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Clinical Images

Intravascular Ultrasound-Guided, Lithotripsy-Facilitated Angioplasty for Treating a Heavily Calcified Renal Artery Stenosis

Konstantinos Aznaouridis, MD, PhD; Kyriakos Dimitriadis, MD, PhD; Stergios Soulaidopoulos, MD; Charalambos Vlachopoulos, MD, PhD; Konstantinos Tsioufis, MD, PhD

June 2024
1557-2501
J INVASIVE CARDIOL 2024;36(6). doi:10.25270/jic/23.00306. Epub February 28, 2024.

© 2024 HMP Global. All Rights Reserved.
Any views and opinions expressed are those of the author(s) and/or participants and do not necessarily reflect the views, policy, or position of the Journal of Invasive Cardiology or HMP Global, their employees, and affiliates.


A 63-year-old woman with uncontrolled hypertension despite taking 5 antihypertensive medications was referred for percutaneous renal artery intervention. Duplex ultrasonography had shown critical left renal artery stenosis (RAS), and computed tomography angiography confirmed the presence of a tight, heavily calcified ostioproximal left RAS, as well as circumferential calcification of the abdominal aorta adjacent to the left renal artery take-off (Figure 1).

 

Figure 1.  Computed tomography angiography
Figure 1. Computed tomography angiography. (A) Severely calcified ostium of left renal artery and almost circumferential heavy calcification of the adjacent abominal aorta. (B) Tight ostioproximal stenosis of the left renal artery in contrast-enhanced image.

 

Renal artery angiogram through the right femoral artery demonstrated a critical severe (> 90%) ostioproximal left RAS (Figure 2A; Video 1) and a non-critical right RAS. Left renal artery was engaged with a 6-French renal double curve guide catheter, and a 300-mm 0.014-inch Regalia XS wire (Asahi) was advanced into a renal artery branch. Intravascular ultrasound (IVUS) showed a 6.0- to 6.2-mm reference diameter with metastenotic dilation up to approximately 7.5 mm, and severe superficial and deep calcification at the site of the RAS (Figure 2B)A Shockwave 5 x 60-mm intravascular lithotripsy (IVL) balloon was advanced across the lesion, and the guide catheter was withdrawn into the abdominal aorta. A total of 180 pulses was administered (6 cycles of 30 pulses each), as the initial cycles did not allow adequate expansion of the IVL balloon (Figure 3A, B; Videos 2 & 3). The lesion was then dilated with a 5 x 20-mm non-compliant balloon, and finally a 6 x 18-mm Express stent (Boston Scientific) was deployed with excellent angiographic result, which was confirmed with IVUS (Figure 3C-F; Videos 4-7).

 

Figure 2.  Renal artery stenosis
Figure 2. (A) Critical ostioproximal left RAS (arrow) (B) Extensive superficial (arrows) and deep calcification (arrowheads) at the site of the left RAS with intravascular ultrasound. RAS = renal artery stenosis.

 

Figure 3.  Renal artery intervention
Figure 3. Renal artery intervention. (A) The Shockwave intravascular lithotripsy balloon remained unexpanded after first therapies (arrow), (B) but expanded fully after the 5th Shockwave therapy. A 6 x 18-mm stent is (C) positioned and (D) deployed with excellent (E) angiographic and (F) intravascular ultrasound result.

 

Three weeks later, the patient had well-controlled blood pressure on 3 antihypertensive medications. Seven months later, the patient had a diagnostic angiogram through the right radial artery due to angina, while her hypertension was optimally controlled. A subsequent renal angiogram showed a patent stent without restenosis (Video 8).  

Percutaneous intervention is an effective treatment in patients with severe RAS and uncontrolled hypertension. Severe calcification of renal artery ostium and adjacent abdominal aorta increases the risk of complications during angioplasty (such as perforation and dissection) and may be related to poor stent expansion. Our case shows that Shockwave IVL is safe and effective in the treatment of severely calcified aortoostial/ostioproximal RAS. Shockwave IVL does not debulk calcified plaques but delivers sonic waves which selectively fragment calcium deposits in the arterial wall, modify the compliance of the lesions, and facilitate stent delivery. Pre-procedure IVUS is crucial in interrogating the calcium burden and assessing the need for Shockwave IVL.  

 

Affiliations and Disclosures

From the 1st Department of Cardiology, Hippokration Hospital, National and Kapodistrian University of Athens, Athens, Greece

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Konstantinos Aznaouridis, MD, PhD, 1st Department of Cardiology, Hippokration Hospital, 114 Vas. Sofias avenue, Athens 11527, Greece. Email: conazna@yahoo.com

 


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