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Renal angiogram of the patient. (A) Significant stenosis at right renal artery bifurcation. (B) Deployment of Genesis stent at main branch and PROMUS stent at side branch using provisional T-stenting technique. (C) After stent placement revealing a patent renal artery with no residual stenosis. (D) Follow-up angiogram showing 20% mild stenosis in main branch and minimal stneosis in side branch.
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Figure 1: Renal angiogram of the patient. (A) Significant stenosis at right renal artery bifurcation. (B) Deployment of Genesis stent at main branch and PROMUS stent at side branch using provisional T-stenting technique. (C) After stent placement revealing a patent renal artery with no residual stenosis. (D) Follow-up angiogram showing 20% mild stenosis in main branch and minimal stneosis in side branch.

Mentions: A 66-yr-old man with history of hypertension, diabetes mellitus, and atrial fibrillation was hospitalized for evaluation of chest pain and control of resistant hypertension on 17 July, 2009. Despite pharmacologic therapy of nebivolol (10 mg daily), amlodipine (5 mg daily), and hydrochlorothiazide (25 mg daily), his blood pressure remained elevated in the range of 180-190/70-90 mmHg. The creatinine was within the normal range (1.1 mg/dL). Coronary angiography was performed for evaluation of chest pain. The test revealed 80% stenosis of the proximal left circumflex artery and diffuse stenosis of the proximal to mid-right coronary artery followed by coronary stenting with the left circumflex artery and the right coronary artery. Subsequent to the evaluation of the resistant hypertension, a renal angiography was obtained, which revealed a nonvisualized left kidney and severe stenosis of the right renal artery bifurcation involving both branches (Fig. 1A). Contrast-enhanced abdominal computed tomography demonstrated atrophic change of the left kidney and stenosis of the right renal artery. On the 4th day of admission, the decision was made to treat the stenosis of the right renal artery bifurcation. An 8 Fr renal double curve (RDC) catheter (Boston Scientific, Natic, MA, USA) was positioned at the ostium of the right renal artery. Two 0.014-inch reflex upper soft wires (Cordis, Miami Lakes, FL, USA) were then placed into each branch vessel of the main renal artery. Kissing balloon angioplasty of the bifurcation was performed using appropriately sized balloons. After the angioplasty, a 7.0 × 24 mm Genesis stent (Cordis, Miami Lakes, FL, USA) was deployed into the main branch (upper pole). This resulted in a "snowplowing" effect, shifting plaque to the side branch (lower pole). A 3.5 × 12 mm PROMUS stent (Boston Scientific, Galway, Ireland) was then deployed into the side branch using provisional T-stenting technique (Fig. 1B). Finally, the main branch was post-dilated with a 6.0 × 12 mm ultrasoft SV balloon (Boston scientific, Natic, MA, USA) at 18 atm, and the side branch was post-dilated with a 3.5 × 12 mm Sprinter legend balloon (Medtronic, Minapolis, MN, USA) at 18 atm in a kissing fashion. An angiogram after stent placement demonstrated widely patent bifurcational stents with normal flow patency (Fig. 1C). Blood pressure was well controlled and the patient was discharged in stable condition. After 18 months, a follow-up angiogram showed mild stenosis in the main branch and the side branch ostium (Fig. 1D). Because the blood pressure was well controlled and lumen diameter loss was less than 30%, the lesion was not treated.

Use of Drug-Eluting Stent with Provisional T-Stenting Technique in the Treatment of Renal Artery Bifurcation Stenosis; Long-term Angiographic Follow-up

Ahn J, Park SH, Shin WY, Lee SW, Lee SJ, Jin DK, Kim D, Kim TH - J. Korean Med. Sci. (2011)

Bottom Line: Atherosclerotic renal artery stenosis (RAS) usually involves the ostium and the proximal one-third of the renal artery main branch.Percutaneous renal artery angioplasty with stent placement is a well recognized treatment for atherosclerotic RAS.Follow-up angiogram showed no significant ISR 18 months after the procedure.

Affiliation: Department of Internal Medicine, Soonchunhyang University Gumi Hospital, Gumi, Korea.

ABSTRACT
Atherosclerotic renal artery stenosis (RAS) usually involves the ostium and the proximal one-third of the renal artery main branch. Percutaneous renal artery angioplasty with stent placement is a well recognized treatment for atherosclerotic RAS. Occasionally, atherosclerotic RAS involves renal artery bifurcations. However, stent implantation in atherosclerotic RAS involving bifurcation is not only troublesome, but also challenging because of side branch occlusion and in-stent restenosis (ISR). In the present report, we describe the use of drug-eluting stents (DES) with provisional T-stenting technique for the treatment of renal artery bifurcation lesion. Follow-up angiogram showed no significant ISR 18 months after the procedure. In the treatment of renal bifurcation lesions, a two-stent strategy using DES could be a viable option in selected patients.

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