The Internet Journal of Cardiology
Slow Flow Phenomenon During Renal
Does It Have the Same Predictors and Treatment as
Javad Kojuri, Reza Mollazadeh: Slow Flow Phenomenon During Renal
Angioplasty: Does It Have the Same Predictors and Treatment as Coronary
Angioplasty?. The Internet Journal of Cardiology. 2007. Volume 4
Renal, angioplasty, slow flow,
Percutaneous treatment of
renovascular disease offers a relatively safe and effective
therapy .Restoration of blood flow in the large arteries is not
necessarily associated with microvascular and tissue perfusion.
Even in coronary bed the mechanisms responsible for no-reflow or
slow-flow and consequently the treatment are uncertain.
Nitroprusside for prevention of slow flow during Percutanous
coronary intervention had conflicting results. Despite reported
slow or no-reflow phenomenon during coronary angioplasty but never
has been proposed during renal angioplasty. Here in we report a
case with this complication that responded to direct injection of
Renovascular disease is an important and often unrecognized
contributor to renal insufficiency, refractory hypertension, and overall
cardiovascular mortality. Percutanous treatment of renovascular disease
offers a safe and effective therapy. It can ameliorate hypertension, can
improve and stabilize renal function, and may delay the need for
hemodialysis. This technique, as is true for other fields of
intervention, could be associated with complications. Here in we report
The patient was a 70 year old diabetic hypertensive man whose blood
pressure had been uncontrollable recently. Despite gradually increase in
the number and dose of his antihypertensive medications, his blood
pressure could not be lowered. Due to high possibility of renal artery
stenosis, magnetic resonance angiography (MRA) was performed which
yielded bilateral stenosis. Meanwhile the patient's renal function
deteriorated during the last 4 months with three-fold of rise in blood
urea nitrogen and creatinine. So the patient was brought to
catheterization laboratory for renal angiography. Renal angiography
revealed bilateral severe renal artery stenosis (Image1, Movie clip 1).
Image1, Movie clip 1: Severe proximal stenosis (black arrow)
in right renal artery with a white oscillating area (white
So staged renal angioplasty with special precautions for minimizing
further renal damage was done. After right renal angioplasty and stent
insertion renal blood flow deteriorated obviously (Image2, Movie clip
Image 2, Movie clip 2: Reduction in renal blood flow after
renal artery stenting.
Due to unpredictability of the situation and lack of access to every
medication and equipment, nitroprusside was injected directly into renal
artery (totally 200 microgram) that lead to resumption of renal blood
flow (Image3, Movie clip 3).
Image 3, Movie clip 3: The final result after nitroprusside
injection which has normal renal blood flow.
left renal angioplasty was not associated with the same complication
despite similar lesion. His blood pressure dropped to160/80 in the
catheterization lab, renal failure recovered during one week and his
blood pressure controlled with amlodipine.
Renovascular hypertension is among the most common secondary forms of
hypertension and is not easily recognizable 1 .The most
common type is atherosclerotic which affects mainly the proximal third
of the main renal artery and is seen most commonly in elderly men.
Renovascular stenosis is often bilateral; although usually one side is
clearly predominant .The possibility of bilateral disease should be
suspected if it develops after the start of angiotensin converting
enzyme inhibitor or angiotensin receptor blockers therapy, onset of
hypertension before 30 or after 50 years of age, severe or resistant
hypertension ,elevated serum creatinin and etc
3 . As it is obvious, considering the aforementioned points
in our patient had a high clinical likelihood of having renovascular
hypertension. The initial diagnostic study in most patients, as our case
was, could be noninvasive and, if abnormal, followed by a study of renal
anatomy invasively 1
5 . The
availability of stents and the associated technological improvements
that facilitate secure delivery of devices to the target site, compared
to surgical approach and its complications, given the advanced age of
many patients with atherosclerotic disease and the significant
perioperative morbidity and operative mortality has led to increase in
utilization of the former therapy 6 .
Endovascular renal artery stenting complications include dissection
of renal artery or the wall of aorta, acute or delayed thrombosis,
infection, rupture of renal artery, access site complication (the most
common) and probably the most dreaded complication: atheroembolism
7 . Here in we present a complication which wasn't reported
previously. As is evident in renal angiography of our patient, there is
a white oscillating area in proximal of renal artery. Distal
embolization of debris or microparticulate atheromatous material in this
patient, maybe the cause of slow flow after stenting .Direct injection
of nitroprusside resulted in recovery of renal blood flow .It is
important to mention that this phenomenon is different from
atheroembolism which is more likely to occur with aggressive
manipulation of the diagnostic and/or guiding catheters .Although slow
or no-reflow phenomenon was previously reported during coronary
angioplasty but never has been proposed during renal angioplasty.
Review of literature
Restoration of blood flow in the large arteries is not necessarily
associated with microvascular and tissue perfusion. Restoration of
perfusion at the tissue level is expected to have beneficial effects on
renal function. Impaired flow following percutaneous coronary
angioplasty (no-reflow or slow reflow phenomenon) is described
thoroughly in the literature 8 ,
. The mechanisms responsible for no-reflow or slow-flow are uncertain
and prevailing mechanism operating in the individual patient may also
differ: distal embolization of debris or microparticulate atheromatous
material, capillary edema, inflammation, neurohormonal reflexes and
vasoconstriction may play a crucial role 8 ,
almost similar pathogenesis exists in renal vascular bed (as could be
assumed), the treatment would be probably alike. When predictors of
impaired flow are discovered, prophylactic pharmacological measures
(glycoprotein IIb/IIIa inhibitors) should be undertaken probably
13 . Other medications such
as adenosine 14 ,
15 , nicorandil
17 , verapamil
18 , nitroprusside
20 were used also.
Intracoronary nitroprusside for prevention of slow flow during
Percutanous coronary intervention had conflicting results
, 20 :Intracoronary bolus injection of nitroprusside using a
3 ml syringe appears to be a feasible, safe, and effective technique for
the management of slow/no-reflow phenomenon complicating primary PCI (
20 ) while others believe that in patients with STEMI,
selective intracoronary administration of a fixed dose of nitroprusside
failed to improve coronary flow and myocardial tissue reperfusion but
improved clinical outcomes at 6 months 19 .
Because of rarity of this complication (slow flow after renal
stenting) and lack of previous studies there is need for further studies
for finding the best treatment of slow flow phenomenon. Direct
administration of nitroprusside could be one of the solutions.
Address correspondence to
Nemazee Hospital, Shiraz, Iran
P.O. Box: 71435-141
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