Acute Pulmonary Edema after Endovascular Treatment for Renal Artery Stenosis - Clinical Evolution after Angioplasty and Stenting in Moderate Stenosis:A Case Report
Thiago Andrade Macedo1*, Ligia Sayuri Teoi Coelho Borges1, Mateus Paiva Marques Feitosa1, Henrique Cotchi Simbo Muela2, Valeria Aparecida Costa-Hong1, Luiz Junia Kajita3, Luiz Aparecido Bortolotto1
1Division of Cardiology,
Hypertension Unit, Heart Institute (InCor), University of Sao Paulo Medical
School, Brazil
2Department of Physiology,
Faculty of Medicine, Agostinho Neto University, Luanda, Angola
3Division of Cardiology, Hemodynamic Laboratory, Heart Institute (InCor), University of Sao Paulo Medical School, Brazil
*Corresponding author: Thiago Andrade Macedo, Hypertension Unit, Cardiology Division Heart Institute (InCor), Zip Code 05403-904, São Paulo, Brazil. Tel: +551126615084; Fax: +551126615948; Email: thiago.macedo@incor.usp.br
Received Date: 11October, 2017; Accepted Date: 16October,
2017; Published Date: 23October, 2017
Citation:Macedo TA, Borges LSTC, Feitosa MPM, Muela HCS, Costa-Hong VA, et al.(2017) Acute Pulmonary Edema after Endovascular Treatment for Renal Artery Stenosis - Clinical Evolution after Angioplasty and Stenting in Moderate Stenosis: A Case Report. J Urol Ren Dis 2017: 159. DOI: 10.29011/2575-7903.000159
1.
Abstract
Renal Artery Stenosis (RAS) is frequent in hypertensive patients undergoing coronary angiography. We present a case of a 42-years-old woman with hypertension, dyslipidemia, type-2 diabetes, chronic kidney disease and previous myocardial infarction, who was admitted at the emergency department with typical angina. She was diagnosed with acute myocardial infarction. Coronary angiography showed severe stenosis in right coronary artery and successfully submitted to angioplasty with stent insertion. Renal ultrasound was performed with a Doppler study of renal arteries and showed bilateral chronic nephropathy and signs of significant stenosis of the left renal artery. The blood pressure was controlled during hospital admission and renal function was normal the patient was discharged for brief outpatient evaluation. However, she was admitted again with Hypertensive Acute Pulmonary Edema (HAPE) and was indicated renal angiography. It demonstrated obstruction of 50% and 70% in the ostium of the right and left renal arteries, respectively. Left renal artery angioplasty was performed without complications. Twenty-four hours after angioplasty and stent insertion the patient evolved with new HAPE and even after medical adjustments the blood pressure persisted high. Because this clinical evolution after angioplasty it was suspected of renal stent stenosis. A new renal ultrasound with Doppler was performed; the left renal artery stent was patent with no stenosis and normal velocity at the origin of the right renal artery. Although the renal ultrasound with Doppler did not demonstrate signs of significant stenosis at right renal artery, was decided perform angioplasty considering clinical features and evolution with recurrent HAPE. After the second angioplasty, the patient had a good clinical evolution, improvement of renal function and blood pressure levels.
2.
Keywords: Atherosclerotic Renovascular Disease; Hypertensive
Acute Pulmonary Edema; Renal Artery Angioplasty; Renal Artery Stenosis
1. Introduction
Renal Artery Stenosis (RAS) affects about 5% of hypertensive patients[1], more than 20% of patients undergoingcoronary angiography[2]and up to 33% of cases of aortic atherosclerotic disease[3].There are three major clinical syndromes related to RAS: incidental finding in an asymptomatic individual, ischemic nephropathy, and renovascular hypertension. The main etiologies are atherosclerotic disease (approximately 90% of cases) and fibromuscular dysplasia, which is more common in young women.Atherosclerotic renovascular disease is more common in men[4], above 50 years old, with multiple atherosclerotic risk factors.RAS is one of the most frequent causes of secondary hypertension and it is challengingto determine whether elevated blood pressure is related to RAStaking into account the degree renal artery obstruction.We report a case of a patient who underwent asuccessful percutaneous interventional treatment in renal arteries, despite non-significant stenosis based on clinical features.
