The procedure was performed under the guidance of digital subtraction angiography (floor-mounted Artis zee; Siemens Medical Solutions, Munich, Germany) using the Seldinger technique. With the patient under local anesthesia, the right femoral artery was punctured by a 21-gauge vascular access needle with an angled tip 0.035-inch guidewire, then catheterized with a 5-French introducer sheath (Terumo Interventional Systems, Tokyo, Japan). The first aortogram was obtained using a pigtail catheter (Fig.
1a), then an 8-French guiding catheter (Cook Medical, Bloomington, IN, USA; Cordis, Hialeah, FL, USA) was used to obtain selective renal angiograms whereby the proximal main flow and the stenosis of both branches and their respective distal flow on the left renal side were revealed. The right renal artery was normal in appearance. The left renal artery angiogram then was used as a reference for further guided interventional procedures in which the individual length and diameter of stenosis were measured. The decision was reached to perform percutaneous transluminal renal angioplasty, and the length and diameter of balloon needed were calibrated. With two balloons of 4 mm × 18 mm (Biotronik, Berlin, Germany), both were was dilated at the same time. Despite expert effort in dilatation, the stenosis was observed to persist (Fig.
1c). Stent placement was considered, and the procedure was continued. A preprocedure intravenous bolus of 5000 IU of heparin was administered. By using two 0.014-inch guidewires (V14; Boston Scientific, Natick, MA, USA), the interventional radiologist guided the stent to cross the upper and lower branches, respectively, through the same vascular sheath
(Fig.
1b). Two balloon expandable stents measuring 4 mm × 18 mm and 5 mm × 18 mm (Biotronik) were placed in parallel (kissing) and simultaneously inflated both branches. A good angiographic result was revealed (Fig.
1d) with no need for further ballooning. Angiography contrast media (Omnipaque 350; GE Healthcare, Shanghai, China) were used. Volumes of 25 ml of contrast agent were injected at a flow rate of 5 ml/s. The final angiogram was obtained to confirm the position of the stent, the patency of the lumen, and distal blood flow. Finally, the femoral access site was closed with Perclose ProGlide (Abbott Vascular, Chicago, IL, USA). After the procedure, the patient was admitted in the ambulatory room for further observation. Her blood pressure was monitored and recorded, it showed a significant reduction of blood pressure to 128/87 mmHg. After 24 h of observation, the patient was discharged to home with aspirin (100 mg/day) and clopidogrel (75 mg/day for 3 months). During 12 months of follow-up, the patient remained well with blood pressure of 126/87 mmHg. Renal ultrasound showed bilateral kidneys of normal size and shape with good cortical medullary differentiation. A bilateral renal Doppler study appeared normal.