Robert J. Ashenburg, MD • Richard J. Blair, MD • Frank J. Rivera, MD • John B. Weigele, MD, PhD
Renal Arterial Rupture Complicating Transluminal Angioplasty: Successful Conservative Management' Vessel rupture complicating transluminal angioplasty is an uncommon event, especially in the renal artery. The authors report such a case, which was treated with immediate balloon tamponade and did not require surgical intervention. Possible causes and appropriate management are discussed, as well as the need for reporting angioplasty-related complications to a registry being developed by the Society of Cardiovascular and Interventional Radiology. transluminal renal angioplasty (PTRA) is now a widely practiced technique with excellent long-term patency rates, particularly in non-ostial atherosclerotic stenoses and lesions of fibromuscular dysplasia (1,2). Despite the increasing popularity and widespread application, serious complications occur, although infrequently (3-7). Of the major complications, vessel rupture at the dilatation site has been reported only a handful of times in the literature, some of which are clearly related to guide-wire perforation (2-4,6-11)._We have recently experienced an angioplasty-related rupture of the renal artery in a patient who had been receiving steroid therapy for a long time. This was immediately treated with balloon tamponade and did not require surgical intervention (as of 4month follow-up). Although this conservative type of therapy is not generDERCUTANEOUS
Index terms: Interventional procedures, complications • Renal arteries, injuries, 461.458 • Renal arteries, stenosis or obstruction, 961.721 • Renal arteries, therapeutic blockade, 961.1299 • Renal arteries, transluminal angioplasty, 961.128 Radiology 1990; 174:983-985
1 From the Department of Radiology, Section of Vascular and Interventional Radiology, SUNY Health Science Center at Syracuse, 750 E Adams St, Syracuse, NY 13210 (R.J.A., R.J.B., J.B.W.); and the Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (F.J.R.). Received October 10, 1989; accepted and revision requested December 10; revision received December 15. Address reprint requests to R.J.A. RSNA, 1990
ally advocated, prompt recognition and management of complications and individualized treatment may spare the patient the unnecessary risk of surgery. CASE REPORT A 47-year-old woman with multiple medical problems was admitted for dilation of a non-ostial left renal artery stenosis. The stenosis measured approximately 75% of the expected luminal diameter and was discovered incidentally on an arteriogram done for unrelated purposes 8 months prior to admission (Fig 1). Three months prior to admission, percutaneous biopsy of a mass in the right kidney revealed renal cell carcinoma necessitating a planned right nephrectomy. The rationale for dilation of the left renal artery was therefore preservation of renal function in what would be a single kidney. Although the patient was hypertensive, renin sampling was not performed since there was already sufficient indication for the procedure. A further historical note of significance is the fact that the patient had been taking steroids for a long time (Prednisone, 5 mg /d for 15 years) for a poorly documented history of systemic lupus erythematosis. There was no angiographic evidence of vasculitis. The renal artery stenosis was traversed without difficulty by means of an angled .035-inch Glidewire (Medi-tech /Boston Scientific, Watertown, Mass), and this was exchanged for a .035-inch Rosen guide wire (Cook, Bloomington, Ind), over which the balloon catheters were placed. Five thousand units of heparin were administered intraarterially after the lesion was crossed, and nitroglycerin was administered intraarterially in bolus doses frequently throughout the procedure. Sizing of the balloon was accomplished by direct measurement of the normal portion of the renal artery, which ranged from 6 to 7 mm. Initial dilation was performed with a 5-F Ultra-thin balloon (Medi-tech/Boston Scientific), 6 mm diameter X 2 cm, inflated three times to a pressure of 6 atm for 45 seconds per inflation. Intraarterial digital imaging showed a persistent significant stenosis, and therefore another Ultra-thin balloon, 7 mm diameter X 2 cm, was exchanged over the guide wire. Again, three inflations were performed for 45 seconds each to 6 atm. Repeat imaging continued to show a residual stenosis of 50%-75%. Inflation of both the 6-mm and 7-mm balloons failed
Figure 1. Predilation subtraction image showing left renal artery stenosis in the range of 75%. Linear density below stenosis (arrow) represents calcified plaque. to obliterate the balloon waist complete-
ly. The diagnostic arteriogram was reevaluated, and it was decided that use of an 8mm-diameter X 3-cm Ultra-thin balloon was reasonable and not overly aggressive. The balloon was inflated on three occasions to 6 atm with no inflation longer than 60 seconds. With each inflation of the 7-mm and 8-mm balloons, the patient experienced left flank pain, which abated with deflation of the balloon except on the final dilation. At this point, she had continued severe left flank pain, and immediate digital imaging documented extravasation of contrast material from the left renal artery (Fig 2). A balloon occlusion catheter (Meditech /Boston Scientific) was then placed over the guide wire and used to tamponade the injured vessel for approximately 15 minutes. (Choice of a balloon occlusion catheter was the personal preference of the authors, and tamponade could have been accomplished with the dilation balloon, which had been removed prior to digital imaging.) The patient's pain decreased over this interval and she remained hemodynamically stable with no change in the baseline blood pressure of approximately 140 /90 mm Hg. Digital arteriography after 15 minutes showed no further extravasation and was repeated
Abbreviation: PTRA = percutaneous transluminal renal angioplasty
983
Figure 2. Sequential intraarterial digital images showing extravasation (arrow) following use of the 8 - mm balloon.
