Vanishing stenosis in renal artery with fibromuscular dysplasia
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IMAGES IN CARDIOVASCULAR INTERVENTION
Vanishing stenosis in renal artery with fibromuscular dysplasia Hiroshi Kubota1 · Tetsuya Nomura1 · Daisuke Miyawaki1 · Masakazu Kikai1 · Natsuya Keira1 · Tetsuya Tatsumi1 Received: 10 November 2018 / Accepted: 12 August 2019 © Japanese Association of Cardiovascular Intervention and Therapeutics 2019
A 23-year-old man was admitted to our hospital with left back pain. He had a medical history of cerebral infarction and underwent stent implantation therapy in the bilateral internal carotid arteries. Since then he had been taking aspirin 100 mg once a day. Contrast-enhanced abdominal computed tomography demonstrated stenosis of the left renal artery and wedge-shaped enhancement defect in the left kidney. There was no evidence of inflammation, and vasculitis was excluded by the unremarkable serologic profile. Digital subtraction angiography (DSA) showed significant focal stenoses in the mid-portion of bilateral renal arteries and localized perfusion defect in the left kidney (Fig. 1a, Supplemental Videos 1, 2). Intravascular ultrasound (IVUS) examination showed diffusely thickened layers at stenotic lesions, and the internal elastic laminas were clearly observed inside them, greatly suggesting that the thickened layer corresponded to a vascular media (Fig. 1b, Supplemental Videos 3, 4). Neither intimal plaque accumulation nor intramural thrombus was observed at the angiographical stenosis lesion. From these findings and his medical backgrounds, we diagnosed fibromuscular dysplasia (FMD) in the bilateral
renal arteries and subacute left renal infarction. Because his renal function was stable, we initiated conservative medical treatments such as anticoagulation and analgesia after hospitalization. His blood pressure was well controlled with angiotensin II receptor blockade (ARB) azilsartan 20 mg/ day throughout the follow-up period. Eight months after the initial admission, DSA showed that stenoses of both renal arteries had completely resolved (Fig. 1c, Supplemental Videos 5, 6). IVUS clearly showed that thickening of medial layers was remarkably reduced, leading to luminal enlargement (Fig. 1d, Supplemental Videos 7, 8). Here, we present a very rare case of vanishing stenoses of renal arteries, which we believed was of FMD origin. To the best of our knowledge, only one case report has reported complete reversal of FMD with 8-year medical treatment [1]. Angiotensin II plays an important role in arterial thickening, fibrosis, and stiffening, resulting in thickening of medial layer [2]. Therefore, thickening of the medial layers in our case may have regressed through inhibition of the angiotensin II mediated signaling pathway. Notably, this structural change was observed 8 months after initiation of ARB.
Electronic supplementary material The online version of this article (https://doi.org/10.1007/s12928-019-00612-x) contains supplementary material, which is available to authorized users. * Hiroshi Kubota [email protected] 1
Department of Cardiovascular Medicine, Kyoto C
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