K.E.M. Radiology
Patients First!
Welcome to the Academic and Educational pages of the
Department of Radiology
Seth G.S. Medical College and K.E.M. Hospital, Mumbai , India
Interventional Case Record
Interventional Case Record
Percutaneous transluminal balloon angioplasty with stenting in post transplant renovascular dysfunction with renovascular hypertension
Percutaneous transluminal balloon angioplasty with stenting in post transplant renovascular dysfunction with renovascular hypertension
Contributed by : Akash Shah
Contributed by : Akash Shah
Introduction:
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)
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.
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:
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.
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.
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.
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.
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.
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.
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.
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.
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,
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:
Interventional technique:
A right femoral access was obtained using a 8Fr introducer sheath after administering appropriate local anaesthesia.
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)
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.
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)
0.018” V18 stiff wire placed across the stenotic lesion involving external iliac artery (Fig, 2,3)
Video 1.mp4Fig 2 : Crossing the renal artery lesion. Stabilizer 0.014” wire used to navigate across the transplanted renal artery stenosis.
Video 2.mp4Fig 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).
After successful parking of the guidewires across the lesions, angiogram was performed (Fig. 4).
Video3.mp4Fig 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)
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)
Video4.mp4Fig 5: Passing the stent across external iliac artery lesion.
Video5.mp4Fig 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.
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).
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).
Video 6.mp4Fig 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) .
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) .
Video 7.mp4Fig 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).
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).
Video 8.mp4Fig 9: Deploying the stent across transplanted main renal artery lesion.
Video 9.mp4Fig 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).
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).
Video 10.mp4Fig 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).
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.
Discussion:
Discussion:
Mechanical or technical mechanisms of TRAS include atherosclerosis of the donor renal arteries or recipient iliac arteries, or both.( 3,4) . In addition, trauma to the vessels during harvesting and transplantation, clamp injury, cannulation for organ perfusion, kinking and compression of the renal artery, size discrepancy between donor and recipient renal arteries, and chronic rejection can contribute to stenosis (5,6,7,8). Excess traction on the vessels, and suture techniques are other potential causes. Small subintimal flaps or dissections are thought to occur, leading to intimal scarring and hyperplasia and eventual anastomotic stenosis.
Mechanical or technical mechanisms of TRAS include atherosclerosis of the donor renal arteries or recipient iliac arteries, or both.( 3,4) . In addition, trauma to the vessels during harvesting and transplantation, clamp injury, cannulation for organ perfusion, kinking and compression of the renal artery, size discrepancy between donor and recipient renal arteries, and chronic rejection can contribute to stenosis (5,6,7,8). Excess traction on the vessels, and suture techniques are other potential causes. Small subintimal flaps or dissections are thought to occur, leading to intimal scarring and hyperplasia and eventual anastomotic stenosis.
Investigation of kidney transplant graft dysfunction includes assessment of possible vascular complications which occur in up to 15% of renal transplant patients and cause graft dysfunction with high morbidity and mortality. These complications include renal artery thrombosis, renal artery stenosis, renal vein thrombosis and, rarely, iliac artery stenosis. The most common vascular complication is stenosis of the graft artery at the site of anastomosis with the recipient iliac artery, leading to graft dysfunction (9). These stenotic lesions may result in reduced blood flow to the ipsilateral lower extremity as well as the kidney graft, leading to renal dysfunction and leg ischemia, and are usually detected because of manifestations such as elevated serum creatinine levels, bruits, low extremity claudication, and renal vascular hypertension (10).
Investigation of kidney transplant graft dysfunction includes assessment of possible vascular complications which occur in up to 15% of renal transplant patients and cause graft dysfunction with high morbidity and mortality. These complications include renal artery thrombosis, renal artery stenosis, renal vein thrombosis and, rarely, iliac artery stenosis. The most common vascular complication is stenosis of the graft artery at the site of anastomosis with the recipient iliac artery, leading to graft dysfunction (9). These stenotic lesions may result in reduced blood flow to the ipsilateral lower extremity as well as the kidney graft, leading to renal dysfunction and leg ischemia, and are usually detected because of manifestations such as elevated serum creatinine levels, bruits, low extremity claudication, and renal vascular hypertension (10).
