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Fig. 1a. Aortography suggests a beaded appearance of both renal arteries.
Fig. 2a. CT demonstrates the periaortic tumor. Case Reference No. CC-0498-04 The patient is a 34-year-old woman who presented with hypertension and buttock claudication. She was (and still is) a heavy smoker and has elevated homocystine levels. An arteriogram showed bilateral fibromuscular dysplasia (FMD) involving the renal arteries (left greater than right) and a high-grade eccentric narrowing of the infrarenal abdominal aorta (Fig. 1). An aortic bypass procedure was attempted but the vascular surgeon found a mass. Upon biopsy, the mass was found to be an angiosarcoma of the aorta (Fig. 2). The patient was treated with chemotherapy and external beam radiation. The infrarenal aorta was removed and an axillary bifemoral graft was placed. During this procedure the left renal artery was injured and subsequently became thrombosed. Seven years later, the patient has done well except for poorly controlled hypertension and claudication. A repeat arteriogram was obtained (not shown) that showed progressive changes of FMD involving the right renal artery. Unsuccessful percutaneous transluminal angioplasty (PTA) was performed and the patient was then referred to our service. From a left axillary approach, the right renal artery was repeatedly dilated but there was always a residual degree of narrowing that we believed was unsatisfactory. A P104 Palmaz stent was then placed across the narrowing and this gave a satisfactory angiographic result (Fig. 3). After the procedure was completed, the axillary sheath was removed and hand pressure was held until hemostasis was achieved. Approximately 30 minutes later, a hematoma developed and the patient developed symptoms of hand pain and paresthesia in the fourth and fifth digits. A vascular surgeon was called. While waiting for the vascular surgery consult, duplex ultrasound was performed which showed a pseudoaneurysm. Directed pressure over the neck of the pseudoaneurysm was applied until it was thrombosed (approximately 30 minutes) (Fig. 4). By this time the vascular surgeon arrived and the pain and paresthesias were gone. The patient has been normotensive since the procedure and has had no upper extremity complications. Questions: 1) This is the first time we have used a stent for FMD (because this patient was not a surgical candidate). We send all our PTA failures to surgeons. What does everyone else do for failed PTA of FMD? 2. This is the first time we have used compression sonography for an axillary puncture complication. I guess it is safe to do while you are waiting for a surgical consult. Does anyone have any thoughts on this? Related Cases: |
Fig. 1b. Selective left renal angiography confirms fibromuscular dysplasia. An eccentric narrowing of the infrarenal aorta is present.
Fig. 2b. CT image of left renal artery demonstrating FMD-related changes.
Fig. 3a. Right renal angiogram, performed after angioplasty.
Fig. 3b. Right renal angiogram after stent placement.
Fig. 3c. S/P stent.
Fig. 4a. Neck of pseudoaneurysm.
Fig. 4b. Thrombosed pseudoaneurysm. | |
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