2. Case Report
A 42-years-old
woman wasadmitted to theEmergency Department (ED) of the Heart Institute, São Paulo Medical School,
Brazil, with typical angina.The patient
reported diagnosis of hypertension since she was 30 years old, a history of
poor drug adherence and worsening of blood pressure control for the last eight
months. Furthermore, she reported dyslipidemia,
type-2 diabetes mellitus with insulin therapy, chronic kidney disease and previous
myocardial infarction. Her initial vital
signs wereas follow: regular heart rate of 87beats per minute, Blood Pressure (BP)
of 180x110 mm Hg, and respiratory rate of 20
breaths per minute. The oxygen saturation was97% while breathing in ambient
air. The
electrocardiogram showed sinus rhythm, left ventricle hypertrophy and no ST
segment abnormality. Serum troponin was 27.89 ng/mL (reference value <
0.04), creatine kinase MB 11.26 ng/mL (reference value < 3.8 ng/mL),
hemoglobin 10.6 g/dL, hematocrit 33%, leukocytes 8120 /mm3, platelets 466.000 /mm3, total cholesterol 199
mg/dL, HDL cholesterol 45, LDL cholesterol 132, triglycerides 108 mg/dL,
glucose 87 mg/dL, urea 91 mg/dL and creatinine 2.05 mg/dL. The admission
diagnosis was consistent with acute myocardial infarction.On the
echocardiogram, theleft ventricular systolic function was mildly reduced with
ejection fractionof 45%. Coronary angiography showed severe stenosis in the right
coronary artery(Figure 1).
that was successfully submitted to angioplasty with stent insertion. Due to the high bloodpressure, therewas necessary the use of nitroglycerin and the patient was referred to the Coronary Unit. There was difficulty in weaning the intravenous vasodilator, requiring the use of three classes of oral antihypertensive (Carvedilol 25 mg twice daily, Amlodipine 5 mg twice daily, Clonidine 0.1 mg twice daily) beyond aspirin 100 mg andAtorvastatin 80 mg once daily.Renal ultrasound was performed with Doppler study of renal arteries and showed bilateral chronic nephropathy and signs of significant stenosis of the left renal artery. The peak flow velocity in the left renal artery was 294 cm/s (reference value <150 cm/s) and in the right renal artery was 94 cm/s (reference value <150 cm/s).Because BP was under controlduring the hospital admission and renal function remained stable,the patient was discharged from the hospital and referred for early outpatient evaluation. However, while waiting for the assessment, she was admitted again at the ED of the Heart Institute, due to acute pulmonary hypertensive oedema (BP-190/120 mmHg).Because of the failure to drug treatment, persistently elevated BP and acute pulmonary hypertensive oedema (APHE) renal angiography was indicated. It showedstenosis of 50% in the right renal artery ostium and 70% in the left renal artery ostium. Left renal artery angioplasty was performed without complications.
Twenty-four hours after angioplasty and stent insertion the patient evolved with new APHE, requiring non-invasive ventilation, vasodilator, intravenous diuretic and the need to increase oral antihypertensive doses(Figure 2).
With the introduction of Enalapril 5
mg twice daily it was registered the worsening renal function (creatinine: 2.6
mg/dL) and hyperkalemia, with improvement after withdraw. The patient remained
with elevatedBP, even with four antihypertensive drugs combination. Face to
this clinical evolution after angioplasty was suspected of renal stent
stenosis. A new renal ultrasound with Doppler was performed and demonstrated increasing
in systolic velocity at the origin of the left renal artery (300 cm/s; normal
value <150 cm/s) and normal velocity at the origin of the right renal artery
(102 cm/s; normal value <150 cm/s). Patient was referred to renal angiography.
The left renal artery stent was patent with no stenosis(Figure 3).
Although the renal ultrasound with Doppler did not demonstrate signs of significant stenosis at right renal artery, was decided perform angioplasty considering clinical features and evolution with recurrent APHE.After the second angioplasty, the patient had a good clinical evolution, improvement of renal function and control of BP levels. She was discharged three days after the procedure, with 3 antihypertensive. Currently, she is been following-up at the ambulatory of the Heart Institute with controlled BP and no further complications.
