1. Aortoiliac angiography with runoff.
2. Selective renal angiography.
3. PTCA and stenting of the left superior renal artery.
INDICATION: Resistant hypertension.
BRIEF HISTORY:
65-year-old man with significant atherosclerotic disease. He has had a resistant hypertension. His workup revealed a high-grade left superior renal artery stenosis. He has also been having bilateral lower extremity claudication. He is now referred for a left renal artery evaluation and possible stenting as well as lower extremity angiography.

PROCEDURE IN DETAIL:
Informed consent was obtained. The patient was brought to the catheterization laboratory in a fasting state. The right groin was prepped and draped in a sterile fashion. 1% Lidocaine was used for local anesthesia. Fentanyl and Versed were used for moderate sedation. A 6-French 10 cm sheath was inserted into the right common femoral artery via modified Seldinger technique. Through this, a 6-French pigtail catheter was advanced to the abdominal aorta and abdominal aortic angiography was performed. The catheter was then pulled down and aortoiliac angiography with bilateral lower extremity runoff was performed. A decision was made to intervene on the left superior renal artery. Heparin was given for anticoagulation. Using a no-touch technique, the left superior renal artery was selectively engaged with a 6-French IM guide catheter. The renal artery was wired with a BMW wire. The vessel was predilated with a 5 x 20 mm compliant balloon and inflated to nominal pressure. The vessel was then stented with a 6 x 18 mm Herculink stents deployed at nominal pressure. The ostium was flared with a stent balloon. There was about 2-mm of stent extending in to the aorta. A final angiography was performed. Prior to the intervention, a translesional gradient was assessed and was found to be approximately 65-70 millimeters of Mercury by a peak-to-peak gradient. Following the procedure, there was no appreciable gradient.

FINDINGS:
Right renal artery has approximately 50% ostial stenosis. There are 2 left renal arteries, the superior renal artery has an approximately 85% ostial stenosis, the left lower renal artery, which supplied only about a third of the renal parenchyma is patent. Abdominal aorta, there is an ulcerated plaque in the distal abdominal aorta, which appears chronic, but is not causing any lumen loss. Right lower extremity, the right common iliac artery is diffusely diseased approximately 30%, the internal iliac artery and external iliac arteries were patent. The common femoral artery is patent, the deep femoral artery is patent, the superficial femoral artery has mild disease proximally 30% in the superficial femoral artery. There is a 3-vessel runoff to the foot. Left lower extremity, the common iliac artery has a 20% mid stenosis. The external iliac and internal arteries were patent. The common femoral artery is patent. The superficial femoral artery has mild disease. The TP trunk is occluded at the ostium. There is one-vessel runoff to the foot by the anterior tibial artery.

IMPRESSION:
1. High-grade left superior renal artery stenosis.
2. Moderate atherosclerotic disease in the left lower extremity with predominantly below-the-knee disease.
3. Successful left superior renal artery stenting as noted above.
PLAN:
1. Medical therapy for atherosclerotic peripheral arterial disease.
2. Dual anti-platelet therapy for at least 1 month, but preferably 3 months.