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Annals of Cardiovascular Diseases

Cite this article: Dieng PA, Sawadogo A, Sow NF, Doumbia M, Gaye M, et al. (2017) Revascularization of Stenosis of the Renal Arteries in Dakar: Inaugural Experience from 3 Cases. Ann Cardiovasc Dis 2(1): 1017.

*Corresponding authorAdama Sawadogo, Department of Cardiovascular and Thoracic Surgery, Cheikh Anta Diop University of Dakar, Av Cheikh Anta Diop PO Box 5035, Dakar, Senegal, Tel: 226-70104922; Email:

Submitted: 08 August 2017

Accepted: 20 October 2017

Published: 23 October 2017

Copyright© 2017 Sawadogo et al.

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Keywords•Renovascular hypertension•Inflammatoryarteritis•Angioplasty•Senegal

Case Series

Revascularization of Stenosis of the Renal Arteries in Dakar: Inaugural Experience from 3 CasesPapa Adama Dieng, Adama Sawadogo*, Ndèye Fatou Sow, Modibo Doumbia, Magaye Gaye, Momar Sokhna Diop, Souleymane Diatta, Pape Salmane Bai, Amadou Gabriel Ciss, Assane Ndiaye, and Mouhamadou NdiayeDepartment of Cardiovascular and Thoracic Surgery, Cheikh Anta Diop University of Dakar, Senegal

Abstract

Introduction: Stenosis of the renal arteries (SRA) is a narrowing of the lumen either at the ostium, trunk, hilum or intraparenchymal branches. The treatment includes angioplasty or, more rarely, an open surgical approach. In this work, the authors discuss the first 3 cases of percutaneous revascularization that have been performed in Dakar, Senegal.

The cases: All 3 patients were female with a mean age of 17.6 years old [6-24 yo]. The three cases presented with hypertension that was resistant to medical treatment but renal function was normal in all these cases. The angioCT showed a stenosis ≥ 90% in each case. The etiologies were Takayasu’s disease in 2 cases and fibromuscular dysplasia in the third. The confirmation of SRA was made by angiography. Management consisted of angioplasty-stenting in 2 cases and angioplasty alone in the third. Renal function was recovered in all cases but in one case, blood pressure remained high.

Conclusion: Any hypertension that is resistant to the standard medical treatment should trigger an alert for stenosis of renal arteries. Where endovascular revascularization has been used, as in Senegal, the results are encouraging.

INTRODUCTION Stenosis of the renal arteries (SRA) is a narrowing of the

lumen either at the ostium, trunk, hilum or intraparenchymal branches. The main etiologies are represented by atherosclerosis, fibromuscular dysplasia and arteritis such as Takayasu’s disease [1]. Some rare causes may include embolism, dissection, aneurysm and malformation of the renal arteries [2]. SRA is one of the preponderant causes of secondary hypertension [3]. The aims of the treatment are to normalize blood pressure and preserve the sets of the nephrons. The procedures include percutaneous angioplasty or, rarely, an open surgical approach. In this work, the authors report on the first 3 cases of percutaneous revascularization for SRA that were been performed in Dakar, Senegal.

CASES PRESENTATION

Case 1

1.2. PN was a 6.5 years old female patient who was suffering from hypertension resistant to medical therapy. She had previously been hospitalized a couple of times for cardiac decompensation. Abdominal auscultation revealed a murmur; the peripheral pulses were normal. Abdominal ultrasound was not

contributive but CT urography showed a delayed excretion of the left kidney. The angio MRI showed multiple stenoses of the aorta and its branches. Both of the renal arteries (RA) were completely occluded at theirs origins. However, the right RA showed contrast on its course after the stenotic zone. The biology showed normal renal function with increased CRP (38.4 mg/l). The angiography found an ostial stenosis of the right RA. Then, the Seldinger technique was used to perform balloon angioplasty. At the end of the procedure, the control showed good arterial flow. The post operative course was uneventful and the patient discharged from hospital on day 5. The blood pressure normalized from the third week.

Case 2

RB, a 23 year old female had been diagnosed with hypertension 3 years earlier. Although she was treated with bisoprolol, amlodipine and indapamide, blood pressure remained high. The left upper limb was pulseless but it did not present symptoms of ischemia. Angio CT showed bilateral proximal stenosis of the RA. The length of the diseased segment was 13 mm on the right RA and 10 mm on the left. Moreover, other stenoses were revealed on the supra-aortic trunks. The creatinine was normal but there was inflammatory syndrome which showed an increased

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erythrocyte sedimentation rate (42 mm at H1) and CRP (96 mg/l). The renal artery angiography showed 90% stenosis on the left and 35% on the right. Balloon angioplasty and stenting (5mm x 4cm) were performed on the left RA. The post-procedural left renal blood flow was improved. The postoperative hospital stay lasted 3 days as no complication was noticed. Following this, 2 months postoperative, a clinical examination found normalized blood pressure.

