A Study of Left Renal Artery Pseudoaneurysm With Multiple Fractures of Stent

ABSTRACT: Percutaneous renal angioplasty with stenting is the predominant method of intervention for artherosclerotic renal artery stenosis. We present the relatively rare complication of formation of pseudoaneurysm after stent fracture in the case of a 74-year-old male with flash pulmonary edema and severe hypertension associated with renal artery stenosis and stenting, followed by formation of a large pseudoaneurysm in his left renal artery. We discuss management of such patients. We recommend that clinicians perform follow-up imaging on patients undergoing renal artery angioplasty for restenosis of renal artery stent to rule out the possibility of stent fracture and pseudoaneurysm formation.

VASCULAR DISEASE MANAGEMENT 2014;11(5):E108-E113

Key words: renal artery stenosis, pseudoaneurysm, stenting, complications, balloon angioplasty

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Renovascular disease affects approximately 2 million to 4 million people in the United States every year. Stenting has become the standard endovascular intervention for atherosclerotic lesions.^1-8 The prevalence of renal artery stenosis (RAS) is high in patients with peripheral vascular disease, renal insufficiency, and coronary heart disease.^9-14 The incidence among Medicare patients, as of 1999-2001 was reported as 3.7 per 1,000 patient years.¹⁵ The prevalence of RAS among certain at-risk populations varies from 3% to 75%.^16-18

RAS is generally treated medically, or with a balloon angioplasty with stenting. Indications of stenting have been changing, especially in the recent past, due to poor long-term results. Complications associated with the stenting procedure are well documented in the literature. They vary from dissection, rupture, or separation of the artery^19-22 to perforation of parenchyma^23,24 to perinephric hematoma^19,20,25 and groin complications.²⁵

A recent literature review has shown that there are very few documented cases of complications resulting from stent fracture in renal arteries^26-28 and even fewer documented cases of pseudoaneurysm following renal stent fracture,^29-31 which may not be obviously detected unless they are specifically suspected and investigated.³⁰ Reports have shown that the left renal artery may be more susceptible to stent fracture than the right renal artery.²⁶

In this paper we describe a case of left renal artery stent fracture after balloon angioplasty and subsequent pseudoaneurysm formation. 

Case Presentation

A 74-year-old male was admitted with shortness of breath and flash pulmonary edema. He was severely hypertensive and had elevated brain natriuretic peptide (BNP) of 4,340. There was an underlying history of heart disease, bilateral renal artery stenosis, methicillin-resistant Staphylococcus aureus hip infection, and recurrent flash pulmonary edema. 

Treatment

The patient had been aggressively managed for hypertension and for ischemic heart disease. Bilateral renal artery stenosis intervention had been performed, with bilateral proximal renal artery stents (6 mm x 18 mm, Medtronic stents) placed approximately 1 year prior to presentation. The patient had an angioplasty (6 mm x 20 mm balloon catheter) of left renal artery 8 months later for restenosis within the stent (Figure 1).

During the current admission, the patient was diuresed, which resulted in some improvement of his symptoms and a dobutamine stress echocardiogram was performed, which showed posterior wall hypokinesis with stress. Ten days after admission, a diagnostic catheterization procedure was performed, which showed a lesion in the obtuse marginal vessel and pseudoaneurysm at the site of the left renal artery stent with multiple fractures of stent struts (Figure 2). An abdominal computed tomography angiography was performed to better define the pseudoaneurysm, which showed a circumferential pseudoaneurysm at the area of the stent without a neck and with thin walled encapsulation (Figures 3 and 4).

Of interest was that the patient had previous left common iliac aneurysms, which had been treated with covered stents. A tagged white blood cell (WBC) scan of this area was obtained to rule out mycotic aneurysm because the patient had previous iliopsoas abscess and infected left hip hardware. The WBC scan was negative. 

Results

The patient was treated medically, stabilized, and discharged. Five days post discharge, the patient was readmitted with shortness of breath and flash pulmonary edema, and was again treated medically. A covered stent was not placed because the patient became septic and subsequently expired, possibly due to sepsis complications and precluding any further treatment.

Clinically significant RAS diagnosis and treatment options have been a dilemma for clinicians. Indications for treatment with balloon angioplasty and stenting have been an issue of debate. It is unclear when and how to treat patients and results have been varying. The embolic protection device, although used for renal artery stenting, has been an important development and may benefit clinical outcomes, but studies so far have only included a small number of patients. Complications after RAS angioplasty and stenting include access site complications, as secondary to renal artery dilatation, embolization, wire perforations, and loss of renal function.

Here we discuss a case with renal artery stenosis causing severe uncontrolled hypertension and flash pulmonary edema. The patient showed an immediate abatement of symptoms after bilateral renal artery stenting. However this was followed by restenosis of the left renal artery stent and subsequent balloon angioplasty. Thereafter it was discovered that the patient had stent fractures with the development of a pseudoaneurysm. It was interesting to note that the pseudoaneurysm did not have a neck as ordinarily seen, but was all around the proximal artery and contained by a thin wall of tissue. This was likely due to the stent fracture causing a perforation leading to a leak contained by the surrounding tissue. The patient’s local symptoms had remained stable, but he had uncontrolled hypertension and multiple admissions for pulmonary edema.

The association between stent fractures and pseudoaneurysm in peripheral arteries other than the renal artery is well documented. However a review of current literature shows that there have been few reported cases of stent fractures in the renal artery in recent years and only 1 case associated with pseudoaneurysm.^26-29,31 There is an apparent relationship between incidence of pseudoaneurysm and stent fractures. However, it is unclear whether spontaneous stent fractures result in a pseudoaneurysm or if the dilation of a restenotic stent with balloon angioplasty and the resultant stent fracture causes pseudoaneurysms. 

Management of pseudoaneurysm in renal arteries is through observation, surgery, or percutaneous exclusion of the pseudoaneurysm.^20,23,32,33 Currently there are no guidelines detailing which of these options is best. We chose to observe the patient and prepare for excluding the pseudoaneurysm with a covered stent. However the approach and choice of self-expanding vs balloon expanding covered stents is debatable. 

Conclusion

As evidenced by the literature, stent fractures resulting in pseudoaneurysm in the renal artery are a rare occurrence or underdiagnosed. Based on our experience we recommend that patients with stent fractures in renal arteries undergo imaging to exclude pseudoaneurysm, as this can result in increased morbidity and mortality. 

Editor’s Note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content of this manuscript. 

Manuscript submitted October 16, 2013; provisional acceptance given November 13, 2013; final version accepted November 26, 2013. 

Address for correspondence: Lamiya Sheikh,Washington Hospital Healthcare System, Department of Cardiology, 2500 Mowry Avenue, Fremont, CA 94538, United States. Email: lamiya_sheikh@whhs.com. 

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