Dolipska, Joanna

Krzanowski, Marcin

Latacz, Paweł

Simka, Marian

Sułowicz, Władysław

Polish Archives of Internal Medicine

English

Jagiellonian Univeristy Repository

CLINICAL IMAGE Acute occlusion of renal arteries 319ev3 Endovascular, Inc., Plymouth, Minnesota, United States), we navigated across the occlud‑ed distal part of the aorta. Since the origin of the LRA was not visible, we dilated the aorta us‑ing angioplastic balloons in the area where such origin should be located, which resulted in vi‑sualization of the proximal portion of the LRA. Revascularization of the renal arteries in case of their acute obstruction resulting in renal failure (RF) remains a therapeutic challenge. Renal isch‑emia is often asymptomatic, and it is also dif‑ficult to determine when the organ is irrevers‑ibly damaged. We present a successful rescue angioplasty of the abdominal aorta and left re‑nal artery (LRA), using the chimney technique. We managed a 52 ‑year ‑old woman presenting with acute RF requiring hemodialysis. Comput‑ed angiography revealed an occlusion of the ab‑dominal aorta just below the origin of the su‑perior mesenteric artery and occlusion of both renal arteries (FIGURE 1A). There were also radio‑logic features of cirrhosis of the right kidney, while the left kidney was normally sized. De‑spite abdominal aortic occlusion, there were no clinical signs of lower limb ischemia, since col‑lateral circulation was good. An actual cause of the occlusion was difficult to determine. The pa‑tient was asymptomatic until symptoms of RF developed. Most likely, the occlusion resulted from aortic dissection followed by thrombosis. Echocardiographic examination demonstrated low ejection fraction (<30%), still with no signs of valvular dysfunction. Preprocedural course was complicated by heparin ‑induced thrombo‑cytopenia, which was successfully managed with fondaparinux. Considering the high risk of an open surgical revascularization, we decided to attempt endo‑vascular angioplasty of the occluded abdominal aorta and the LRA, using the chimney technique. First, we cannulated the aorta up to the level of occlusion. Contrast injected at this level revealed that the distal part of the LRA, about 4 cm from the aorta, was patent and received blood supply from collateral circulation (FIGURE 1B and 1C). Us‑ing a hydrophilic guidewire (AqWireTM, Covidien, CLINICAL IMAGEComposed revascularization techniques for rescue endovascular management of acute occlusion of abdominal aorta and renal arteriesPaweł Latacz1, Marian Simka2, Marcin Krzanowski3, Joanna Dolipska3, Władysław Sułowicz31  Department of Neurology, Jagiellonian University Medical College, Kraków, Poland2  Department of Anatomy, University of Opole, Opole, Poland3  Department of Nephrology, Jagiellonian University Medical College, Kraków, PolandCorrespondence to:Paweł Latacz, MD, PhD,  Klinika Neurologii, Uniwersytet Jagielloński, Collegium Medicum,  ul. Botaniczna 3, 31-503 Kraków, Poland, phone: +48 12 424 86 46, email: pawlat@me.comReceived: March 17, 2018.Accepted: April 17, 2018.Published online: April 17, 2018.Conflict of interest: none declared.Pol Arch Intern Med. 2018;  128 (5): 319-321doi:10.20 452/pamw.4249Copyright by Medycyna Praktyczna, Kraków 2018FIGURE 1 A – computed tomography angiography showing occlusion of the abdominal aorta (Ao) coexisting with occlusions of the left renal artery (LRA); SMA, superior mesenteric artery AAoSMALRAPOLISH ARCHIVES OF INTERNAL MEDICINE 2018; 128 (5)320therapy (aspirin and clopidogrel), anticoagulation with fondaparinux for 3 months, and antihyper‑tensive therapy. Control computed angiography at 6 months (FIGURE 1G) and ultrasound examina‑tion at 12 and 18 months revealed good flow in all arteries where stents were implanted.In our opinion, endovascular