Treatment of Refractory Hypertension with Timely Angioplasty in Total Renal Artery Occlusion with Atrophic Kidney

Abstract

Angioplasty for cases of chronic total occlusion of renal artery with/without atrophic kidney is generally not recommended. We herein report a 57-year-old man who presented with renin-mediated refractory hypertension caused by occlusion of a unilateral renal artery leading to kidney atrophy (length: 69 mm). Angioplasty favorably achieved blood pressure control with normalized renin secretion and enlargement of the atrophic kidney to 85 mm. Timely angioplasty can be beneficial in select patients, even with an atrophic kidney and total occlusion, especially in cases with deterioration of hypertension within six months and the presence of collateral perfusion to the affected kidney.

Keywords: atherosclerotic renovascular disease; diffusion-weighted MRI; renal artery stenosis; renin-angiotensin system inhibitors; renovascular hypertension.

Figure 1.

Total occlusion of the right renal artery, leading to renal atrophy. A: Enhanced computed tomography (CT) image. B: Three-dimensional CT angiography image. C: T2-weighted magnetic resonance imaging (MRI) scan. D: Diffusion-weighted MRI scan. E: Apparent diffusion coefficient (ADC) in diffusion-weighted MRI scan.

Figure 2.

Angioplasty for total occlusion in the renal artery. A: First percutaneous transluminal renal angioplasty (PTRA) procedure for the right renal artery. Angiography obtained by cannulating the adrenal artery providing collateral flow to the right kidney before PTRA and renal artery angiography after PTRA. B: Computed tomography one month after the first PTRA procedure showing thrombotic in-stent re-occlusion (arrows) C: Second PTRA procedure for the right renal artery.

Figure 3.

Clinical course. BP: blood pressure, PTRA: percutaneous transluminal renal angioplasty, Renin: active renin concentration, Aldo: aldosterone, s-Cr: serum creatinine

Figure 4.

Kidney enlargement and improved intrarenal hemodynamics after the second PTRA procedure. A: The right kidney image on ultrasonography. Scale, 1 cm. B: The intrarenal flow velocity pattern in the interlobar region in the right kidney. C: ^99mTc-DTPA scintigraphy during the vascular phase. L: left kidney, R: right kidney. D: Parameters on ultrasonography and scintigraphy before and after PTRA. Pressure systolic velocity (PSV), endo diastolic velocity (EDV), resistive index, and acceleration time (AcT) were measured in the interlobar region in the right kidney.