every 30 minutes for 2 hours with no change. After consultation with the Vascular Surgical Service, the patient was transferred to the intensive care unit with an arterial sheath in the right femoral artery. The previously administered heparin was not reversed with protamine because of stable hemodynamics and minimal symptoms. Arteriography was repeated approximately 5 hours after the incident and again 4 days later. Neither study showed extravasation or pseudoaneurysm formation, and the renal artery was patent, although with a residual stenosis in the range of 50%. The following day computed tomography (CT) of the abdomen was performed and demonstrated hematoma in the left posterior pararenal space and paraspinal area as well as thickening of Gerota fascia (Fig 3). The patient's hematocrit level had fallen from an admission value of 37% to 27% the day of PTRA, and had then stabilized. Three months after dilation, abdominal aortography was performed (Fig 4). The renal artery had remodeled with less than 30% residual stenosis, and there was no longer evidence of poststenotic dilatation. At this writing, a right nephrectomy is still planned, although it has been delayed because of the patient's intercurrent respiratory problems. DISCUSSION Despite the increasing frequency with which percutaneous transluminal angioplasty is performed, there is a noticeable absence in the literature of large studies assessing the morbidity and mortality of the procedure. Gardiner et al reported a comprehensive analysis of the complications of transluminal angioplasty in 453 patients and is one of few such studies in the radiology literature (3). There is a smattering of case reports dealing with the complications of angioplasty; however, these anecdotal reports do not provide the statistical relevance of large series. Fortunately, the information available in984 • Radiology
dicates that the incidence of major complications related to angioplasty is low and morbidity figures compare favorably with those of alternative surgical procedures (3). Complications of angioplasty may occur at the puncture site, at the dilatation site, in the distal circulation, or may be systemic in nature. Undoubtedly, hematoma at the puncture site is the most frequent minor complication associated with renal angioplasty, while occlusion of the renal artery and renal failure are the most frequent major complications (3-5,7). Rupture of the renal artery secondary to balloon inflation seems to be a rare occurrence, with only 12 cases reported in a review of the recent literature (2-4,6,8,10). This occurred with a frequency of 0.4% in Gardiner's series (3). We have performed 97 dilations of the renal artery in the past 5 years, and this was the first rupture we have seen. In the setting of angioplasty-related arterial rupture, the traditional treatment is immediate tamponade with a balloon catheter while the patient is readied for surgery (1,9). The surgical mortality for renal revascularization has been reduced to less than 1%, and prior transluminal angioplasty has been shown to not adversely affect the success of surgical revascularization even in the setting of acute perforation or thrombosis (8,12). This was certainly our initial plan and should probably be the course of action in the majority of these cases. The absence of extravasation after a short period of balloon tamponade and the significant improvement in the patient's symptoms led to our adopting an approach of observation with frequent imaging early on. Intensive care unit monitoring and an arterial sheath with blood pressure monitoring were absolutely mandatory as a safeguard against recurrence of rupture. The nonsurgical treatment of arterial