revascularization of an acutely occluded renal artery is a promising alternative for open surgical repair.1-5 It should be emphasized that it is difficult to determine the du‑ration of irreversible renal ischemia. Therefore, endovascular revascularization of renal arteries resulting in RF should always be considered, es‑pecially in high ‑risk patients.3-5Using a 0.014” guidewire, we navigated through the occluded segment of this artery (FIGURE 1D). Then, using the chimney technique and simulta‑neous expansion of stents, we implanted 2 Be‑Graft stents (Bentley InnoMed, Hechingen, Ger‑many) in the superior mesenteric artery and in the LRA, and bigger BeGraft stents in the abdom‑inal aorta (FIGURE 1E and 1F). The final angiographic outcome of the procedure was good, with restored flow to the left kidney parenchyma (FIGURE 1F). Af‑ter the procedure, normal levels of renal biochem‑ical parameters and diuresis were restored. The pa‑tient was discharged after 12 days of hospitaliza‑tion, with a recommendation of dual antiplatelet FIGURE 1 B – abdominal aorta (Ao) recanalized and dilated with angioplasty balloons; C – angiography of the left renal artery (LRA), which was patent in its distal portion; D – cannulation of the LRA; E – stent implantation in the abdominal aorta, superior mesenteric artery (SMA), and LRA; F – final outcome after stent implantation, with good flow restored in all revascularized arteries: abdominal aorta, SMA, and LRA; G – control computed tomography angiography at 6 months: good outcome with flow restorationB CDE FGAoAoAoAoLRALRALRALRASMASMACLINICAL IMAGE Acute occlusion of renal arteries 321OPEN ACCESS This is an Open Access article dis‑tributed under the terms of the Creative Com‑mons Attribution ‑NonCommercial ‑ShareAlike 4.0 International License (CC BY ‑NC ‑SA 4.0), allowing third parties to copy and redistribute the material in any medium or format and to re‑mix, transform, and build upon the material, pro‑vided the original work is properly cited, distrib‑uted under the same license, and used for non‑commercial purposes only. For commercial use, please contact the journal office at pamw@mp.pl.RREFERENCES1 Silverberg D, Menes T, Rimon U, et al. Acute renal artery occlusion: pre-sentation, treatment and outcome. J Vasc Surg. 2016; 64: 1026-1032.2 Latacz P, Rudnik A, Gutowska A, et al. Percutaneous angioplasty of the left renal artery in a patient with acute infarction of the left kidney with persistent occlusion of the right renal artery treated with angiotensin con-verting enzyme inhibitor. Kardio Pol. 2011; 69: 702-705.3 Kanamori H, Toma M, Fukatsu A., Improvement of renal function after opening occluded atherosclerotic renal arteries. J Invasive Cardiol. 2009; 21: E171 -174.4 Hedayati N, Lin PH, Lumsden AB, et al. Prolonged renal artery occlusion after endovascular aneurysm repair: endovascular rescue and renal function salvage. J Vasc Surg. 2008; 47: 446-449.5 Jongkind V, Kievit JK, Wiersema AM, Recovery of renal function after prolonged anuria in acute suprarenal aortic occlusion. Ann Vasc Surg. 2016; 30: 307.e11 -307.e14.

Composed revascularization techniques for rescue endovascular management of acute occlusion of abdominal aorta and renal arteries

Paweł Latacz

Marian Simka

Marcin Krzanowski

Joanna Dolipska

Władysław Sulowicz

Crossref

Rescue endovascular management of acute occlusion of abdominal aorta and renal arteries using composed revascularization techniques

https://ruj.uj.edu.pl/xmlui/bitstream/handle/item/143185/latacz_et-al_composed_revascularization_techniques_2018.pdf?sequence=1&isAllowed=y

Composed revascularization techniques for rescue endovascular management of acute occlusion of abdominal aorta and renal arteries

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