Abstract

BACKGROUND

Renal artery stenosis is a frequent vascular complication post transplantation. It is prudent that early detection and prompt correction can lead to reducing risk of morbidity and allograft dysfunction. Although noninvasive imaging can detect an underlying stenosis but not confirmatory and making decision of contrast arteriography is challenging in already failing allograft.  However, angiography with subsequent angioplasty with or without stenting, provides definitive diagnosis and treatment. 

CASE DESCRIPTION

A 69 year old man with past medical history of end stage renal disease on hemodialysis, diabetes type 2, with history of right nephrectomy due to Renal cell carcinoma, who underwent a deceased donor kidney transplant and his baseline creatinine was near normal on discharge. After three months patient presented with lower extremity edema with decrease urine output in setting of uncontrolled hypertension and worsening renal function. A prompt renal artery duplex then revealed high resistive indices with a significant renal artery stenosis. Subsequently patient had a renal angiogram which demonstrates origin of the transplant renal artery from the left external iliac artery with a high grade more than 90% ostial stenosis. Renal angiography followed by stent placement which restored normal blood flow and resulted in patent transplant renal artery. The Procedure resulted in optimal blood pressure control, improvement in symptoms and normalization of renal functions in few days.

DISCUSSION-     

Renal artery stenosis is a noted complication of renal transplantation. Prompt diagnosis is crucial to aid in management. Stenoses can occur in multiple locations according to etiology. To treat the aforementioned problem, we should take the following approaches. Treat underlying hypertension, percutaneous transluminal angioplasty (PTA) or surgical intervention with revascularization.

Medical management may be used to control hypertension with unknown effect on kidney function. This approach is indicated if the degree of stenosis is not considered hemodynamically significant or the risk of percutaneous intervention is considered high for graft loss, or both. Intervention is justified if there is a reasonable expectation of success in improving hypertension and renal function or stopping progressive renal deterioration.^2,4,5

 

Surgery is considered a major operation with graft loss following vascular reconstruction approaching 30% with a recurrence rate of ∼12%^5-7. PTA is recognized as the initial treatment of choice for transplant renal artery stenosis and does not preclude subsequent surgical correction.^{3, 9-12}  Initial technical success of PTA has been reported to be over 80% and clinical success is ∼74 to 87%.^{1,8,9,11,12,14} Long-term clinical success, defined as either improvement in blood pressure control or stabilization or improvement in renal function, is between 53 and 70% at 1 year with the restenosis rate of PTA of transplant renal artery stenosis to be in the range of 10 to 33%.^{3,7,9,10,12,13} Complication rates are generally low with the rate of graft loss lower for PTA than for surgery.

CONCLUSION  

Advances in diagnostic and device technology have allowed improved diagnosis and percutaneous management of TRAS. Percutaneous transluminal angioplasty with or without intravascular stenting has high technical success with an acceptable complication rate and it could be preferred initial therapy in these patients.