Revascularization for multisite artery disease with atherosclerotic renovascular lesion - indications and difficulties

E. V. Zakharova; A. A. Shubin; A. V. Arablinsky; T. A. Makarova; G. M. Tkhakokhova; Y. U. Magomadov; V. V. Bedin; A. V. Shabunin

doi:10.28996/2618-9801-2023-2-294-298

Revascularization for multisite artery disease with atherosclerotic renovascular lesion - indications and difficulties

E. V. Zakharova, A. A. Shubin, A. V. Arablinsky, T. A. Makarova, G. M. Tkhakokhova, Y. U. Magomadov, V. V. Bedin, A. V. Shabunin

https://doi.org/10.28996/2618-9801-2023-2-294-298

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Abstract

Endovascular revascularization preferably used as initial treatment of chronic mesenteric ischemia, while the patients with mesenteric artery occlusive disease and aneurisms and those with multisite disease should undergo open surgical revascularization [1, 2]. Definite indications for revascularization in the patients with atherosclerotic renovascular disease and renal artery stenosis >75% are as follows: pulmonary edema, chronic kidney disease progression, renin-angiotensin system inhibitors intolerance, and acute kidney injury due to acute renal artery occlusion [3-6]. We report a case of successful surgical revascularization of celiac artery and superior mesenteric artery and endovascular revascularization of renal artery in the setting of multisite artery disease. 65-year-old female with a history of overweight (BMI 29 kg/m2), arterial hypertension, and pulmonary edema two months prior to admission, was admitted for BP 250/100 mm Hg on multi-agent therapy. Her urinalysis and total blood count were normal, serum creatinine (SCr) 193 µmol/L, glucose 8.6mmol/L, НbА1С 6.6%, and total cholesterol 9.6 mmol/L. Plain chest X-ray: aortic sclerosis and pulmonary circuit congestion. Kidney ultrasound: contracted left kidney. Echocardiography: aortic calcification, atrium dilatation, left ventricular hypertrophy with diastolic dysfunction. Separate renal veins (RV) blood sampling for renin levels: left RV - 54.3 pg/mL, right RV - 28.2 pg/mL (normal range 3.8-47.8). Angiography: right renal artery (RA) proximal stenosis 80-90%; left RA isthmic occlusion; celiac artery (CA) and superior mesenteric artery (SMA) occlusion, and inferior mesenteric artery (IMA) isthmic stenosis >80% (Figure 1A). Computed tomographic angiography: aorta, its visceral branches and lower extremity arteries atherosclerosis, proximal CA and SMA occlusion (9 mm and 30 mm respectively) with collateral blood flow through narrowed up to 80% IMA with massive anastomotic arches 2-5 mm at the pancreatic level and aneurism 7 mm at the proximal transverse colon level; left RA occlusion with severe kidney hypoperfusion (Figure 1B). Given CA and SMA occlusion with a high risk an acute disturbance of mesenteric circulation, and resistant arterial hypertension resulting from hyperreninemia due to severe hypoperfusion of the contracted left kidney, we decided to perform urgent surgical CA and SMA revascularization and simultaneous left nephrectomy. 27.12.2021 the patient underwent CA prosthetics, SMA bypass grafting (Figures 1C-1F ), and left nephrectomy; post-surgery period was uneventful and 2 weeks later she was discharged. We scheduled right RA stenting within a month but she did not show. Three months later, she arrived to emergency room complaining of right flank pain, vomiting and anuria, her SCr was 899 µmol/L, Duplex ultrasound revealed RA occlusion. She received two hemodialysis sessions and underwent urgent stent placement (Figures 2A-2D), resulted in immediate polyuria (9.6-8.5-4.5-2.0 L/24 h), rapid decline of SCr to 140 µmol/L, and BP decrease to 150/80 mm Hg. Eight months later her BP is controlled, stent is patent, and SCr is 113 µmol/L. Our patient with obesity, dyslipidemia, type 2 diabetes, multisite atherosclerosis with CA, SMA and left RA occlusion and IMA and right RA stenosis, had definite indications for right RA revascularization [6]. However, we postponed this intervention due to the high risk of acute disturbance of mesenteric circulation. Given multisite artery disease [1, 2] and increased renin excretion from contracted left kidney, we performed CA and SMA surgical revascularization and left nephrectomy first, and scheduled right RA endovascular revascularization. Acute right RA occlusion with anuria demanded urgent stent placement, which led the complete resolution of the acute kidney injury and good blood pressure control. Informed consent was obtained from the individual participant included in the study. None of the authors declares a conflict of interests.