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C A S E R E P O R T Open Access
Revascularization of a single-kidney
occluded stent for renal salvage
complicated by guide wire distal artery
perforation and reperfusion injury
Angeliki Pastroma
1*
, Stavros Spiliopoulos
2
, Konstantinos Palialexis
2
, Lazaros Reppas
2
and Elias Brountzos
2
Abstract
Background: The complexity of the case, including the rarefied simultaneous occurrence of complications—
iatrogenic, as well as reperfusion injury, invite reporting and publication.
Case presentation: A 39-year-old woman with a single-functioning left kidney, previous left renal artery stenting
(RAS), and known hypercoagulopathy was hospitalized for flash pulmonary edema, elevated serum creatinine (9.7
mg/dl), and refractory hypertension. She was subsequently referred to our center [2] for endovascular treatment of
acute renal ischemia (AKI) due to RAS occlusion.
Periprocedural complications of guide-wire arterial perforation and reperfusion injury resulted in life-threatening
hemorrhage.
Conclusions: Following more than 48 h of hypoperfusion of the left kidney, revascularization of the thrombosed
RAS was successfully attempted with selective, trans-catheter thrombolysis, and balloon angioplasty. Ultra-selective,
nephron-sparing coil embolization was successfully performed. The patient’s creatinine level decreased to 2.8 mg/dl
at 12 days and to 1.5 mg/dl at 3 months. After 1 year of follow-up, the stent remains patent, and the patient is
asymptomatic with stable renal function.
Keywords: Acute renal ischemia, Endovascular treatment, Balloon angioplasty, Trans-catheter arterial thrombolysis
Background
In the setting of renovascular hypertension (RVHT),
anti-hypertensive drugs are indicated as initial treatment,
while endovascular revascularization (RAS) is preserved
for refractory cases, or as renal-salvage procedure in
single-kidney cases with significant renal artery stenosis
and deteriorating renal function [1]. As the American
Heart Association/American College of Cardiology
(AHA/ACC) guidelines do not match utterly those of
the European Society of Cardiology (ESC) considering
the indications for percutaneous revascularization, the
SCAI expert consensus concluded in 2014 that the can-
didates fit for renal artery stenting should present with
cardiac disturbance syndromes, like flash pulmonary
edema, as in our case, or acute coronary syndrome,
hypertension resistant to medical treatment, not con-
trolled by three or more medications at maximal doses,
bilateral renal stenosis, or severe stenosis in a single-
functioning kidney not controlled medically [2]. Positive
outcomes following RAS have been reported in 96 to
100% of cases, with complications occurring in approxi-
mately 14%, including renal artery rupture/dissection,
distal embolization, contrast-induced nephropathy, renal
bleeding, and stent thrombosis leading to acute kidney
ischemia (AKI) [3–5]. Acute kidney ischemia is a med-
ical emergency and should be treated immediately, as
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* Correspondence: angeliki.pastroma@gmail.com
1
Department of Radiology, Metropolitan Hospital, Piraeus, Greece
Full list of author information is available at the end of the article
Egyptian Journal of Radiolog
y
and Nuclear Medicin
e
Pastroma et al. Egyptian Journal of Radiology and Nuclear Medicine
(2020) 51:178
https://doi.org/10.1186/s43055-020-00284-1
high rates of kidney loss have been reported in the lit-
erature after over 5 h of ischemia, despite revasculariza-
tion [6].
Case presentation
A 39-year-old woman was emergently referred to our hos-
pital with dyspnea, tachypnea, elevated serum creatinine
and urea (9.7 mg/dl and 173.5 mg/dl respectively), and re-
fractory hypertension (190/85 mmHg). The patient was
initially admitted to another hospital for flash pulmonary
edema and deterioration of her previously medically con-
trolled hypertension The patient was known with hyper-
coagulopathy (positive for Factor V G1691A (FV-Leiden)
mutation) and single-functioning left kidney with previ-
ously treated stenotic left renal artery by balloon-
expandable stent placement (12 months ago). The right
renal artery was occluded, according to digital subtraction
angiography (DSA). She was regularly followed up by a
nephrologist, with a relatively stable serum creatinine level
at 1.3 mg/dl, and was systematically prescribed clonidine,
nifedipine, and acetylsalicylic acid (ASA).
Prior to her referral to our hospital’s Interventional
Radiology Unit, a duplex ultrasound (DUS) was per-
formed, which demonstrated a markedly increased flow
velocity within the proximal left renal artery, with a
maximal velocity above 350 cm/s, along with aliasing ar-
tefacts within the stent, which appeared to be occluded.
The intrarenal resistance index was also markedly re-
duced. The right kidney was morphologically diminished
in size with concomitant loss of cortical thickness. The
diagnosis of over 48 h, acute renal ischemia (ARI) was
made and taking into consideration the radiological find-
ings, in addition to the patient’s young age and gravely
impaired renal function, a multidisciplinary team
concluded that urgent endovascular treatment was ap-
propriate. The patient was treated with intravenous hep-
arin infusion during hospitalization, which was stopped
12 h prior endovascular treatment.
