Orbital Atherectomy in the Renal Artery: A New Frontier for an Emerging Technology?

Abstract: Orbital atherectomy has been developed as a method to modify calcified plaque in the peripheral vasculature, with extensive experience and data supporting its use in infrainguinal peripheral arterial disease. However, calcific atherosclerotic disease occurs in other vascular beds and may benefit from the application of this technology. In this case report, we describe the first reported use of orbital atherectomy in a renal artery. A 55-year-old male with severe drug-refractory hypertension was found to have renal artery stenosis, with severe calcification of the right renal artery. Orbital atherectomy was utilized for initial plaque modification, and he underwent stenting of the renal artery lesion with an excellent angiographic and clinical result at follow-up. In conclusion, orbital atherectomy is a safe and effective means of plaque modification for severely calcified lesions. The safe and effective use of orbital atherectomy in the renal vasculature suggests an opportunity for ongoing evaluation into expanded roles for this technology beyond the coronary and lower-extremity arterial beds.

J INVASIVE CARDIOL 2017;29(1):E10-E12.

Key words: peripheral arterial disease, peripheral vascular intervention, atherectomy

The optimal treatment of severely calcified lesions in the peripheral vasculature has been the subject of intense investigation. Previous research has suggested that percutaneous transluminal angioplasty (PTA) of highly calcified lesions is associated with higher rates of procedural complications, including target-vessel dissection and the need for bailout stenting.¹ Orbital atherectomy has been developed as a method to optimize plaque modification and increase lesion compliance in severely calcified lesions. In doing so, orbital atherectomy may minimize procedural complications including peripheral arterial dissection.² Observational cohorts and randomized study data have demonstrated the safety and efficacy of this technology in severely calcified coronary artery disease and infrainguinal peripheral arterial disease.³ However, calcific atherosclerotic disease occurs in other vascular beds and may benefit from the application of this technology.

Renal arterial calcification is relatively common, occurring in approximately 20% of patients with peripheral arterial disease. In addition, previous research has demonstrated that renal artery calcification is associated with the development of resistant hypertension.⁴ Severe calcification of the renal artery can create technical challenges among patients undergoing percutaneous renal artery revascularization for the treatment of symptomatic renal artery stenosis. In this case, we report the successful use of orbital atherectomy followed by stent placement in a hypertensive patient resistant to multiple medications with heavily calcified renal artery stenosis.

Case Presentation

A 55-year-old male with a past medical history of peripheral arterial disease and claudication, as well as severe drug-resistant hypertension was found to have severe renal artery stenosis. Despite management with four antihypertensive medications, his systolic blood pressure remained persistently >180 mm Hg. He was referred for renal artery stenting, and as part of his evaluation underwent computed tomography that demonstrated a heavily calcified aorta and calcified anterior take-off of the right renal artery (Figure 1).

A 6 Fr multipurpose guide catheter was used to engage the right renal artery from a left radial approach. Initial angiography is demonstrated in Figure 2 and Video 1. A 0.014˝ Grand Slam wire (Asahi Intecc) was advanced into the right renal artery, and intravascular ultrasound was performed for vessel sizing (Figure 3). A microcatheter was then used to exchange the Grand Slam wire for a coronary ViperWire (Cardiovascular Systems, Inc), which was advanced into the distal right renal artery. A Diamondback 360 Coronary Orbital Atherectomy System (Cardiovascular Systems, Inc) using a 1.25 classic coronary crown was advanced over the ViperWire and used to perform orbital atherectomy to the ostial right renal artery using two passes at low and high speeds (Figures 4 and 5). Following atherectomy, a 3.5 mm Angiosculpt scoring balloon (Spectranetics) was advanced over the wire to the proximal right renal artery and inflated for predilation. A 5.0 x 19 mm Express SD renal/biliary stent (Boston Scientific) was advanced over the wire into the renal artery ostium and deployed. A 5.5 x 15 mm Maverick XL balloon (Boston Scientific) was advanced over the wire for postdilation. Final angiography was performed (Figure 6 and Video 2) and demonstrated an excellent angiographic result. Follow-up with the patient has demonstrated continued renal stent patency, without adverse events and improved hypertension control.

Discussion

Calcific atherosclerotic disease in the peripheral vasculature is prevalent, and presents unique and complex technical challenges for revascularization. Orbital atherectomy is an emerging technology that has demonstrated promise in calcific coronary and infrainguinal peripheral vascular disease. Here, we demonstrate the safe and effective use of orbital atherectomy in the renal vasculature, a novel application of this emerging technology that has not been previously reported. The safe and effective use of orbital atherectomy in the renal vasculature suggests an opportunity for ongoing evaluation into expanded roles for this technology beyond the coronary and lower-extremity arterial beds.

Conclusion

Orbital atherectomy is an emerging technology in the treatment of calcific vascular disease, and an opportunity exists to evaluate the expansion of its use beyond coronary and lower-extremity vascular beds.

References

1.     Shammas NW, Lam R, Mustapha J, et al. Comparison of orbital atherectomy plus balloon angioplasty vs. balloon angioplasty alone in patients with critical limb ischemia: results of the CALCIUM 360 randomized pilot trial. J Endovasc Ther. 2012;19:480-488.

2.    Dattilo R, Himmelstein SI, Cuff RF. The COMPLIANCE 360 degrees trial: a randomized, prospective, multicenter, pilot study comparing acute and long-term results of orbital atherectomy to balloon angioplasty for calcified femoropopliteal disease. J Invasive Cardiol. 2014;26:355-360.

3.    Das T, Mustapha J, Indes J, et al. Technique optimization of orbital atherectomy in calcified peripheral lesions of the lower extremities: the CONFIRM series, a prospective multicenter registry. Catheter Cardiovasc Interv. 2014;83:115-122.

4.    Allison MA, Lillie EO, DiTomasso D, et al. Renal artery calcium is independently associated with hypertension. J Am Coll Cardiol. 2007;50:1578-1583.

From the ¹University of Colorado; Denver, Colorado; and ²Veterans Affairs Eastern Colorado Health Care System, Denver, Colorado.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Valle is supported by NIH T32 grant HL0782. Dr Armstrong has received educational grants from Cardiovascular Systems, Inc. and serves on the consultant/advisory boards for Abbott Vascular, Medtronic, and Spectranetics. Dr Waldo is supported by grant funding from Merck, Inc.

Manuscript submitted July 11, 2016, final version accepted July 19, 2016.

Address for correspondence: Javier A. Valle, MD, Fellow in Cardiovascular Diseases, University of Colorado School of Medicine, 12361 East 17th Avenue, B130, Denver, CO 80045. Email: javier.valle@ucdenver.edu