- Case Report
- Open Access
Renal artery rupture following cutting balloon angioplasty for fibromuscular dysplasia: a case report
© Brountzos et al.; licensee Cases Network Ltd. licensee BioMed Central Ltd. 2009
- Received: 20 August 2009
- Accepted: 24 August 2009
- Published: 14 September 2009
Angioplasty with the use of cutting balloons has been suggested by some case reports and small series for the treatment of renal artery stenoses that are resistant to conventional balloon catheters. Based on this limited experience, the use of this technology has been suggested as safe. Herein, we report a renal artery rupture following angioplasty with a cutting balloon. The complication was salvaged with a stent graft.
A 30-year-old white female patient with resistant hypertension caused by a severe renal artery stenosis attributed to fibromuscular dysplasia, was submitted to conventional balloon angioplasty without success. Dilatation of the lesion with a cutting balloon resulted in arterial rupture, with concomitant retroperitoneal hematoma.
Cutting balloon angioplasty of renal artery lesions resistant to conventional balloon angioplasty should not be considered as safe as previously thought. When proceeding with such a procedure, a stent graft should be available for immediate use.
- Renal Artery
- Balloon Angioplasty
- Stent Graft
- Fibromuscular Dysplasia
- Conventional Balloon
Renal artery stenoses are the cause of hypertension in only 1% to 5% of the hypertensive patients. While atherosclerotic occlusive lesions consist the majority of renal artery lesions, the most common cause of renal artery lesions in young individuals is fibromuscular dysplasia (FMD). The most common type of FMD is medial fibroplasia, while intimal and perimedial FMD are less common [1, 2].
Percutaneous balloon angioplasty is the first-line treatment for young individuals with hypertension caused by FMD renal artery stenoses . Renal artery FMD lesions of the medial fibroplasia type respond favorably to balloon angioplasty with a technical success of 90% and clinical success rate of 85%, the other FMD types are more difficult to treat because they are more fibrotic and elastic -. Recently, few case reports and small series have introduced the cutting balloon angioplasty (CBA) in the management of non-atherosclerotic renal artery lesions that do not respond to conventional balloon angioplasty. These reports suggest that this technology is effective where the conventional approach has failed and is relatively safe -.
We present a hypertensive female patient with a renal artery FMD lesion which was not responsive to conventional angioplasty and was treated with CBA. The lesion was dilated but the intervention was complicated by renal artery rupture and retroperitoneal hematoma. The patient was salvaged with the use of a stent-graft.
Our patient is 30-year-old, white female, single, of Greek ethnicity. At the time of her admission her height was 170 cm, and weight was 62 kg. Her medical history and family history were unremarkable. She reported that she was not smoking or using alcohol.
The technical failure of the procedure predicted a clinical failure, so the decision to proceed with CBA was taken after discussing the risks and benefits with the patient. Also the vascular surgery department was informed and consented to this decision.
She undergoes regular clinical and ultrasonographic follow up. She is normotensive without medications while the Doppler ultrasonography of the right renal artery is normal one year after the intervention.
FMD is defined as an idiopathic non-atherosclerotic, non-inflammatory disease. Pathologically three types of FMD have been described: the medial fibroplasia which accounts for nearly 85% of the renal artery FMD lesions and is characterized by alternating webs and aneurysms; the intimal type which accounts for 5% and it is characterized by irregularly arranged mesenchymal cells within a loose matrix and fragmented elastic lamina; perimedial FMD consists approximately 10% of cases and is characterized by excessive tissue deposition at the junction of the media and adventitia [1, 2].
Pathological angiographic correlation has shown that the alteration of web and aneurysms which produces the "string-of-beads" sign in angiography is typical of the medial type of FMD, while focal or tubular lesions cannot with certainty be attributed to specific histological types of FMD . However, some authorities believe that a focal lesion is consistent with the intimal type of FMD .
Percutaneous balloon angioplasty is currently considered the first line treatment for young hypertensive patient with renal FMD lesions [2, 3]. For the small subset of these patients, whose lesions are resistant to balloon angioplasty, there only therapeutic alternative was until recently open surgery.
Since its introduction in 1991, the indications of the CBA were the management of vascular stenoses that were resistant to conventional balloon angioplasty . These among others include arterial stenoses in coronaries and pulmonary arteries, venous stenoses, and in-stent stenoses . More recently, CBA has been used for peripheral arterial stenoses . Haas et al first reported, in 2002, of a 12-year old boy with a stenotic lesion of the left renal artery that was successfully dilated with CBA. They reported of minimal extravasation that healed spontaneously . To our knowledge, there are to date 15 patients reported for CBA treatment of renal artery lesions of various etiologies, while in seven of them the lesions were attributed to FMD with certainty -. In none of these seven patients the angiographic appearance was of the "beads-of-strings" type, the lesions were rather focal or tubular, suggestive of the hard-to-treat type of renal artery FMD [4, 5, 8]-. In six of the seven patients CBA was successful, while in one there was a failure because the renal artery ruptured . This patient was operated because balloon tamponade failed to seal the rupture, while attempts to use a stent graft failed because the authors used a balloon expandable device which was very rigid to be navigated into the tortuous renal artery. In three of the successful cases the procedure was complicated by an extravasation (n = 2) or a dissection (n = 1). In one patient who was followed up for a longer time the development of a false aneurysm was reported , while in the remaining no long term follow up is available.
Our patient suffered from hypertension caused by a hard-to-treat type of renal artery FMD, most probably the intimal type. Although histological confirmation was not available, on the basis of angiographic appearance our patient had similar lesion to that of Oguzurt et al. Our decision to proceed to CBA was encouraged by the increasing enthusiasm dwelling in the literature. Our fault might have been that we used a CBA with diameter matching the normal diameter of the renal artery, instead of using an undersized CBA to induce intimal incisions and then dilate further with a conventional balloon catheter . We were able however to salvage the complication by using a self expandable stent-graft of the appropriate length and diameter.
The take-home message from our case report is that the use of CBA for the management of resistant to conventional angioplasty renal artery FMD lesions should not be considered as safe as previously thought. Because salvage of a renal artery rupture with a stent graft is depended not only on their immediate availability in the interventional radiology suite, but also on the renal artery anatomy, we suggest that patients with FMD lesions resistant to conventional angioplasty should be given the option of open surgery, while cutting balloon angioplasty should be considered a second line treatment for this group of patients. Had the interventionist made the decision to proceed with CBA, he or she should use an undersized CBA, and leave a sheath in the renal artery ostium throughout the procedure, which could accommodate a stent-graft of the appropriate dimensions.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
ENB was the first operator of the procedure, has analyzed the data and has written the manuscript; NP was the second operator, and has performed literature search; HT and IP have evaluated the patient clinically initially and during follow and have contributed to the writing of the manuscript; TNS has critically analyzed the literature data; EPM, and AK have critically evaluated the data and edited the manuscript. All authors have read and approved the final manuscript.
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