Case 3

FS, a 24 years old female patient had been diagnosed with hypertension 3 months earlier. The medical treatment included amolodipine and ramipril but this did not normalize the blood pressure. Physical exam was normal. Angio CT of the RA found a pre-occlusive stenosis of the right RA at the ostium. Angiography confirmed a 90% stenosis in addition to ectasia of the distal segment of the right RA (Figure 1). Balloon angioplasty (Figure 2) and stenting (5 mm x 5.5 cm) were performed (Figure 3). The patient developed a postoperative fever at 38.5°C that was successfully treated by antimalarial and paracetamol. She stayed 14 days in hospital and was discharged with normal renal function but with persistent hypertension. The clinical check 6 months later showed persistent hypertension. Nevertheless, the vascularization of the right kidney was satisfactory (Figure 4).

DISCUSSIONAnatomically, stenosis of the renal arteries corresponds to

a narrowing of at least 50% in their lumen. The hemodynamic threshold is rather 60% corresponding to a decrease of 80% in their area [4]. All 3 patients reported above were young, with a maximum age of 24 years old. However, Gloviczki et al. [5], have found a mean age of 65 years old in their series (14 patients). This age-gap is probably linked to the etiology of the SRA. In their series, atherosclerosis was the main cause and this is known to occur in older patients. In 2 female patients of our series, multiple locations of arterial disease in inflammatory context were found. We concluded that it was an arteritis such as Takayashu’s disease [6]. We did not find the classic image of “string of beads” in the third patient; nevertheless, we have seen post-stenotic ectasia of the right RA and so, we concluded to fibromuscular dysplasia as there was no inflammation [7]. The clinical features of our patients defined, renovascular syndrome [7] as they all presented with hypertension that was resistant to standard medical treatment. Clinically, the renovascular syndrome was confirmed by an abdominal murmur in one patient. In the two others, we could not reject this syndrome

Figure 1 Angiography showing proximal stenosis of the right renal artery.

Figure 2 Balloon during dilatation.

Figure 3 Stent seen at the end of the procedure.

Figure 4 Angio CT on postoperative day 45 showing the stent in the right renal artery.

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Dieng PA, Sawadogo A, Sow NF, Doumbia M, Gaye M, et al. (2017) Revascularization of Stenosis of the Renal Arteries in Dakar: Inaugural Experience from 3 Cases. Ann Cardiovasc Dis 2(1): 1017.

Cite this article

because the abdominal murmur is not pathognomonic: 6.5 to 31 % of the general population may present innocent abdominal murmurs even though theirs renal arteries are not stenotic [1]. Function and sizes of the kidneys were preserved in our series probably because of early diagnoses in our cases. Some studies found that complete occlusion happens in 49% of cases in year 4 or 5 during the development of SRA. Moreover, the severity of glomerular lesions is not linked to the degree of stenosis [3]. We prescribed ultrasound in 2 patients but it was not contributive. The diagnosis was made by angio CT and angio MRI but confirmation was made per-operatively by angiography. It is clear that the interpretation of the ultrasound of renal arteries widely depends on the operator. Furthermore, Williams et al. [8], found that it to be less precise because assessment depends on the peak systolic velocity whose sensitivity is moderate (85%). Although CT and MRI remain useful to make the diagnosis of SRA, angiography remains the confirmation test that also allows assessment of pressures and leads, eventually, to a performance of endovascular procedure [2,9]. The 3 aims of the management of SRA should be to take control of blood pressure, to preserve renal function and to avoid complications such us pulmonary edema. The most recommended antihypertensive drugs are angiotensin receptor blockers [3]. The Seldinger technique was used to perform angiography followed by angioplasty and stenting. Indeed, since the 1990s, endovascular procedures have overtaken classic open surgical repair for the management of SRA as they are more efficient and there is less morbidity. Angioplasty is efficient at unblocking the renal arteries in the short term but with this alone, secondary stenoses are frequent. Therefore, the recommendation should be to additionally perform stenting [2]. The size of the stent depends on the dimensions of the stenosis. Although the postoperative course was uneventful in our series, there are a number of procedural complications reported in the literature. These include dissection, renal toxicity due to contrast product, embolism of cholesterol and arterial re-stenosis. Renal function was recovered in all the patients but regarding blood pressure, there was a persistent hypertension in one patient. According to Phan et al., revascularization cannot solve all renovascular hypertensions because, once there are lesions of nephroangiosclerosis, the evolution of hypertension is irreversible [3,10].

CONCLUSIONAny hypertension that is resistant to the conventional

treatments should be regarded as an alert to look for a secondary cause such as stenosis of the renal arteries. Where endovascular approach has been used such as in Senegal, the results have been encouraging.

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Revascularization of Stenosis of the Renal Arteries in Dakar: Inaugural Experience from 3 CasesAbstractIntroduction Cases PresentationCase 1 Case 2 Case 3

DiscussionConclusionReferencesFigure 1Figure 2Figure 3