Thus, an anastomotic stenosis is the most likely related to trauma to the donor or recipient vessels during harvesting, clamping, or suturing and usually arises early after trans-plantation (11). Small, subtle intimal flaps or subintimal dissections of the vascular wall precede intimal scarring and hyperplasia that result in narrowing or occlusion of the lumen (12) .Stenoses occurring later, sometimes several years post-transplant, usually reflect atherosclerotic disease either of the transplant renal artery or of the adjacent proximal iliac artery (13). Diffuse stenoses occurring late after transplantation may reflect immune-mediated endothelial damage.
Thus, an anastomotic stenosis is the most likely related to trauma to the donor or recipient vessels during harvesting, clamping, or suturing and usually arises early after trans-plantation (11). Small, subtle intimal flaps or subintimal dissections of the vascular wall precede intimal scarring and hyperplasia that result in narrowing or occlusion of the lumen (12) .Stenoses occurring later, sometimes several years post-transplant, usually reflect atherosclerotic disease either of the transplant renal artery or of the adjacent proximal iliac artery (13). Diffuse stenoses occurring late after transplantation may reflect immune-mediated endothelial damage.
The most common late vascular complication is stenosis of the graft artery at the site of anastomosis with the recipient iliac artery, leading to graft dysfunction and renal vascular hypertension. A number of case reports in the literature described graft dysfunction with low extremity claudication secondary to stenosis of the iliac artery proximal to the graft implantation sitec(14).
The most common late vascular complication is stenosis of the graft artery at the site of anastomosis with the recipient iliac artery, leading to graft dysfunction and renal vascular hypertension. A number of case reports in the literature described graft dysfunction with low extremity claudication secondary to stenosis of the iliac artery proximal to the graft implantation sitec(14).
Percutaneous transluminal angioplasty (PTA) of both renal allograft and native iliac artery stenosis has become accepted as the initial treatment of choice (15). Intravascular stents have greater long-term patency rates in randomized studies. The most commonly used stents are the balloon-expandable and self-expandable stents (15). In our case, a balloon mounted stent was placed at the stenosis site.
Percutaneous transluminal angioplasty (PTA) of both renal allograft and native iliac artery stenosis has become accepted as the initial treatment of choice (15). Intravascular stents have greater long-term patency rates in randomized studies. The most commonly used stents are the balloon-expandable and self-expandable stents (15). In our case, a balloon mounted stent was placed at the stenosis site.
In summary, iliac artery stenosis with main transplant renal artery stenosis can be a potentially hazardous complication with serious clinical implications and can lead to lower extremity claudication, hypertension and kidney dysfunction of the transplant. Percutaneous transluminal angioplasty with or without intravascular stenting has high technical success with an acceptable complication rate and is the preferred initial therapy in these patients. The introduction of newer technology such as lower profile balloon catheters, premounted balloon-expandable stents, and cutting angioplasty balloon catheters is likely to improve the outcome of percutaneous interventions for TRAS. The success of these interventions requires appropriate selection of patients and attention to meticulous technique.
In summary, iliac artery stenosis with main transplant renal artery stenosis can be a potentially hazardous complication with serious clinical implications and can lead to lower extremity claudication, hypertension and kidney dysfunction of the transplant. Percutaneous transluminal angioplasty with or without intravascular stenting has high technical success with an acceptable complication rate and is the preferred initial therapy in these patients. The introduction of newer technology such as lower profile balloon catheters, premounted balloon-expandable stents, and cutting angioplasty balloon catheters is likely to improve the outcome of percutaneous interventions for TRAS. The success of these interventions requires appropriate selection of patients and attention to meticulous technique.
References:
References:
1. Wong W, Fynn S P, Higgins R M, et al. Transplant renal artery stenosis in 77 patients—does it have an immunological cause? Transplantation. 1996; 61:215–219.
1. Wong W, Fynn S P, Higgins R M, et al. Transplant renal artery stenosis in 77 patients—does it have an immunological cause? Transplantation. 1996; 61:215–219.
2. Chan H W, Ho Y W, Chan C M, Yiu T F, Tong M K, Wong P H. Treatment of anastomotic ostial allograft and renal artery stenosis with the Palmaz stent. Transplantation. 1995; 59:436–439.
2. Chan H W, Ho Y W, Chan C M, Yiu T F, Tong M K, Wong P H. Treatment of anastomotic ostial allograft and renal artery stenosis with the Palmaz stent. Transplantation. 1995; 59:436–439.
3. Loubeyre P, Cahen R, Grozel F, et al. Transplant renal artery stenosis. Evaluation of diagnosis with magnetic resonance angiography compared with color duplex sonography and arteriography. Transplantation. 1996; 62:446–450.
