Overcoming Diagnostic Dilemma and Optimizing Intervention with Optical Coherence Tomographic Guidance in an Angiographically Ambiguous Renal Artery Stenosis Due to Fibromuscular Dysplasia

Figures & data

Figure 1 Various Imaging modalities used in diagnosing Renal artery stenosis in fibromuscular dysplasia.

Notes: (A) CT angiography shows bilateral critical stenosis of renal arteries at mid-segment (arrows). (B and C) Selective renal angiography shows bilateral mid-segment focal stenosis of renal arteries (arrows). OCT imaging shows (D) longitudinal reconstruction with a string of beads appearance (arrowheads). (E) An intima-medial dissection by an intimal flap (arrow), (F) thickened media (six-line arrows) along with fibrosis in the inner half (three-block arrows), characteristic of predominantly medial fibroplasia and normal intima (two notched arrows). (G) Normal Intima and Media (arrows) in reference segment. (H) Post-angioplasty right renal artery OCT shows medial fibroplasia (line arrows) with normal intima (notched arrows).

Figure 2 Current bilateral renal angiogram showing significant restenosis (arrows) in the left (A) and right (B) renal arteries. Longitudinal reconstruction of optical coherence tomography (OCT) imaging (C) of left renal artery depicting the corresponding lesion indicated by white arrows. Cross-sectional images showing distal (D) and proximal (F) reference zones are free of disease and measure 4.2mm. The area of focal restenosis on the angiogram correlate with extensive medial and intimal hyperplasia (arrows) on OCT (E), causing 87% area (re) stenosis.

Figure 3 Angiogram showing stent deployment in the left renal artery (A) with an excellent angiographic result (B). The right renal artery shows (C) a good result with balloon angioplasty alone. Longitudinal (D) and cross-sectional (E) OCT images of left renal artery show good stent expansion and apposition (arrows) without residual stenosis. Cross-sectional OCT image (F) of right renal artery after balloon angioplasty shows good result with some intimal tears (arrows) and no residual stenosis (correlate with Image (C)).