rupture is not without precedent and has recently been reported in both the common and external iliac artery (13,14). One of the reports advocated temporary balloon occlusion as a means of avoiding surgery and maintaining vessel patency (13). Nonsurgical treatment of renal arterial rupture has also been reported. However, angiographic embolization was performed afterward in both cases to prevent possible complications of rebleed or pseudoaneurysm (3,10). To our knowledge, ours is only the second description of renal arterial rupture treated conservatively with continued vessel patency (6). In selected cases, this approach may be appropriate particularly in patients who are poor surgical risks. Regardless, attention to such details as persistent flank pain, leaving a guide wire across the lesion, and availability of a balloon catheter for the purpose of tamponade is crucial to preventing a bad situation from turning worse. The mechanism of transluminal angioplasty is related to plaque fracture with splitting of intima and media and some stretching of the vessel followed by a remodeling process over several months (1). Vessel rupture is a less well understood phenomenon but could certainly be accomplished by the use of inappropriately large balloons with subsequent overstretching of the vessel. The risk of vessel rupture is lower with the current low-compliance balloons (polyethylene and polyurethane) that do not increase in diameter with increasing pressure (1). Obviously the choice of balloon size is critical both for a successful dilation and for avoidance of complications. Most angiographers measure normal luminal diameter from the arteriogram and choose a balloon size accordingly. Because of the inherent magnification there is necessarily overdilation. Others use a more aggressive approach and choose a balloon 1-2 mm larger than the measured diameter March 1990 • Part 2
Figure 4. Subtraction image obtained 3 months following PTRA. Note remodeling of the left renal artery with resolution of the poststenotic dilatation and residual stenosis less than 30%.
Figure 3. CT scan 5 days after PTRA showing soft-tissue density adjacent to the renal artery (arrow). Contiguous images (not shown) documented hematoma in the posterior pararenal space. Note low-attenuation area in right kidney representing hypernephroma (arrowhead).
(9). Our initial choice of balloon size was in keeping with the former method. However, after an unsatisfactory result, we chose to be more aggressive with an 8-mm balloon in an artery measuring closer to 7 mm. A factor that may be more significant than balloon size in our case is related to the patient's chronic steroid therapy. Steroids, with their known deleterious effect on collagen synthesis, may lead to weakening of the arterial wall and render the vessel more susceptible to injury (15). Lois et al have reported two vessel ruptures by balloon catheters in a single patient who was receiving steroid therapy (16). We agree with their conclusion that this particular group of patients should be approached with caution when considering percutaneous intervention, and, based on our experience, we believe aggressive overdilation should be avoided. Perhaps these patients fall into the same group as those with fibromuscular hyperplasia and an associated aneurysm distal to the stenosis, a subset more prone to rupture. Some groups avoid angioplasty in these patients (5), although this practice is controversial. Several questions have been raised by our experience with this case. They include the cause of vessel rupture and the role of steroids as well as the prop,
Volume 174 • Number 3 • Part 2
er course of management in cases such as ours. Without sufficient data, answers to these questions can only be speculative. Large series of complications provide more valuable data on which rational decisions can be based, but they are generally compiled only at academic centers. A more comprehensive data base is necessary and can be achieved by means of a national registry, currently under development by the Society of Cardiovascular and Interventional Radiology. With more broadbased data and a knowledge of both institutional and individual experiences, as well as those of our surgical colleagues, better management decisions can be made and our patients will be better served. n Acknowledgments: The authors thank Maria Pembrook for her secretarial contribution in preparation of this manuscript.
References 1. Becker GJ, Katzen BT, Dake MD. Noncoronary angioplasty. Radiology 1989; 170:921-940. 2. Tegtmeyer CJ, Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery: results and long-term followup. Radiology 1984; 153:77-84. 3. Gardiner GA Jr, Meyerovitz MF, Stokes KR, Clouse ME, Harrington DP, Bettmann MA. Complications of transluminal angioplasty. Radiology 1986; 159:201-208.
