Author + information
- Praskas Chandra Mandal1
Patient initials or identifier number
Relevant clinical history and physical exam
Mr.KP. 67 years-old diabetic, hypertensive,hypothyroid, smoker presented in a gasping state with dyspnoea and sweating for one hour duration. He had “CABG” 12 years backs. Cardiac Troponin was not raised. Pulse-162/min. Resp-46/min. BP-220/130 mmHg. The LVS3 present. Chest -reputations (Killip Class-IV). He was intubated and ventilated with other supportive therapy. Clinically stabilized and extubated on 3rd day. But despite continuing medical therapy he developed Flash pulmonary edema again on same day.
Relevant test results prior to catheterization
Routine Laboratory Parameters: Hb-9.8 gm%. Serurm Creatinine-5.8 mg% (Creatinine Clearance-34 ml/kg/M2). Na+ -138 meq/L. K+-5.1 meq/L.
Cardiac Troponin-I -normal.
ECG- LVH. Global ST-T changes.
Echocardiography: Concentric LVH. Grade-II ‘LV’ diastolic dysfunction. ‘LVEF’-68%. No ‘RWMA’.
USG Abdomen: Bilateral renal parenchymal disease. RK-8.9 cm. LK-8.4 cm.
Relevant catheterization findings
The Renal Vascular Doppler Study: Spectral broadening with parvus et tardus wave pattern in intrarenal arteries of both kidneys suggestive of bilateral renal artery stenoses with very poor flow.
Coronary Angiography: Native triple vessel coronary artery disease. Patent Grafts (LIMA-LAD, RSVG-D1/OM1/PDA).
Renal Angiography: Totally occluded both renal arteries at their origins.
“PTRA” with stent to Left Renal Artery: Right Femoral Access with 7F sheath. The RDC guide catheter. First tried with coronary intermediate wire but failed. 5F IMA catheter used as child catheter. Lesion crossed and pre-dilated with 3.0 x 12 mm sprinter legend coronary balloon. Flow appeared and whole contour with nephrogram of left kidney visualized. Lesion stented with 6 x 18 mm stent. Ostium flared in high pressure. TIMI-3 flow achieved with good nephrogram and ureterogram. An episode sevre “BP” surge with systolic BP of 240 mmHg. Contralateral artery was not attempted.
Diuresis improved from 3rd post-procedure day and serum creatinine improved (3.4 mg% on 7th day). Haemodialysis was stopped after one month and for last 9 months he is off dialysis. BP well controlled and no recurrence of pulmonary edema.
Intervention in totally occluded renal arteries is highly feasible. Coronary ‘CTO' hard wires can safely be used for this purpose. Patients with flash pulmonary edema respond very well to renal re vascularization and may be the most effective therapeutic option in presence of critical renal ischemia. The Renal ischemia evokes strong neuro-hormonal activation which plays a central role in aetiopathogenesis of flash pulmonary edema as well as hypertensive emergencies. Patients with resistant hypertension specially with hypertensive urgencies and emergencies also got neuroendocrinal, beneficial effects of renal re vascularization.