Chronic total occlusion of renal artery in symptomatic young patient with resistant hypertension: is a revascularization necessary or redundant?

Abstract

Renal artery stenosis (RAS) can be described as a narrowed vessel lumen at least 60% which hemodynamic significance may be subsequently confirmed by the pressure gradient measuring with endovascular methods. Frequency with which a disease appears in a population is 5-10% and its dominant cause is the occurrence of atherosclerotic plaque. Infrequent causes include fibromuscular dysplasia and vasculitis such as Takayasu arteritis. Diagnostic gold standard of RAS is digital subtraction angiography (DSA) with pressure measurements. Nevertheless, Doppler ultrasonography (DUS), magnetic resonance angiography (MRA) and computed tomography angiography (CTA) may also play a key role during diagnostics process. Revascularization of narrowed or occluded vessel consists of percutaneous transluminal angioplasty (PTA) with balloon, drug-coated balloon or stent implantation. Surgical procedures are rare and dedicated only to treatment-resistant cases. We reported a 19-year-old patient with resistant arterial hypertension, left ventricular hypertrophy and stenosis of the proximal segment of the right renal artery, confirmed in angio-CT examination. Subsequent follow-up endovascular diagnostic procedure after 12 months revealed complete occlusion of renal artery with angiographic features of chronic total occlusion (CTO). Additionally, laboratory tests showed increase of creatinine level, with an estimated eGFR of 32.9 ml/min/1.73 m2. Considering the whole case - history of fibromuscular dysplasia, deterioration of renal function and the presence of resistant hypertension in a young patient - the invasive treatment was decided. Revascularization with paclitaxel-coated balloon was performed leading to renal perfusion improvement and normalization of the creatinine level. The patient was discharged from hospital with significantly reduced doses of antihypertensive drugs. There are few publications on opening CTOs of renal arteries. The method is rarely used and research in this field should be extended. While routine revascularization is not recommended, in some cases, we should take under consideration that early restoration of normal renal perfusion can bring benefits to the patient both clinical and related to the number of drugs taken and quality of life.