4. Bergquist D, Jonsson K, Weibull H. Complications after percutaneous transluminal angioplasty of peripheral and renal arteries. Acta Radiol 1987; 28:3-12. 5. Ring EJ. Complications of transluminal angioplasty. Presented at the International Symposium on Peripheral Vascular Intervention, Miami, Florida. January 1989. 6. Chiesura-Corona M, Feltrin GP, Miotto D, Savastano S. Complications of renal angioplasty: incidence and effects on clinical outcome. J Intervent Radiol 1989; 4:75-84. 7. Martin LG, Casarella WJ, Alspaugh JP, Chuang VP. Renal artery angioplasty: increased technical success and decreased complications in the second 100 patients. Radiology 1986; 159:631-634. 8. McCann RL, Bollinger RR, Newman GE. Surgical renal artery reconstruction after percutaneous transluminal angioplasty. J Vasc Surg 1988; 8:389-394. 9. Tegtmeyer CJ, Sos TA. Techniques of renal angioplasty. Radiology 1986; 161:577586. 10. Dixon GD, Anderson S, Crouch TT. Renal arterial rupture secondary to percutaneous transluminal angioplasty treated without surgical intervention. Cardiovasc Intervent Radiol 1986; 9:83-85. 11. Puijlaert CB, Mali WP, Rosenbusch G, van Straalen AM, Klinge J, Feldberg MA. Delayed rupture of renal artery after renal percutaneous transluminal angioplasty. Radiology 1986; 159:635-637. 12. Wise KL, McCann RL, Dunnick NR, Paulson DF. Renovascular hypertension. J Urol 1988; 140:911-924. 13. Joseph N, Levy E, Lipman S. Angioplasty-related iliac artery rupture: treatment by temporary balloon occlusion. Cardiovasc Intervent Radiol 1987; 10:276279. 14. Smith TP, Cragg AH. Non-surgical treatment of iliac artery rupture following angioplasty. J Intervent Radiol 1989; 4:16-18. 15. Baxter JD, Lorsham PH. Tissue effects of glucocorticoids. Am J Med 1972; 53:573589. 16. Lois JF, Takiff H, Schechter MS, Gomes AS, Machleder HI. Vessel rupture by balloon catheters complicating chronic steroid therapy. AJR 1985; 144:1073-1074.
Radiology • 985
Renal Arterial Rupture Complicating Transluminal Angioplasty: Successful Conservative Management' Vessel rupture complicating transluminal angioplasty is an uncommon event, especially in the renal artery. The authors report such a case, which was treated with immediate balloon tamponade and did not require surgical intervention. Possible causes and appropriate management are discussed, as well as the need for reporting angioplasty-related complications to a registry being developed by the Society of Cardiovascular and Interventional Radiology. transluminal renal angioplasty (PTRA) is now a widely practiced technique with excellent long-term patency rates, particularly in non-ostial atherosclerotic stenoses and lesions of fibromuscular dysplasia (1,2). Despite the increasing popularity and widespread application, serious complications occur, although infrequently (3-7). Of the major complications, vessel rupture at the dilatation site has been reported only a handful of times in the literature, some of which are clearly related to guide-wire perforation (2-4,6-11)._We have recently experienced an angioplasty-related rupture of the renal artery in a patient who had been receiving steroid therapy for a long time. This was immediately treated with balloon tamponade and did not require surgical intervention (as of 4month follow-up). Although this conservative type of therapy is not generDERCUTANEOUS
Index terms: Interventional procedures, complications • Renal arteries, injuries, 461.458 • Renal arteries, stenosis or obstruction, 961.721 • Renal arteries, therapeutic blockade, 961.1299 • Renal arteries, transluminal angioplasty, 961.128 Radiology 1990; 174:983-985
1 From the Department of Radiology, Section of Vascular and Interventional Radiology, SUNY Health Science Center at Syracuse, 750 E Adams St, Syracuse, NY 13210 (R.J.A., R.J.B., J.B.W.); and the Department of Radiology, University of Texas Health Science Center, San Antonio, Texas (F.J.R.). Received October 10, 1989; accepted and revision requested December 10; revision received December 15. Address reprint requests to R.J.A. RSNA, 1990
