Endovascular treatment of transplant renal artery stenosis based on hemodynamic assessment using a pressure wire: a case report

Yoshito Kadoya, Kan Zen, Satoaki Matoba

Transplant renal artery stenosis (TRAS) is a serious complication after renal transplantation, leading to hypertension, deterioration in renal function, and/or graft loss. The incidence of TRAS reportedly varies from 1 to 23%, depending on its definition or diagnostic tools. The hemodynamic definition or therapeutic indication of TRAS is unclear. A 66-year-old man with a history of diabetes, chronic kidney disease, and angina presented with a 2-week history of dyspnea and leg edema. He had undergone living-donor kidney transplantation for end-stage renal disease secondary to diabetic nephropathy 7 years earlier. He developed acute deterioration in renal function after the administration of an angiotensin II receptor blocker and required emergency hospitalization owing to acute congestive heart failure with pulmonary edema. A vasodilator and loop diuretics were administered following his admission, and the patient's symptoms resolved quickly. Further investigation, including magnetic resonance angiography and ultrasonography, revealed severe stenosis of the transplant renal artery. Renal arteriography and pressure gradient measurement using a 0.014-inch pressure wire were performed. The systolic pressure gradient was 40 mmHg, and the resting Pd/Pa ratio (ratio of mean distal to lesion and mean proximal pressures) was 0.90 without hyperemia. Hemodynamically significant stenosis was suspected. Intravascular ultrasonography revealed vessel shrinkage in the stenotic area, suggestive of the end-to-end anastomosis site. Pre-dilation using a 4-mm balloon, implantation of a 6-mm self-expandable stent, and post-dilatation using a 5-mm balloon were performed. Although the moderate stenosis persisted angiographically, the systolic pressure gradient dropped to 20 mmHg with the mean systolic pressure ratio increased to 0.95, which was considered an acceptable result. One month after the procedure, the patient's renal function and blood pressure control had significantly improved. Hemodynamic assessment using a pressure wire is useful in determining the appropriate therapeutic indication and endpoint of endovascular treatment of TRAS.