3. Discussion
In this case report we present the net benefit of renal revascularization in a patient with no significant renal stenosis but with clinical features of renovascular hypertension. The aim of revascularization in RAS is to reduce obstruction to renal perfusion, thereby improving downstream ischemia and reducing activation of Renin-Angiotensin-Aldosterone System (RAAS), resulting in improved blood pressure control and preservation of renal function. The difficulty lies in knowing which patients will benefit from revascularization as a high degree of stenosis may not correlate with significant hemodynamic effects and RAS may be an incidental finding[5]. In our patient we have seen an improvement in the blood pressure levels control, renal function and no more recurrent pulmonary edema.Data from studies in the United States have indicated that revascularization is performed in 16% of patients with newly diagnosed atherosclerotic renovascular disease[6]. Since endovascular interventions are associated with substantial morbidity[7],inconvenience, and cost, with little apparent benefit, the widespread use of such procedures outside of clinical trials have been questioned.
Data
from randomized clinical trials, including the Angioplasty and Stenting for
Renal Artery Lesions (ASTRAL) trial[8] and the Stent Placement and Blood
Pressure and Lipid Lowering for the Prevention of Progression of Renal
Dysfunction Caused by Atherosclerotic Ostial Stenosis of the Renal Artery
(STAR) trial[9],that assessed the
usefulness of renal artery stenting with respect to kidney function showed no
significant difference with respect to renal function, blood pressure, renal or
cardiovascular events, or mortality compared endovascular revascularization
plus medical therapy with medical therapy alone in patients with
atherosclerotic renovascular disease. These studies have been criticized for
enrolling some participants who did not have clinically significant
renal-artery stenosis and for not having their findings confirmed by core laboratories[10].The Cardiovascular
Outcomes in Renal Atherosclerotic Lesions (CORAL) study included patients with
severe renalartery stenosis that was defined angiographically as stenosis of at
least 80% but less than 100% of the diameter or stenosis of at least 60% but
less than 80% of the diameter of an artery, with a systolic pressure gradient
of at least 20 mm Hg. It was found no benefit of stenting with respect to the
rate of the composite primary end point or any of its individual components,
including death from cardiovascular or renal causes, stroke, myocardial
infarction, congestive heart failure, progressive renal insufficiency, and the
need for renal-replacement therapy(Figure 4).
Current clinical consensus would generally not advocate screening for atherosclerotic RAS in everyone, particularly where it will not the alter management plan[11]. Suggested criteria for which patients to investigate are outlined below: rapid onset of hypertension over the age of 55 years with additional adverse features (difficult-to-control blood pressure, association with decline in renal function, association with heart failure); rapid, unexplained decline in renal function (more than 50% increase in serum creatinine concentration over 12 months) or significant deterioration in renal function after introduction of an ACE inhibitor or angiotensin II receptor blocker; and repeated hospital admissions for heart failure with preserved left ventricular function on echocardiography.
The management goals in RAS are to control hypertension, preserve renal function and prevent recurrent flash pulmonar edema. The use of revascularization in management of flash pulmonar edema is supported by some evidence from older case series [12,13].In one series of patients with proven RAS, 41% of patients with bilateral disease had a history of pulmonar edema, and following stenting, 77% of these patients had no further episodes of pulmonary edema[14]. A recent systematic review included data from 173 patients and concluded that the quality of evidence was low and justified only a weak recommendation for Percutaneous Transluminal Renal Artery Angioplasty (PTRAA) with or without stenting in patients with atherosclerotic RAS and either flash pulmonar edema or chronic heart failure and renal insufficiency[15]. The interpretation of the results of the large trials so far in the management of atherosclerotic RAS has been limited by patient selection and methodological issues including crossover from medical to intervention arms and analysis based on intention to treat (when not all randomized patients actually underwent a procedure).
4. Conclusion
Well-selected patients with moderate
renal arterial stenosis and clinical features of renovascular hypertension may
benefit from percutaneous transluminal renal artery angioplasty for the
treatment of atherosclerotic RAS.
Figure
1: Coronary angiography showing severe
stenosis on proximal third of the right coronary artery.
Figure
2: Coronary angiography showing the
final view after angioplasty and stent insertion.
Figure
3:(A) Renal angiography showing severe
stenosis in the ostium of the left renal artery.(B) final view after angioplasty
and stent insertion.
Figure
4:(A) Renal angiography showing
moderate stenosis in the ostium of the right renal artery. (B) final view after
angioplasty and stent insertion.