ally advocated, prompt recognition and management of complications and individualized treatment may spare the patient the unnecessary risk of surgery. CASE REPORT A 47-year-old woman with multiple medical problems was admitted for dilation of a non-ostial left renal artery stenosis. The stenosis measured approximately 75% of the expected luminal diameter and was discovered incidentally on an arteriogram done for unrelated purposes 8 months prior to admission (Fig 1). Three months prior to admission, percutaneous biopsy of a mass in the right kidney revealed renal cell carcinoma necessitating a planned right nephrectomy. The rationale for dilation of the left renal artery was therefore preservation of renal function in what would be a single kidney. Although the patient was hypertensive, renin sampling was not performed since there was already sufficient indication for the procedure. A further historical note of significance is the fact that the patient had been taking steroids for a long time (Prednisone, 5 mg /d for 15 years) for a poorly documented history of systemic lupus erythematosis. There was no angiographic evidence of vasculitis. The renal artery stenosis was traversed without difficulty by means of an angled .035-inch Glidewire (Medi-tech /Boston Scientific, Watertown, Mass), and this was exchanged for a .035-inch Rosen guide wire (Cook, Bloomington, Ind), over which the balloon catheters were placed. Five thousand units of heparin were administered intraarterially after the lesion was crossed, and nitroglycerin was administered intraarterially in bolus doses frequently throughout the procedure. Sizing of the balloon was accomplished by direct measurement of the normal portion of the renal artery, which ranged from 6 to 7 mm. Initial dilation was performed with a 5-F Ultra-thin balloon (Medi-tech/Boston Scientific), 6 mm diameter X 2 cm, inflated three times to a pressure of 6 atm for 45 seconds per inflation. Intraarterial digital imaging showed a persistent significant stenosis, and therefore another Ultra-thin balloon, 7 mm diameter X 2 cm, was exchanged over the guide wire. Again, three inflations were performed for 45 seconds each to 6 atm. Repeat imaging continued to show a residual stenosis of 50%-75%. Inflation of both the 6-mm and 7-mm balloons failed
Figure 1. Predilation subtraction image showing left renal artery stenosis in the range of 75%. Linear density below stenosis (arrow) represents calcified plaque. to obliterate the balloon waist complete-
ly. The diagnostic arteriogram was reevaluated, and it was decided that use of an 8mm-diameter X 3-cm Ultra-thin balloon was reasonable and not overly aggressive. The balloon was inflated on three occasions to 6 atm with no inflation longer than 60 seconds. With each inflation of the 7-mm and 8-mm balloons, the patient experienced left flank pain, which abated with deflation of the balloon except on the final dilation. At this point, she had continued severe left flank pain, and immediate digital imaging documented extravasation of contrast material from the left renal artery (Fig 2). A balloon occlusion catheter (Meditech /Boston Scientific) was then placed over the guide wire and used to tamponade the injured vessel for approximately 15 minutes. (Choice of a balloon occlusion catheter was the personal preference of the authors, and tamponade could have been accomplished with the dilation balloon, which had been removed prior to digital imaging.) The patient's pain decreased over this interval and she remained hemodynamically stable with no change in the baseline blood pressure of approximately 140 /90 mm Hg. Digital arteriography after 15 minutes showed no further extravasation and was repeated
Abbreviation: PTRA = percutaneous transluminal renal angioplasty
983
Figure 2. Sequential intraarterial digital images showing extravasation (arrow) following use of the 8 - mm balloon.
