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Relevant clinical history and physical exam
A 28 year-old woman referred to our hospital for treatment of renal artery stenosis probably due to fibromuscular dysplasia(FMD). Her blood pressure(BP) was 162/88 mmHg despite taking four types of anti hypertensive agents. Laboratory data showed both plasma renin activity(PRA) and plasma aldosterone concentration(PAC) were extremely high.
Relevant test results prior to catheterization
The computerized tomography(CT), color duplex ultrasonography(US) and angiography showed irregularity of the vessel wall and stenosis in bilateral of the ventral and dorsal branch. Other vascular such as the carotid artery were normal. A 99mTc-MAG3 renography showed the split renal function in the right side was lower, and Resistive Index in color duplex US was higher in the same side.
Relevant catheterization findings
The catheter angiography showed irregularity of the vessel wall and strings of beads appearance due to post-stenotic aneurysms in bilateral of the ventral and dorsal branch. Intravascular ultrasound(IVUS) and optical coherence tomography(OCT) revealed remarkable hypertrophy media in the renal artery, so we diagnosed FMD.
We underwent percutaneous transluminal renal angioplasty(PTRA) for the right renal artery for the first session. After percutaneous old balloon angioplasty(POBA) for stenosis lesions, Fractional Flow Reverse(FFR) was improved from 0.81 to 0.91 in the ventral branch and from 0.51 to 0.80 in the dorsal branch. Her BP, PRA and PAC were improved almost normal.
However, three months after the treatment, BP became gradually high and both PRA and PAC were getting worse. CT angiography did not show restenosis of the lesion, but progression stenosis in middle of right renal artery. We underwent PTRA for this progression lesion and the left renal artery because of high hyperemic systolic gradient for the second session. After POBA for these lesions, FFR was improved from 0.79 to 0.91 in the middle of right artery, from 0.71 to 0.95 in the left ventral branch and from 0.72 to 0.93 in the left dorsal branch. After the second session, she was able to reduce the number of oral medicine, and has been followed as an outpatient no symptom of HT and normal range of PRA and PAC.
A PTRA for bilateral renal artery at hilum is very rare. Our treatment results in good angiographic and clinical results. Like this case, even if stenosis were at the hilum, PTRA might be the first choice in renal artery stenosis when medical treatment fails to control renovascular hypertension.