Renal Artery Angioplasty and Stenting with Embolic Protection

Technique • If unilateral RA to be treated, puncture ipsilateral CFA so the secondary curve of the guide catheter can abut the contralateral aortic wall for stability • Initial 5 F sheath and 5 F pigtail catheter for single aortic flush study – localise renal arteries relative to bony landmarks • Exchange sheath for 35 cm 8 F sheath (if using embolic protection) to maximise guide catheter torque control

Technique • 8 F guide catheter – usually RDC shape • Heparin (ACT > 250 s), GTN boluses • Attempt primary passage of embolic filter (eg Angioguard 6 -7 mm) • If successful, deploy filter in distal MRA • If unsuccessful, use “buddy wire” technique

Technique • Pre-dilate critical stenoses (eg 4 mm monorail balloon) • Introduce BE stent (eg 6 -7 mm X 12 mm) • Consider oblique view to optimally profile renal artery ostium • Deploy stent using semi-compliant balloon, monitoring patient discomfort • With deflated balloon catheter in place, introduce guide catheter so it sits in the stented segment

Technique • Remove balloon catheter leaving guide catheter in place • Completion angiogram with embolic filter in place • Recapture embolic filter • Completion angiogram with embolic filter removed

Technique • Preliminary aortic flush study to localise RAs

Technique • Primary passage of distal embolic filter

Technique • Stent deployed with semi-compliant balloon

Technique • Completion angiogram with filter in place

Technique • Completion angiogram with filter removed

Embolisation of IMA Type 2 Endoleak

Technique • Careful evaluation of CTA to identify origin and orientation of marginal artery off SMA • Retrograde CFA approach • Aortic flush angiography to exclude other causes of endoleak (proximal and distal type 1, type 3)

Technique • Selective SMA injections with catheter in proximal SMA (eg 5 F C 2 NS, Simmons 2) • Important not to have the catheter too distal in SMA as may miss marginal artery origin • Try and select marginal artery origin with 5 F catheter (may need coaxial approach – eg 7 F Ansel 2, selective 5 F catheter)

Technique • Use co-axial mico-catheter and wire (eg Terumo Progreat) • Manipulate micro-catheter down ascending left colic and into IMA trunk • Embolise IMA trunk (usually microcoils eg Cook 0. 018” Tornados) leaving ascending colic and superior rectal arteries in continuity

IMA embolisation

IMA embolization

IMA embolization Pre-embolisation Post-embolisation

Post IMA embolisation CT