Recurrent hypertension from stent fracture

Abstract

A 20-year-old man with Takayasu's arteritis with poor response to steroids and persistently high blood pressure (BP) was referred to our institution for control of his hypertension. The right radial pulse was absent, BP was 156/110 mm Hg, and an abdominal bruit was noted. Serum creatinine was 0.8 mg per 100 ml with normal serum electrolytes, and two-dimensional echo showed dilated cardiac chambers with mild left ventricular systolic dysfunction. Arteriography revealed total occlusion of right subclavian artery, bilateral renal artery stenosis with 90% occlusion at the origins, and 100% occlusion of proximal right coronary artery. He underwent percutaneous transluminal angioplasty with stenting of both the renal arteries using a non-drug-eluting renal bridge stent. He continued on furosemide 40 mg once daily (OD), amlodipine 5 mg OD, and atenolol 50 mg OD, and his BP normalized and antihypertensive requirement came down gradually in course of time. He was initiated on aspirin 150 mg OD and clopidogrel 75 mg OD. Two years later he came back with BP of 160/110 mm Hg, serum creatinine was 0.7 mg per 100 ml, and urine output was 1600 ml day- 1. A duplex ultrasonography of the renal arteries showed in-stent restenosis of the left renal artery. Renal arteriogram revealed bilateral renal artery stent fracture causing significant in-stent restenosis in the left renal artery and non-flow-limiting restenosis in the right side. Patient underwent plain balloon angioplasty for in-stent restenosis of left renal artery and as the final angiography showed non-flow-limiting residual stenosis. Post-intervention BP was 130/90 mm Hg. In-stent restenosis can occur usually secondary to progression of disease process, failure of antiplatelet therapy, and very rarely stent fracture as in our case. Thus, a surveillance duplex ultrasonography needs to be performed every 6 months after stent placement. The finding of restenosis during screening warrants immediate reintervention. Long-term follow-up of Takayasu's arteritis patients who have undergone stenting for renal artery stenosis is required to validate the beneficial effect and rate of restenosis. To our knowledge, this is the first reported case of bilateral renal artery stent fracture (Figure 1).