Following skin antisepsis at the right groin with
povidone-iodine solution scrub, administration of
prophylactic intravenous antibiotics (cefazolin) and
local anesthesia, a right common femoral artery ac-
cess was obtained using a 6F sheath. “A bolus intra-
arterial dose of unfractionated heparin 5000 IU was
administrated through the sheath. Standard heparin-
ized saline was used during the procedure.”Angiog-
raphy with a pigtail catheter within the aorta at the
level of the renal arteries depicted occlusion of the
right renal artery and occlusion of the stent at the
origin of the left renal artery (Fig. 1a). However, the
renal artery distal to the stent remained perfused by
collaterals and appeared patent at delayed DSA im-
ages (Fig. 1b). The occluded stent was successfully
catheterized using a 5Fr USL 2 catheter (Cordis,
USA) and in-stent thrombus was depicted (Fig. 1c).
A bolus dose of rtPA 5 mg was administrated
through the catheter within the thrombus. The lesion
was then surpassed using a 0.018 in. guide wire (V18,
Boston Scientific, USA), and angioplasty was per-
formed with a 5.5 × 40 mm, low-profile, mono-rail,
angioplasty balloon catheter (Submarine Rapido; Inva-
tec S.p.A, Italy) (Fig. 2a). During balloon angioplasty,
the patient experience left flank pain, and the looped
V18 guide wire was noted to be erroneously advanced
within the distal renal branches (Fig. 2b, c). During
the final DSA, extravasation of contrast media was
depicted at the site of guide wire manipulation, but
also at multiple sites of the kidney irrelevant to
Fig. 1 aDSA at the level of the renal arteries demonstrating bilateral renal artery occlusion. bDelayed phase demonstrating perfusion of the
distal renal artery (arrow) from collateral network. cSelective catheterization of the occluded stent and contrast infusion demonstrating in-stent
thrombosis with characteristic contrast media feeling defects (circle)
Pastroma et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:178 Page 2 of 5
guide-wire distal migration and therefore attributed to
reperfusion injury (Fig. 3a). The patient’s flank pain
increased remarkably, the systolic blood pressure
dropped from 190 mmHg to 120 mmHg, and a sig-
nificant sub capsular hematoma was noted during
parenchymal phase DSA (Fig. 3a). Nephron-sparing,
ultra-selective, coil embolization was performed (Fig.
3b, c) using a microcatheter (Progreat, Terumo,
Japan) and by deploying two pushable 3 × 40 mm
and 3 × 70 mm micro-coils (Nester, Cook, USA).
However, following embolization extravasation was
still noted, at the site of guide wire trauma while all
the other sites of extravasation were not depicted
(Fig. 3c). The feeding branch was catheterized with
the microcatheter and another pushable 3 × 140 mm
micro-coil was deployed (Fig. 3d). The vessel ap-
peared occluded at fluoroscopy with minimal contrast
infusion, and final DSA was not performed as the
operator was convinced that the bleeding was stopped
and further contrast media administration was
deemed unnecessary and harmful to the already com-
promised renal function. Supportive conservative
treatment was initialized, and the patient was trans-
fused with three units of blood and remained
hemodynamically stable.
After 12 days, the patient was discharged with normal
blood pressure, serum creatinine level of 2.8 mg/dl, urea
115.2 mg/dl, and hemoglobin 10.2 mg/dl along with elec-
trolytes within normal range. After 1 month, the creatinine
level was 2.1 mg/dl, which after 3 months returned to
nearly baseline value of 1.5 mg/dl. The patient was pre-
scribed dual antiplatelet therapy (clopidogrel 75 mg and as-
pirin 100 mg once daily) for 1 year and was scheduled for a
strict clinical and DUS follow-up at 1, 3, 6, and 12 months.
After 1 year of follow-up, the stent remains patent and the
patient is asymptomatic with stable renal function.
Fig. 2 aBalloon angioplasty of the origin of the renal artery and proximal stent segment, followed by 2nd balloon inflation more distally within
the stent and the renal artery (b). Note the accidental distal migration of the guide wire (arrows)
Fig. 3 aFinal DSA demonstrating multiple foci of active extravasation at the upper, middle, and lower pole of the kidney (arrowhead) with
corresponding large subcapsular hematoma (double arrow). bSelective DSA following the first coil embolization of one renal artery branch
depicted a remaining site of active bleeding at the point of guide-wire distal migration (arrow). cNote that all other foci of extravasation are not
depicted anymore. dFluoroscopic image following second coil embolization of the more caudal renal artery branch
Pastroma et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:178 Page 3 of 5
Discussion
We describe the case of a young adult with thrombophi-
lia, suffering from right functional nephrectomy and sig-
nificant left renal artery stenosis, who underwent initial
RAS due to both uncontrollable hypertension and de-
teriorating renal function. The procedure was clinically
successful, as creatinine levels nearly normalized and
hypertension was controlled with two hypertensive
drugs. However, in-stent thrombosis occurred 12
months after stent placement, despite ongoing single an-
tiplatelet therapy, and was correlated to the patient's hy-
percoagulable state. Perhaps single antiplatelet therapy
was not adequate in this case, considering the underlying
hypercoagulopathy. For that reason, following revascu-
larization, the patient was prescribed with dual antiplate-
let therapy for at least 1 year, despite the fact that high
level of evidence and guidelines concerning the type and
duration of antithrombotic therapy in such cases do not
exist. The patient suffered from symptomatic AKI caus-
ing a hypertensive crisis and flash pulmonary edema,
due to long lasting in-stent thrombosis. According to
the literature, acute renal ischemia lasting for over 5
hours has been correlated with kidney loss despite revas-
cularization [6]. Nevertheless, successful delayed endo-
vascular revascularization of ARI even 72 h after the
occlusive event has been sporadically reported in the lit-
erature and therefore, revascularization could be
attempted in selected cases [7]. The patient’s young age,
excellent performance status, and the presence of minor
perfusion within the renal parenchyma at DUS set the
indication for the attempt of endovascular renal-salvage
revascularization, despite the long-standing ischemia.
