Drug-coated balloon used to treat in-stent restenosis of the renal artery

During recent years, drug-coated balloons (DCBs) have emerged as a promising therapeutic option. DCBs directly transfer antiproliferative drugs to the arterial wall in order to decrease myointimal hyperplasia. We describe a case of de novo renal artery in-stent restenosis (ISR) treated with drug-coated balloon angioplasty with acceptable short-term results, achieving blood pressure control using fewer antihypertensive agents. The experience and results obtained with DCBs in other territories could suggest and justify use of this technology in renal artery ISR.

Keywords:
in-stent restenosis; renal artery stenosis; renovascular hypertension

Authorship

Rodrigo Gibin Jaldin ^** Correspondence Rodrigo Gibin Jaldin Universidade Estadual Paulista – UNESP, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia Via Domingos Sartori, s/n - Distrito de Rubião Junior CEP 18607-621 - Botucatu (SP), Brasil Tel.: +55 (14) 38116305 E-mail: rgibin@fmb.unesp.br ; rgibin@uol.com.br

Universidade Estadual Paulista – UNESP, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil. Universidade Estadual PaulistaBrasilBotucatu, SP, Brasil Universidade Estadual Paulista – UNESP, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia, Botucatu, SP, Brasil.

Marcone Lima Sobreira

Regina Moura

Matheus Bertanha

Rafael Elias Fares Pimenta

Ricardo de Alvarenga Yoshida

Jamil Victor de Oliveira Mariúba

Winston Bonetti Yoshida

Conflicts of interest: No conflicts of interest declared concerning the publication of this article.

* Correspondence Rodrigo Gibin Jaldin Universidade Estadual Paulista – UNESP, Faculdade de Medicina de Botucatu, Departamento de Cirurgia e Ortopedia Via Domingos Sartori, s/n - Distrito de Rubião Junior CEP 18607-621 - Botucatu (SP), Brasil Tel.: +55 (14) 38116305 E-mail: rgibin@fmb.unesp.br ; rgibin@uol.com.br

Author information RGJ and REFP - Board-certified in Vascular Surgery, Endovascular Surgery, and Doppler Vascular Ultrasound; Vascular and endovascular surgeon, Hospital das Clínicas de Botucatu, Universidade Estadual Paulista (UNESP). MLS, RM and MB - Assistant professor of Vascular and Endovascular Surgery, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP). RAY - Collaborating professor of Vascular and Endovascular Surgery, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP). JVOM - Tenured adjunct professor of Vascular and Endovascular Surgery, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP). WBY - Full professor of Vascular and Endovascular Surgery, Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (UNESP).

Author contributions Conception and design: RGJ, MLS, WBY Analysis and interpretation: RGJ, MLS, WBY Data collection: RGJ, MB Writing the article: RGJ, WBY Critical revision of the article: RGJ, WBY, HAR, MLS, RM Final approval of the article*: RGJ, MLS, RM, MB, HAR, WBY Statistical analysis: N/A Overall responsibility: RGJ *All authors have read and approved of the final version of the article submitted to J Vasc Bras.

SCIMAGO INSTITUTIONS RANKINGS

Figures

Figures (7)

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Figure 1
First renal in-stent restenosis. Angiographs before and after the reintervention, in which a 7 × 19 mm stent was fitted coaxially.

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Figure 2
Aortography via a brachial access, showing signs of intra-stent hyperplasia, confirming the duplex mapping findings.

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Figure 3
Access sequence for intra-stent drug-coated balloon angioplasty. Selective catheterization of the right renal artery with a 5F 125 cm vertebral catheter, crossing the lesion with a 0.035” 260 cm stiff hydrophilic guidewire, swapping the guidewire for a 0.035” 260 cm extra-stiff, and advancing the 6F 90 cm introducer up to the emergence of the right renal artery.

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Figure 4
Pre-dilation of the lesion with a 4 × 40 mm balloon (A) and angioplasty with a 6 × 40 mm paclitaxel-covered balloon, with signs of a “waist” in the balloon at the point of greatest stenosis, followed by complete inflation of the balloon up to its nominal pressure (B). Selective angiography for post-angioplasty control, showing residual stenosis of 30-40% (C).

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Figure 5
Periodic assessments with renal duplex mapping. (A) Examination at 30 days after angioplasty; (B) Examination at 90 days after the procedure; (C) Examination at 6 months after the procedure; (D) Examination at 12 months after the procedure.

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Figure 6
Curves for Doppler velocity measurement parameters over the first 9 months of post-angioplasty follow-up. Dotted lines indicate the 50-70% stenosis range, according to Doppler velocity measurement. Above, peak systolic velocity (PSV) in centimeters per second (cm/s). Below, renal-aortic ratio (RAR), obtained by dividing the PSV measured at the renal artery by the PSV at the suprarenal aorta.

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Figure 7
Duplex mapping of renal artery, hilum, and parenchyma for control at 24 months post angioplasty with drug-coated balloon (DCB).

Figure 1 First renal in-stent restenosis. Angiographs before and after the reintervention, in which a 7 × 19 mm stent was fitted coaxially.

Figure 2 Aortography via a brachial access, showing signs of intra-stent hyperplasia, confirming the duplex mapping findings.

Figure 3 Access sequence for intra-stent drug-coated balloon angioplasty. Selective catheterization of the right renal artery with a 5F 125 cm vertebral catheter, crossing the lesion with a 0.035” 260 cm stiff hydrophilic guidewire, swapping the guidewire for a 0.035” 260 cm extra-stiff, and advancing the 6F 90 cm introducer up to the emergence of the right renal artery.

Figure 4 Pre-dilation of the lesion with a 4 × 40 mm balloon (A) and angioplasty with a 6 × 40 mm paclitaxel-covered balloon, with signs of a “waist” in the balloon at the point of greatest stenosis, followed by complete inflation of the balloon up to its nominal pressure (B). Selective angiography for post-angioplasty control, showing residual stenosis of 30-40% (C).

Figure 5 Periodic assessments with renal duplex mapping. (A) Examination at 30 days after angioplasty; (B) Examination at 90 days after the procedure; (C) Examination at 6 months after the procedure; (D) Examination at 12 months after the procedure.

Figure 6 Curves for Doppler velocity measurement parameters over the first 9 months of post-angioplasty follow-up. Dotted lines indicate the 50-70% stenosis range, according to Doppler velocity measurement. Above, peak systolic velocity (PSV) in centimeters per second (cm/s). Below, renal-aortic ratio (RAR), obtained by dividing the PSV measured at the renal artery by the PSV at the suprarenal aorta.

Figure 7 Duplex mapping of renal artery, hilum, and parenchyma for control at 24 months post angioplasty with drug-coated balloon (DCB).

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Drug-coated balloon used to treat in-stent restenosis of the renal artery

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[1] Conflicts of interest: No conflicts of interest declared concerning the publication of this article.