3. Loubeyre P, Cahen R, Grozel F, et al. Transplant renal artery stenosis. Evaluation of diagnosis with magnetic resonance angiography compared with color duplex sonography and arteriography. Transplantation. 1996; 62:446–450.
4. Sutherland R S, Spees E K, Jones J W, Fink D W. Renal artery stenosis after renal transplantation: the impact of the hypogastric artery anastomosis. J Urol. 1993; 149:980–985.
4. Sutherland R S, Spees E K, Jones J W, Fink D W. Renal artery stenosis after renal transplantation: the impact of the hypogastric artery anastomosis. J Urol. 1993; 149:980–985.
5. Sankari B R, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick A C. Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control. J Urol. 1996; 155:1860–1864.
5. Sankari B R, Geisinger M, Zelch M, Brouhard B, Cunningham R, Novick A C. Post-transplant renal artery stenosis: impact of therapy on long-term kidney function and blood pressure control. J Urol. 1996; 155:1860–1864.
6. Kauffman H M, Sampson D, Fox P S, Doyle T J, Maddison F E. Prevention of transplant renal artery stenosis. Surgery. 1977; 81:161–167.
6. Kauffman H M, Sampson D, Fox P S, Doyle T J, Maddison F E. Prevention of transplant renal artery stenosis. Surgery. 1977; 81:161–167.
7. Tilney N L, Rocha A, Strom T B, Kirkman R L. Renal artery stenosis in transplant patients. Ann Surg. 1984; 199:454–460.
7. Tilney N L, Rocha A, Strom T B, Kirkman R L. Renal artery stenosis in transplant patients. Ann Surg. 1984; 199:454–460.
8. Smith R B, Cosimi A B, Lordon R, Thompson A L, Ehrlich R M. Diagnosis and management of arterial stenosis causing hypertension after successful renal transplantation. J Urol. 1976;115:639–642.
8. Smith R B, Cosimi A B, Lordon R, Thompson A L, Ehrlich R M. Diagnosis and management of arterial stenosis causing hypertension after successful renal transplantation. J Urol. 1976;115:639–642.
9. Aktas S, Boyvat F, Sevmis S, Moray G, Karakayali H, Haberal M. Analysis of vascular complications after renal transplantation. Transplant Proc. 2011;43(2):557-61.
9. Aktas S, Boyvat F, Sevmis S, Moray G, Karakayali H, Haberal M. Analysis of vascular complications after renal transplantation. Transplant Proc. 2011;43(2):557-61.
10. Aikimbaev K, Akgul E, Aksungur E, Demir E, Erken U. Iliac artery stenosis as a cause of posttransplant renal failure and claudication. Int Urol Nephrol. 2007;39(4):1273-6.
10. Aikimbaev K, Akgul E, Aksungur E, Demir E, Erken U. Iliac artery stenosis as a cause of posttransplant renal failure and claudication. Int Urol Nephrol. 2007;39(4):1273-6.
11. Lacombe M: Arterial stenosis complicating renal allotransplantation in man. Ann Surg 181:283, 1975
11. Lacombe M: Arterial stenosis complicating renal allotransplantation in man. Ann Surg 181:283, 1975
12. Fervenza FC, Lafayette RA, Alfrey EJ, et al: Renal artery stenosis in kidney transplants. Am J Kidney Dis 31:142, 1998
12. Fervenza FC, Lafayette RA, Alfrey EJ, et al: Renal artery stenosis in kidney transplants. Am J Kidney Dis 31:142, 1998
13. Smellie WA, Vinik M, Hume DM: Angiographic investigation of hypertension complicating human renal transplantation. Surg Gynecol Obstet 128:963, 1969.
13. Smellie WA, Vinik M, Hume DM: Angiographic investigation of hypertension complicating human renal transplantation. Surg Gynecol Obstet 128:963, 1969.
14. Becker BN, Odorico JS, Becker YT, et al: Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease. Clin Transplant 13:349, 1999
14. Becker BN, Odorico JS, Becker YT, et al: Peripheral vascular disease and renal transplant artery stenosis: a reappraisal of transplant renovascular disease. Clin Transplant 13:349, 1999
15. Rengel M, Gomes-Da-Silva G, Inchaustegui L, et al: Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach. Kidney Int Suppl 68:S99, 1998. Gray DW
15. Rengel M, Gomes-Da-Silva G, Inchaustegui L, et al: Renal artery stenosis after kidney transplantation: diagnostic and therapeutic approach. Kidney Int Suppl 68:S99, 1998. Gray DW