Bilateral renal artery occlusion was confirmed by initial
DSA, while following selective catheterization of the left
renal artery, the presence of in-stent thrombus was in-
dubitably demonstrated by the characteristic pattern of
contrast filling defect. Nevertheless, acute thrombosis in
the ambit of gradually progressive renal artery stent re-
stenosis could not be ruled out. The fact that collateral
filling of the renal artery, distal to the occluded stent,
was noted at delayed phase DSA and was probably the
main factor contributing to the preservation of paren-
chymal perfusion after 48 h of ALI and ultimately renal
salvage. Direct stenting was not attempted as it was
thought that the stent would not surpass the occlusion
without balloon pre-dilation, especially in the presence
of significant restenosis. Low-profile balloon angioplasty
was successfully performed, following trans-catheter
thrombolysis. However, during the last balloon advance-
ment within the stent, the patient experienced sudden
left flank pain and the V18 guide wire was noted to be
more distally advanced than previously causing vessel
perforation and severe hemorrhage. It is known that the
specific guide-wire, if not correctly contained, can
perforate small caliber vessels. However, the V18 was
thought to provide the adequate support and lesion
“cross-ability”required in this case. Moreover, following
renal artery reperfusion, multiple bleeding sites were
noted at the upper, mid, and lower pole of the distal
renal parenchyma. As the guide-wire never approached
the specific areas, bleeding was attributed to reperfusion
injury. Sudden restoration of blood flow in previously
stenotic or occluded renal arteries may trigger kidney in-
jury [1].Hyperperfusion of ischemic tissue with oxygen-
ated blood leads to immense oxidative stress, activating
an inflammatory cascade [5]. Analogous to the cerebral
hyperperfusion syndrome following revascularization of
the internal carotid artery, the dominant hypothesis con-
sidering the mechanism of injury is loss of auto-
regulation [8,9]. While the pathophysiology remains un-
clear, it is suggested that post-procedural hyperperfusion
results in augmented pressure in the distal renal bed,
rendering it susceptible to hemorrhage [9].
Conclusion
To our knowledge, this is the first case report of iatro-
genic severe bleeding due to both accidental guide-wire
perforation and reperfusion injury attributed to the
long-standing acute renal ischemia. Despite the fact that
the exact time of in-stent thrombosis could not be deter-
mined (as in the vast majority of ARI cases reported in
the literature), this case demonstrates the value of revas-
cularization attempt in selected cases, especially when
there is strong suspicion that renal perfusion is margin-
ally preserved by collateral flow.
Abbreviations
RAS: Renal artery stenting; AKI: Acute renal ischemia; RVHT: Renovascular
hypertension; AHA/ACC: American Heart Association/American College of
Cardiology; ESC: European Society of Cardiology; DSA: Digital subtraction
angiography; ASA: Acetylsalicylic acid; DUS: Duplex ultrasound; ARI: Acute
renal ischemia
Acknowledgements
Not applicable
Authors’contributions
AP: data curation, writing original draft—editing. SS: conceptualization,
writing review—editing, procedure performance. KP: image curation,
procedure performance. LR: procedure performance, patient follow-up. EB:
supervision, validation, procedure performance. Written consent was ob-
tained from the participant prior to publication.
All authors have read and approved the manuscript before submission.
Funding
None
Availability of data and materials
Data and material used during the current study are available from the
corresponding author upon reasonable request.
Ethics approval and consent to participate
The patient included in this study/case report gave written informed
consent to undergo the medical procedure, as well as to participate in this
research.
Pastroma et al. Egyptian Journal of Radiology and Nuclear Medicine (2020) 51:178 Page 4 of 5
Consent for publication
The patient included in this study/case report gave written informed
consent to publish their data contained within this study.
Competing interests
None
Author details
1
Department of Radiology, Metropolitan Hospital, Piraeus, Greece.
2
2nd
Department of Radiology, Interventional Radiology Unit, University of Athens,
University General Hospital “Attikon”, Athens, Greece.
Received: 18 June 2020 Accepted: 9 August 2020
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