Nephrol Dial Transplant (2001) 16: 427-428
© 2001 European Renal Association-European Dialysis and Transplant Association
Images in Nephrology
Successful treatment by recombinant tissue plasminogen activator of a renal infarction complicating percutaneous transluminal renal angioplasty
(Section Editor: G. H. Neild)
Institute of Nephrology, Department of Medicine, D'Annunzio University, Chieti, Italy
Keywords: hypertension; percutaneous transluminal renal angioplasty; recombinant tissue plasminogen activator; renal failure
A 74-year-old woman with recent worsening of long-standing hypertension and mild renal failure was admitted to our Unit in January 2000. On physical examination, the patient had a para-umbilical and a carotid murmur. Blood pressure was 190/105 mmHg. She had a history of intermittent claudication and several transient ischaemic episodes.
Renal ultrasound examination showed a very small left kidney and a right kidney of 10.5 cm with slightly irregular margins. A presumptive diagnosis of atheromatous renal artery disease was made, and magnetic resonance angiography was performed. The proximal portion of the right renal artery showed a severe stenosis, whereas the contralateral artery could not be detected. Renal digital arteriography showed a complete occlusion of the left renal artery and a severe para-ostial atheromatous stenosis of the right artery (Fig. 1
).
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After informed consent, we proceeded with angioplasty of the right renal artery associated with wall stent placement. Within 10 min of the procedure, however, the patient developed acute thrombosis with consequent right renal ischaemia (Fig. 2
). Local intra-arterial thrombolysis with a 2-mg bolus of recombinant tissue plasminogen activator (r-tPA) was performed. A subsequent angiographic control showed a recanalization of the artery with good patency and normal nephrography (Fig. 3).
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Duplex sonography performed 1 week after revascularization showed a normal peak systolic velocity and normal resistive indices. Renal function remained stable.
Atherosclerotic disease of the renal arteries is an important cause of renal failure in elderly patients [1]. Various mechanisms contribute to renal insufficiency: renal damage due to hypertension [2], atheroembolism of the renal arteries, and a low perfusion pressure beyond the stenosis of the artery [3]. Percutaneous transluminal angioplasty with or without wall stenting is a well-known method of treating ischaemic nephropathy. The aim of revascularization in this type of pathology is the attempt to preserve or improve renal function, to prevent end-stage renal failure, and to make hypertension more responsive to medical therapy. Mid-term follow-up indicates that in about 75% of the cases, the result of PTA with stenting is satisfactory at more than 18 months [4]. The overall complication rate, including artery dissection and acute thrombosis, is considered to be 9% [5].
Our report demonstrates that prompt treatment with r-tPA may be safe and successful.
Notes
Correspondence and offprint requests to: U. Brümmer, Institute of Nephrology, SS Annunziata Hospital, Via dei Vestini, I-66013 Chieti, Italy. 
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