every 30 minutes for 2 hours with no change. After consultation with the Vascular Surgical Service, the patient was transferred to the intensive care unit with an arterial sheath in the right femoral artery. The previously administered heparin was not reversed with protamine because of stable hemodynamics and minimal symptoms. Arteriography was repeated approximately 5 hours after the incident and again 4 days later. Neither study showed extravasation or pseudoaneurysm formation, and the renal artery was patent, although with a residual stenosis in the range of 50%. The following day computed tomography (CT) of the abdomen was performed and demonstrated hematoma in the left posterior pararenal space and paraspinal area as well as thickening of Gerota fascia (Fig 3). The patient's hematocrit level had fallen from an admission value of 37% to 27% the day of PTRA, and had then stabilized. Three months after dilation, abdominal aortography was performed (Fig 4). The renal artery had remodeled with less than 30% residual stenosis, and there was no longer evidence of poststenotic dilatation. At this writing, a right nephrectomy is still planned, although it has been delayed because of the patient's intercurrent respiratory problems. DISCUSSION Despite the increasing frequency with which percutaneous transluminal angioplasty is performed, there is a noticeable absence in the literature of large studies assessing the morbidity and mortality of the procedure. Gardiner et al reported a comprehensive analysis of the complications of transluminal angioplasty in 453 patients and is one of few such studies in the radiology literature (3). There is a smattering of case reports dealing with the complications of angioplasty; however, these anecdotal reports do not provide the statistical relevance of large series. Fortunately, the information available in984 • Radiology
dicates that the incidence of major complications related to angioplasty is low and morbidity figures compare favorably with those of alternative surgical procedures (3). Complications of angioplasty may occur at the puncture site, at the dilatation site, in the distal circulation, or may be systemic in nature. Undoubtedly, hematoma at the puncture site is the most frequent minor complication associated with renal angioplasty, while occlusion of the renal artery and renal failure are the most frequent major complications (3-5,7). Rupture of the renal artery secondary to balloon inflation seems to be a rare occurrence, with only 12 cases reported in a review of the recent literature (2-4,6,8,10). This occurred with a frequency of 0.4% in Gardiner's series (3). We have performed 97 dilations of the renal artery in the past 5 years, and this was the first rupture we have seen. In the setting of angioplasty-related arterial rupture, the traditional treatment is immediate tamponade with a balloon catheter while the patient is readied for surgery (1,9). The surgical mortality for renal revascularization has been reduced to less than 1%, and prior transluminal angioplasty has been shown to not adversely affect the success of surgical revascularization even in the setting of acute perforation or thrombosis (8,12). This was certainly our initial plan and should probably be the course of action in the majority of these cases. The absence of extravasation after a short period of balloon tamponade and the significant improvement in the patient's symptoms led to our adopting an approach of observation with frequent imaging early on. Intensive care unit monitoring and an arterial sheath with blood pressure monitoring were absolutely mandatory as a safeguard against recurrence of rupture. The nonsurgical treatment of arterial
rupture is not without precedent and has recently been reported in both the common and external iliac artery (13,14). One of the reports advocated temporary balloon occlusion as a means of avoiding surgery and maintaining vessel patency (13). Nonsurgical treatment of renal arterial rupture has also been reported. However, angiographic embolization was performed afterward in both cases to prevent possible complications of rebleed or pseudoaneurysm (3,10). To our knowledge, ours is only the second description of renal arterial rupture treated conservatively with continued vessel patency (6). In selected cases, this approach may be appropriate particularly in patients who are poor surgical risks. Regardless, attention to such details as persistent flank pain, leaving a guide wire across the lesion, and availability of a balloon catheter for the purpose of tamponade is crucial to preventing a bad situation from turning worse. The mechanism of transluminal angioplasty is related to plaque fracture with splitting of intima and media and some stretching of the vessel followed by a remodeling process over several months (1). Vessel rupture is a less well understood phenomenon but could certainly be accomplished by the use of inappropriately large balloons with subsequent overstretching of the vessel. The risk of vessel rupture is lower with the current low-compliance balloons (polyethylene and polyurethane) that do not increase in diameter with increasing pressure (1). Obviously the choice of balloon size is critical both for a successful dilation and for avoidance of complications. Most angiographers measure normal luminal diameter from the arteriogram and choose a balloon size accordingly. Because of the inherent magnification there is necessarily overdilation. Others use a more aggressive approach and choose a balloon 1-2 mm larger than the measured diameter March 1990 • Part 2
Figure 4. Subtraction image obtained 3 months following PTRA. Note remodeling of the left renal artery with resolution of the poststenotic dilatation and residual stenosis less than 30%.
Figure 3. CT scan 5 days after PTRA showing soft-tissue density adjacent to the renal artery (arrow). Contiguous images (not shown) documented hematoma in the posterior pararenal space. Note low-attenuation area in right kidney representing hypernephroma (arrowhead).
