1. TECHNINIQUES OF RENAL ARTERY STENTING
Aravinda Nanjundappa, MD
Professor of Medicine and Surgery
West Virginia University
Charleston, WV

2. Disclosure Statement of Financial Interest
I, Aravinda Nanjundappa, DO NOT have a financial interest/arrangement or affiliation with one or more organizations that could be perceived as a real or apparent conflict of interest in the context of the subject of this presentation.

3. Indications for revascularization of RAS
Hemodynamic RAS
= > 50-70% stenosis
+ Peak gradient >20 mmHg
or mean gradient >10 mmHg

4. SCAI consensus 2014: RAS maybe appropriate for significant renal artery stenosis
Cardiac disturbance: severe HTN with Flash pulmonary edema or ACS
Resistant HTN on diuretic and maximal dose of anti hypertensives
Ischemic nephropathy: Bilateral severe renal artery stenosis or unilateral stenosis in solitary kidney with GFR <45

5. Patient Preparation Antiplatelet Hydration HCO3- (?)
ASA and Clopidogrel at least 5-7 days
Hydration
HCO3- (?)
N-acetylcysteine, if renal insufficiency
600 mg bid
Visipaque® for high risk patient

6. Abdominal Angiography
Renal arteries usually originate at the L1/L2 level
So, position pigtail at about T12
Use digital subtraction angiography

7. Abdominal Aortography

8. Non-selective Abdominal Aortogram
Exclude presence of accessory RA
Demonstrate disease of the aorta (eg., AAA)
Identify origin of the RA’s
Facilitate placement of diagnostic catheter and guide catheter
Avoid unnecessary “windshield wiping” in aorta

9. Cholesterol embolization

10. LAO 20° Lt Rt Lt

11. Angiography: Gold Standard
AP View
20° LAO View
LAO 10-20°

12. Common Femoral approach

13. Cobra
JR 4
IMA
AR 1
Lateral take-off

14. RC 2
HK 1
Contra 2
SOS Omni 2
Inferior take-off

15. Sos-Omni Engagement

16. Brachial approach
Iliac or aortoiliac disease
Downward take off RA’s

17. Selective Angiography
5/6 French
Insist on backflow and no pressure damp before injecting
Use 3 cc syringe on manifold- forces one to use less contrast
Contrast
Dilute by 50:50
2-6 cc per injection with good reflux

18. Don’t inject if pressure damp

19. Equipments 5/6 Fr diagnostic catheter 7-Fr, 55 cm RDC guide catheter
JR4, IMA,
7-Fr, 55 cm RDC guide catheter
0.014-inch extrasupport wire
IVUS (?)
Predilate balloon ?
Balloon expandable stent
Directly stent?

20. Guiding Catheter IM
RDC
RDC 1

21. Medication Unfractionated Heparin - 50 units/kg (ACT 200-250 sec)
No post procedure heparin

22. Techniques for guide engagement
Direct engagement
Telescoping technique
Exchange technique
No touch technique

23. Direct engagement

24. Telescoping technique
Preload diagnostic through rotating hemostat valve and guide cath, advance over wire to renal

26. Exchange technique
0.018 guidewire (more supportive wire required to do the excahnge)

28. No touch technique

29. Renal Stenting TechniqueB C D E F
Monitor pain during balloon inflation

30. Potential Mechanisms of deterioration in renal function post renal intervention
Contrast
Reperfusion injury
Distal embolization
Obstruction to flow and renal infarction (but, with normal renal function, up to 50% of nephron mass may be lost without change in Cr)
Inflammatory response from cholesterol emboli
Increased ESR
Urinary eosinophils

32. Stent Size and Restenosis rates
Reference Vessel Diameter, mm
Restenosis Rate, %

33. Say NO!! To Hostile aorta and aneurysm

34. 92 year old physician with uncontrolled HTN, CHF recurrent episodes
92 year old physician with uncontrolled HTN, CHF recurrent episodes. CT scan shows 90% stenosis of the left renal artery

35. Follow-up DAPT 1 month (? Data) Clinically driven follow up
Duplex ultrasound or CTA – to detect restenosis
MRA – limited to use due to metallic artifact