient underwent catheter angiography. Digital subtraction angiography (DSA), using a Terumo stiff wire (Terumo , Leuven, Belgium) and a Sidewinder I catheter, confirmed total renal artery occlusion and further depicted multiple segmental artery stenoses consistent with the diagnosis of fibromuscular dysplasia (FMD; Fig. 3 Preview this figure
Figure 3: Angiography, Interventional
49-year-old female patient with diagnosis of FMD. Digital subtraction angiography (DSA): Pigtail catheter placed in the aorta at the level above the renal arteries and demonstration of complete occlusion of the right renal artery. The right kidney is supplied by strong lumbar collaterals (*). Selective probing of the right renal artery using a Terumo stiff wire (Terumo , Leuven, Belgium) and a sidewinder II catheter, no parenchymal contrastation is seen (b).
and Fig. 4 Preview this figure
Figure 4: Angiography, Interventional
49-year-old female patient with diagnosis of FMD. Placement of a cobra catheter further distal in the right renal artery depicts in addition multifocal stenoses of the segmental renal arteries (a). Step by step dilation of the main renal artery up to 7mm (using a 7mm Wanda balloon catheter) and segmental arteries using a 4mm Wanda balloon catheter and control series in between (b). Final control after additional placement of a Herkulink stent (7mm) in the proximal portion of the right renal artery because of an intima flap (not shown). No residual stenosis and homogeneous parenchymal contrastation can be appreciated (c).
). Interventional recanalization of the right renal artery and segmental arteries by means of percutaneous transluminal angioplasty (PTA) and additional stent implantation (due to a focal dissection which occurred in the course of main artery dilatation) was successful. Overall, 200ml of i.a. contrast agent (Visipaque , GE Healthcare, München, Germany) and 30mg of Buscopan i.v. (Boehringer Ingelheim, Ingelheim, Germany) for reduction of bowel movement and improvement of image quality were administered. A drop of serum creatinine from 1138 to 163 mol/l (normal range 50-80 mol/l) within the first week after intervention could be appreciated and the patient was spared from further hemodialysis. Antihypertensive therapy was continued with a single medication (Captopril) and follow-up (five years) has been uneventful with no signs of recurrent disease. A life-long medication of 100mg salicylic acid has been recommended.

  DISCUSSION
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Fibromuscular dysplasia (FMD) is a non-inflammatory, non-atherosclerotic disease characterized by muscular hyperplasia in one or more layers [1]. FMD is a rare disease of unknown cause and accounting for less than 10% of renal artery stenosis. It most often affects the middle and distal portion of the main renal artery or its segment branches in contrast to atherosclerotic disease, which tends to be located at the origin or proximal portion of the renal artery [5].

Depending on the predominantly affected layer varying histologic types can be differentiated. Whereas medial fibroplasia is the most common cause (75-80%), intimal and adventitial fibroplasia is less often (less than 10% and less than 1%, respectively). Although any artery can be affected, FMD most often occurs in the renal (60-75%; 35% bilateral) and carotid arteries [3]. FMD typically occurs in young women (less than 35 years). Symptoms may include arterial hypertension with a sudden onset of high blood pressure or an epigastric bruit, transient ischemic attack (TIA) and stroke. Renal failure appears less often. FMD may be diagnosed incidentally or in the course of evaluation for hypertension [4]. Diagnosis can be made by duplex ultrasound, however catheter angiography still is the gold standard with characteristic findings such as focal stenosis or a "string of beads" appearance indicating multiple stenoses and aneurysms [5].

Treatment is indicated in patients with renal artery stenosis and hypertension or impairment of renal function. In asymptomatic patients watch and wait strategy is implemented. Treatment of choice in symptomatic patients is interventional recanalization by means of percutaneous transluminal angioplasty. Cure or improvement of renal function can be achieved in a high percentage of these patients. Primary stent implantation is recommended only in case of suboptimal PTA result or dissection. Surgery may be necessary in patients presenting with macroaneurysms or complex arterial disease [6,7]. It has been demonstrated before that delayed revascularization of renal artery occlusion can be successful and is recommended for treatment of renovascular hypertension and acute renal failure [8]. Based on our case report we would like to emphasize on this, and encourage to attempt renal artery recanalization in symptomatic patients with FMD even in the later course of the disease as affected patients are typically young and as this condition usually has a good prognosis.

  TEACHING POINT
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Fibromuscular dysplasia (FMD) is a rare non-inflammatory, non-atherosclerotic disease characterized by muscular hyperplasia in one or more layers and accounting for less than 10% of renal artery stenosis. Characteristic imaging findings include focal stenosis or a "string of beads" appearance indicating multiple stenoses and aneurysms. Renal artery recanalization in symptomatic patients with FMD by means of percutaneous transluminal angioplasty should be attempted even in the later course of the disease as affected patients are typically young and as this condition usually has a good prognosis.



  FIGURES
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Display figure 1 in original size

Figure 1: 49-year-old female patient with diagnosis of FMD. CTA (arterial phase; 120 kV, 1247 mAs) after injection of 120ml Ultravist (Bayer HealthCare, Leverkusen): On axial (a) and coronal (b) reformations no right renal artery is seen in terms of total vessel occlusion (red arrows). Parenchymal contrast is reduced with proper differentiation of renal medulla and cortex. Status post nephrectomy on the left side (red asterisk).