(9). Our initial choice of balloon size was in keeping with the former method. However, after an unsatisfactory result, we chose to be more aggressive with an 8-mm balloon in an artery measuring closer to 7 mm. A factor that may be more significant than balloon size in our case is related to the patient's chronic steroid therapy. Steroids, with their known deleterious effect on collagen synthesis, may lead to weakening of the arterial wall and render the vessel more susceptible to injury (15). Lois et al have reported two vessel ruptures by balloon catheters in a single patient who was receiving steroid therapy (16). We agree with their conclusion that this particular group of patients should be approached with caution when considering percutaneous intervention, and, based on our experience, we believe aggressive overdilation should be avoided. Perhaps these patients fall into the same group as those with fibromuscular hyperplasia and an associated aneurysm distal to the stenosis, a subset more prone to rupture. Some groups avoid angioplasty in these patients (5), although this practice is controversial. Several questions have been raised by our experience with this case. They include the cause of vessel rupture and the role of steroids as well as the prop,
Volume 174 • Number 3 • Part 2
er course of management in cases such as ours. Without sufficient data, answers to these questions can only be speculative. Large series of complications provide more valuable data on which rational decisions can be based, but they are generally compiled only at academic centers. A more comprehensive data base is necessary and can be achieved by means of a national registry, currently under development by the Society of Cardiovascular and Interventional Radiology. With more broadbased data and a knowledge of both institutional and individual experiences, as well as those of our surgical colleagues, better management decisions can be made and our patients will be better served. n Acknowledgments: The authors thank Maria Pembrook for her secretarial contribution in preparation of this manuscript.
References 1. Becker GJ, Katzen BT, Dake MD. Noncoronary angioplasty. Radiology 1989; 170:921-940. 2. Tegtmeyer CJ, Kellum CD, Ayers C. Percutaneous transluminal angioplasty of the renal artery: results and long-term followup. Radiology 1984; 153:77-84. 3. Gardiner GA Jr, Meyerovitz MF, Stokes KR, Clouse ME, Harrington DP, Bettmann MA. Complications of transluminal angioplasty. Radiology 1986; 159:201-208.
4. Bergquist D, Jonsson K, Weibull H. Complications after percutaneous transluminal angioplasty of peripheral and renal arteries. Acta Radiol 1987; 28:3-12. 5. Ring EJ. Complications of transluminal angioplasty. Presented at the International Symposium on Peripheral Vascular Intervention, Miami, Florida. January 1989. 6. Chiesura-Corona M, Feltrin GP, Miotto D, Savastano S. Complications of renal angioplasty: incidence and effects on clinical outcome. J Intervent Radiol 1989; 4:75-84. 7. Martin LG, Casarella WJ, Alspaugh JP, Chuang VP. Renal artery angioplasty: increased technical success and decreased complications in the second 100 patients. Radiology 1986; 159:631-634. 8. McCann RL, Bollinger RR, Newman GE. Surgical renal artery reconstruction after percutaneous transluminal angioplasty. J Vasc Surg 1988; 8:389-394. 9. Tegtmeyer CJ, Sos TA. Techniques of renal angioplasty. Radiology 1986; 161:577586. 10. Dixon GD, Anderson S, Crouch TT. Renal arterial rupture secondary to percutaneous transluminal angioplasty treated without surgical intervention. Cardiovasc Intervent Radiol 1986; 9:83-85. 11. Puijlaert CB, Mali WP, Rosenbusch G, van Straalen AM, Klinge J, Feldberg MA. Delayed rupture of renal artery after renal percutaneous transluminal angioplasty. Radiology 1986; 159:635-637. 12. Wise KL, McCann RL, Dunnick NR, Paulson DF. Renovascular hypertension. J Urol 1988; 140:911-924. 13. Joseph N, Levy E, Lipman S. Angioplasty-related iliac artery rupture: treatment by temporary balloon occlusion. Cardiovasc Intervent Radiol 1987; 10:276279. 14. Smith TP, Cragg AH. Non-surgical treatment of iliac artery rupture following angioplasty. J Intervent Radiol 1989; 4:16-18. 15. Baxter JD, Lorsham PH. Tissue effects of glucocorticoids. Am J Med 1972; 53:573589. 16. Lois JF, Takiff H, Schechter MS, Gomes AS, Machleder HI. Vessel rupture by balloon catheters complicating chronic steroid therapy. AJR 1985; 144:1073-1074.
Radiology • 985
