K.E.M. Radiology
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Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Percutaneous transluminal balloon angioplasty with stenting in post transplant renovascular dysfunction with renovascular hypertension
Contributed by : Akash Shah
Introduction:
Renal transplantation is the definitive therapy for end-stage renal disease and has especially flourished in the post–cyclosporine-mediated immunosuppression era. Transplant renal artery stenosis (TRAS) is the most frequent vascular complication in renal transplantation with an incidence varying between 1 and 25% (1), Patients can present early or late in the post-transplantation period. They may present with poorly controlled hypertension, compromised renal function of the allograft or rejection refractory to immunotherapy (2)
Early (within a few months of surgery) TRAS is likely to be caused by mechanical or technical trauma; whereas TRAS developing remote (more than 6 months) from the time of transplantation cannot be explained and may be associated with progression of underlying atherosclerotic disease. Hypertension may occur suddenly or may have a more insidious onset. The interval between transplantation and diagnosis of TRAS ranges from 2 to 45 months.
Case Presentation:
We present the case of a 58 year old man suffering from end stage renal disease who underwent renal transplant in February 2024. Immediately after the renal transplant, the patient developed gradually progressive swelling and claudication on activity of the right lower limb which was managed medically. After a period of 1.5 months, the patient developed gradual progressive worsening of renal function with progressive increase in the serum creatinine levels and mild proteinuria. Medical management with use of corticosteroids, diuretics, antiplatelet agents was advised.
His lab investigations were as follows: S. Creat 2.3 which progressively increased to 8.9 over next the next three months. The patient had mild proteinuria of less than 3gm/day. Hb – 12.1gm%, WBC count of 8,400. There was a subtle decrease in the temperature of the right foot with slight pallor. Distal pulses in the right lower limb were feeble.
Right lower limb arterial doppler revealed narrowing at the external iliac artery just proximal to the site of renal artery implantation with monophasic waveforms distally in the ATA, PTA and Dorsalis Pedis artery in the right lower limb with significantly reduced peak systolic velocities in all arteries of the right limb compared to the left suggesting arterial stenosis.
Renal Doppler revealed a raised RI (0.92), prolonged acceleration time (0.10s) with increased peak systolic velocities in the transplanted renal artery with demonstration of a parvus-tardus waveform strongly suggesting a diagnosis of renal artery stenosis in the transplanted kidney.
CT angiography revealed a near complete stenosis involving the transplanted main renal artery as well as the external iliac artery just distal to the vascular anastomotic site.
The above findings were confirmed on a diagnostic DSA which revealed near complete stenosis involving the external iliac artery just proximal to the origin of the transplant renal artery as well as the main transplant renal artery.
Further management was planned in the form of angioplasty + stenting of external iliac artery stenosis as well as the main transplant renal artery stenosis. The plan of treatment was explained to the patient and their relatives with detailed counselling regarding the benefits of the procedure as well as the potential risks and complications involved.
Percutaneous angioplasty with stenting was decided as the treatment.
The patient was evaluated for fitness for the procedure by team of anaesthetists, nephrologists as well as intervention radiologists. After ensuring necessary patient fitness, informed consent was obtained,
Interventional technique:
A right femoral access was obtained using a 8Fr introducer sheath after administering appropriate local anaesthesia.
Pre procedure angiogram was performed through the introducer sheath placed into the right common femoral artery which documented 80-85% stenosis involving external iliac artery just proximal to origin of transplanted main renal artery as well as 80-85% stenosis involving the transplanted main renal artery with delayed filling and perfusion of the transplanted kidney (Fig 1)
Fig. 1: Near complete stenosis involving transplanted main renal artery as well as the external iliac artery just proximal to the anastomotic site.
A 0.014” Stabilizer wire was passed through the 8F sheath and parked across the stenotic lesion involving transplant renal artery.
0.018” V18 stiff wire placed across the stenotic lesion involving external iliac artery (Fig, 2,3)

Fig 2 : Crossing the renal artery lesion. Stabilizer 0.014” wire used to navigate across the transplanted renal artery stenosis.

Fig 3: Crossing External Iliac Artery Lesion. V18 0.018” wire used to navigate across the external iliac artery stenosis
After successful parking of the guidewires across the lesions, angiogram was performed (Fig. 4).

Fig 4: Angiogram after crossing the Lesions.
A balloon expandable stent was the placed across the stenotic lesion at an appropriate position in the external iliac artery. A 7 x 17mm stent was advanced and deployed by inflating the balloon up to the nominal pressure till disappearance of the waist (Fig, 5,6)

Fig 5: Passing the stent across external iliac artery lesion.

Fig 6 Deploying the stent across the external iliac artery lesion.
An angiogram was obtained after deploying the stent, This showed some residual irregular narrowing of the lumen. Angioplasty was performed with serial inflation above nominal pressure below rated burst pressure till the waist disappeared.
Post stent deployment angiogram showed satisfactory widening of the lumen of with good contrast opacification and good calibre of the external iliac artery. There was no residual hemodynamically significant stenosis (Fig. 7).

Fig 7 : Post Stent deployment angiogram of the external iliac artery lesion. showing satisfactory widening of the external iliac artery lumen with good caliber contrast opacification.
The choice of stent for the transplanted main renal artery was a 5 x 15mm balloon expandable stent . It was advanced over the 0.014” stabilizer wire which was parked across the stenotic lesion (Fig. 8) .

Fig 8: Passing the stent across the transplanted main renal artery stenosis.
The balloon was inflated gradually up to the nominal pressure till disappearance of the waist. The stent was deployed in the appropriate position and confirmed on post stent deployment angiogram (Fig. 9, 10).

Fig 9: Deploying the stent across transplanted main renal artery lesion.

Fig 10: Inflation of the Balloon mounted stent across the transplanted main renal artery lesion.
Post balloon expandable stent deployment angiogram showed good widening of the lumen of the stenosed segment with improved calibre and contrast opacification with significantly improved renal perfusion (Fig. 11).

Fig 11: Post stenting angiogram. Satisfactory widening of the lumen of the transplant main renal artery with good caliber contrast opacification.
Final antegrade angiogram was performed with a 4F pigtail catheter with its tip above the aortic bifurcation which demonstrates successful angioplasty and stent deployment in external iliac artery as well as main transplant renal artery with no hemodynamically significant residual stenosis,. There was satisfactory widening of the lumen with good contrast opacification (Fig. 12).
Fig 12: Post procedure angiogram after successful stent deployment across both the transplant main renal artery and external iliac artery lesions adjacent to the anastomotic site. Good widening of the caliber of both the vessels with no hemodynamically significant residual stenosis. Significantly improved and prompt renal parenchymal blush visualized.