Successful Treatment of Renal Artery Stenosis with Adjunctive Intravascular Shockwave Lithotripsy (IVL)

Introduction: To date, several landmark studies including STAR, ASTRAL and CORAL have shown no significant benefit to revascularization for renal artery stenosis when compared to medical management alone. In fact, most now believe that potential adverse risks associated with the procedure outweigh the advantages. However, it has been discovered that IVL technology helps prepare heavily calcified vessels for easier dilation by creating microfractures within plaques. Case Description: An 85 year old man presented for orthopnea and lower extremity edema. He had a history of hypertension from primary hyperaldosteronism, well controlled type 2 diabetes, CVD and CKD stage 3a with a baseline serum creatinine of 1.4 mg/dL. His blood pressure had been labile for years and his underlying kidney disease was presumed renovascular as he had no signs of glomerular pathology and no associated proteinuria. Over the preceding 3 months, he was found to have a significant rise in creatinine to around 2.8 mg/dL. He then received renal angiography showing severe right renal artery stenosis and a nearly occluded left renal artery. Angioplasty was facilitated using shockwave balloons with five cycles of IVL on the right and seven on the left. Post procedure, he had improved blood pressures and volume status. Serum creatinine trended back down to 1.2 mg/dL. Discussion: Renal artery stenosis must be considered in any elderly patient with CVD presenting with volume overload, hypertension and renal impairment. Although the aforementioned studies showed no benefit to intervention, IVL has since proven effective in cases of peripheral arterial disease and aortic valve implantations. The technology allows for easier stenting and theoretically reduces the risk of common complications, including recoil and perforation. Here we presented a patient with progressive renal failure successfully treated with angioplasty and stenting facilitated by IVL. While typically only reserved for those cases in which previous therapies have failed, we propose that this modality be seen as a reasonable option for the treatment of any clinically and hemodynamically significant renal artery stenosis.