Figure 1: Computed Tomography (Open in original size)
49-year-old female patient with diagnosis of FMD. CTA (arterial phase; 120 kV, 1247 mAs) after injection of 120ml Ultravist (Bayer HealthCare, Leverkusen): On axial (a) and coronal (b) reformations no right renal artery is seen in terms of total vessel occlusion (red arrows). Parenchymal contrast is reduced with proper differentiation of renal medulla and cortex. Status post nephrectomy on the left side (red asterisk).

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Display figure 2 in original size
Figure 2: 49-year-old female patient with diagnosis of FMD. Coronal maximum intensity projection (MIP, a) and 3D volume rendered image (VR, b): Complete occlusion of the right renal artery (red arrow) with refilling of the segmental arteries via lumbar collaterals (white arrow) can be appreciated.

Figure 2: Computed Tomography (Open in original size)
49-year-old female patient with diagnosis of FMD. Coronal maximum intensity projection (MIP, a) and 3D volume rendered image (VR, b): Complete occlusion of the right renal artery (red arrow) with refilling of the segmental arteries via lumbar collaterals (white arrow) can be appreciated.

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Display figure 3 in original size
Figure 3: 49-year-old female patient with diagnosis of FMD. Digital subtraction angiography (DSA): Pigtail catheter placed in the aorta at the level above the renal arteries and demonstration of complete occlusion of the right renal artery. The right kidney is supplied by strong lumbar collaterals (*). Selective probing of the right renal artery using a Terumo stiff wire (Terumo , Leuven, Belgium) and a sidewinder II catheter, no parenchymal contrastation is seen (b).

Figure 3: Angiography, Interventional (Open in original size)
49-year-old female patient with diagnosis of FMD. Digital subtraction angiography (DSA): Pigtail catheter placed in the aorta at the level above the renal arteries and demonstration of complete occlusion of the right renal artery. The right kidney is supplied by strong lumbar collaterals (*). Selective probing of the right renal artery using a Terumo stiff wire (Terumo , Leuven, Belgium) and a sidewinder II catheter, no parenchymal contrastation is seen (b).

Back Back


Display figure 4 in original size
Figure 4: 49-year-old female patient with diagnosis of FMD. Placement of a cobra catheter further distal in the right renal artery depicts in addition multifocal stenoses of the segmental renal arteries (a). Step by step dilation of the main renal artery up to 7mm (using a 7mm Wanda balloon catheter) and segmental arteries using a 4mm Wanda balloon catheter and control series in between (b). Final control after additional placement of a Herkulink stent (7mm) in the proximal portion of the right renal artery because of an intima flap (not shown). No residual stenosis and homogeneous parenchymal contrastation can be appreciated (c).

Figure 4: Angiography, Interventional (Open in original size)
49-year-old female patient with diagnosis of FMD. Placement of a cobra catheter further distal in the right renal artery depicts in addition multifocal stenoses of the segmental renal arteries (a). Step by step dilation of the main renal artery up to 7mm (using a 7mm Wanda balloon catheter) and segmental arteries using a 4mm Wanda balloon catheter and control series in between (b). Final control after additional placement of a Herkulink stent (7mm) in the proximal portion of the right renal artery because of an intima flap (not shown). No residual stenosis and homogeneous parenchymal contrastation can be appreciated (c).

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Display figure 5 in original size
Figure 5: Table 1. Summary table for fibromuscular dysplasia (FMD)

Figure 5: Table (Open in original size)
Table 1. Summary table for fibromuscular dysplasia (FMD)

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Display figure 6 in original size
Figure 6: Table 2. Differential diagnosis table for fibromuscular dysplasia (FMD)

Figure 6: Table (Open in original size)
Table 2. Differential diagnosis table for fibromuscular dysplasia (FMD)

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  REFERENCES
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1. Slovut DP, Olin JW. Fibromuscular dysplasia. N Engl J Med 2004; 350: 1862-1871 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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2. Lassiter FD. The String-of-Beads Sign. Radiology 1998; 206: 437-438 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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3. Olin JW. Recognizing and managing fibromuscular dysplasia. Clev Clin J Med 2007; 74: 273-274 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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4. Das CJ, Neyaz Z, Thapa P, Sharma S, Vashist S. Fibromuscular dysplasia of the renal arteries: a radiological review. Int Urol Nephrol 2007; 39: 233-238 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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5. Safian RD, Textor SC. Renal artery stenosis. N Engl J Med 2001; 344: 431-442 Get full text
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6. Hirsch AT, Haskal CJ, Hertzer NR. ACC/ AHA 2005 Guidelines for the management of patients with peripheral arterial disease (lower extremity, renal, mesenteric and abdominal aorta), executive summary. Circulation 2006; 113: e463-654 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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7. Olin JW, Pierce M. Contemporary management of fibromuscular dysplasia. Curr Opin Cardiol 2008; 23: 527-536 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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8. Sela E, Fajer S, Karmeli R. Successful delayed revascularization for renal artery occlusion. Eur J Vasc Endovasc Surg 2002; 23: 79-81 Get full text
Find similar topics on Read this article on PubMed :: Find similar articles on Google scholarScholar :: Search for similar topics with the Radiology specific search engine Radiology search engine

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  ABBREVIATIONS
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CTA = computed tomography angiography
DSA = digital subtraction angiography
FMD = fibromuscular dysplasia
MIP = maximum intensity projection
PTA = percutaneous transluminal angioplasty
TIA = transitory ischemic attack
VR = volume rendered








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