Fig. 1. Carbon dioxide renal arteriography demonstrating a high-grade proximal left renal artery stenosis. There are two right renal arteries. The dominant upper pole right renal artery is occluded (arrowhead). There is a high-grade stenosis at the origin of the small lower pole right renal artery (arrow).

This 82-year-old male with inoperable four vessels coronary artery disease, and recurrent episodes of unstable angina, had a 30-year history of mild hypertension. Over the 6 months prior to presentation his hypertension became markedly more difficult to control, requiring the institution of four medications. This contributed to increasing episodes of unstable angina, which also became more difficult to control. One month prior to presentation, the patient was also noted to develop acute onset of renal insufficiency, with creatinine clearance decreasing from 50 ml/min to 22 ml/min. Ultrasonography showed the right kidney to be 8 cm in length, and the left kidney to be 11 cm in length. There was the suggestion of bilateral renal artery stenosis.

Carbon dioxide renal arteriography (Fig.1) demonstrated a high-grade proximal left renal artery stenosis. There were two right renal arteries. The dominant upper pole right renal artery was occluded, and there was a high-grade stenosis at the origin of the small lower pole right renal artery. The left renal artery stenosis was treated with placement of an endovascular stent (Fig 2). Renal vein renin samples were obtained prior to treatment, and returned two week later, markedly lateralizing to the right kidney (20:1).

Following treatment of the left renal artery stenosis, the patient's renal function improved slightly, and stabilized. However, the patient continues to have extremely difficult to control hypertension, making his unstable angina very difficult to control.

1. The patient's profound unstable angina prohibits him from undergoing right nephrectomy. Is there any endovascular therapy that can help reduced renin this patient?

2. Should alcohol ablation be attempted, given the fact that the majority of flow to the right kidney had been via the dominant upper pole right renal artery, is now occluded?

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