Renal Artery Angioplasty and Stenting with Embolic Protection

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Presentation transcript:

Renal Artery Angioplasty and Stenting with Embolic Protection

Technique If unilateral RA to be treated, puncture ipsilateral CFA so the secondary curve of the guide catheter can abut the contralateral aortic wall for stability Initial 5F sheath and 5F pigtail catheter for single aortic flush study – localise renal arteries relative to bony landmarks Exchange sheath for 35cm 8F sheath (if using embolic protection) to maximise guide catheter torque control

Technique 8F guide catheter – usually RDC shape Heparin (ACT > 250s), GTN boluses Attempt primary passage of embolic filter (eg Angioguard 6-7mm) If successful, deploy filter in distal MRA If unsuccessful, use “buddy wire” technique

Technique Pre-dilate critical stenoses (eg 4mm monorail balloon) Introduce BE stent (eg 6-7mm X 12mm) Consider oblique view to optimally profile renal artery ostium Deploy stent using semi-compliant balloon, monitoring patient discomfort With deflated balloon catheter in place, introduce guide catheter so it sits in the stented segment

Technique Remove balloon catheter leaving guide catheter in place Completion angiogram with embolic filter in place Recapture embolic filter Completion angiogram with embolic filter removed

Technique Preliminary aortic flush study to localise RAs

Technique Primary passage of distal embolic filter

Technique Stent deployed with semi-compliant balloon

Technique Completion angiogram with filter in place

Technique Completion angiogram with filter removed

Embolisation of IMA Type 2 Endoleak

Technique Careful evaluation of CTA to identify origin and orientation of marginal artery off SMA Retrograde CFA approach Aortic flush angiography to exclude other causes of endoleak (proximal and distal type 1, type 3)

Technique Selective SMA injections with catheter in proximal SMA (eg 5F C2 NS, Simmons 2) Important not to have the catheter too distal in SMA as may miss marginal artery origin Try and select marginal artery origin with 5F catheter (may need coaxial approach – eg 7F Ansel 2, selective 5F catheter)

Technique Use co-axial mico-catheter and wire (eg Terumo Progreat) Manipulate micro-catheter down ascending left colic and into IMA trunk Embolise IMA trunk (usually microcoils eg Cook 0.018” Tornados) leaving ascending colic and superior rectal arteries in continuity

IMA embolisation

IMA embolization

IMA embolization Pre-embolisation Post-embolisation

Post IMA embolisation CT