Journal of Invasive Cardiology

ABSTRACT: We sought to describe the evolution in imaging and interventional options for endovascular treatment of significant infrarenal aortic stenosis. Balloon angioplasty and stent implantation for infrarenal aortic stenosis has generally required large-sized arterial access sheaths in the past, and was typically guided by visual size assessment. Computerized tomography angiography enables accurate preprocedural assessment of severity and extent of aortic atherosclerosis, degree of calcification, and luminal dimensions at both stenosis and reference sites, and visualizes possible aneurysm. Intraprocedural pressure gradient measurements evaluate the hemodynamic response to revascularization. On the other hand, intravascular ultrasound can further verify accuracy of equipment sizing. Small-profile stents and balloons can be used via small-sized sheaths, thereby rendering the procedure possible in patients with extensive peripheral arterial disease or small iliofemoral arteries. Improved non-invasive and intravascular imaging can guide with great accuracy infrarenal aortic stenosis procedures and may enable the use of reduced-size access sheaths and devices in fragile patients with vasculopathies.

J INVASIVE CARDIOL 2011;23:E192–E196

Key words: CT scan, intravascular ultrasound, renal artery stenosis

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Atherosclerotic infrarenal aortic stenosis is an infrequent, though difficult to treat condition. Previous studies have indicated very good long-term patency with endovascular treatment.^1–5 However, the unfamiliar sizing of interventional equipment in very large vessels (with the potential risk of catastrophic aortic rupture) and the relatively large-diameter access sheath requirement in these arteriopathic patients can pose unique technical challenges. Recent advances in imaging techniques and interventional equipment enable preprocedural and intraprocedural planning and assessment, and ultimately safer performance of these complex cases. We hereby present a case of infrarenal aortic stenosis, performed with multimodality imaging.

Case Report. This case involved a 80-year-old female with a body mass index of 28.3 m/kg², chronic renal insufficiency with estimated glomerular filtration rate (GFR) of 49 ml/min per 1.73 m² and significant comorbidities including refractory hypertension, cervical spinal cord compression (awaiting surgery), coronary artery disease recently treated with bare-metal stent implantation in the left anterior descending coronary artery, and peripheral vascular disease manifesting as severe bilateral claudication (right greater than left). The patient was taking aspirin 81 mg daily and clopidogrel 75 mg daily for 1 month following the coronary stent implantation.