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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Renovascular hypertension is defined as high blood pressure &#40;HBP&#41; caused by renal hypoperfusion&#44; and it results from renal ischaemia due to stenosis or occlusion of one or both renal arteries&#46; One requirement for establishing this diagnosis is that reperfusion of the kidney reduces hypertension&#46; This is one of the most frequent causes of secondary HBP&#44; which is present in 1&#37; of the general population and 30&#37; of the population group with clinical characteristics suggesting this disease&#46;</p><p class="elsevierStylePara">Another consequence of renal hypoperfusion is ischaemic nephropathy&#44; which leads to renal atrophy and loss of nephrons&#44; increasing the risk of progressing to end-stage renal disease&#44; which causes chronic renal failure in 11&#37;-18&#37; of dialysis patients&#46;</p><p class="elsevierStylePara">Atherosclerotic renal vascular disease may lead to ischaemic nephropathy&#44; which is accompanied by severe bilateral dysfunction or overall renal ischaemia leading to treatment-resistant HBP&#46; Atherosclerosis is a common and underreported cause of hypertension and renal failure&#46; The risk of kidney atrophy depends on the degree of arterial stenosis and the disease progresses more rapidly in severe cases of stenosis&#46;</p><p class="elsevierStylePara">Renal stenosis is the most common cause of secondary hypertension&#44; with a prevalence of between 3&#37; and 5&#37; in patients with high blood pressure&#46; Percutaneous transluminal angioplasty and revascularisation surgery are the two main options for treatment&#46; The re-stenosis rate observed for renal stents is quite variable&#44; ranging from 0&#37; to 38&#37; in recent studies&#46;</p><p class="elsevierStylePara">Revascularisation surgery is the best treatment option for re-stenosis&#44; but it is more complex&#46;</p><p class="elsevierStylePara">We present the following case study in which we evaluate the management of renal stent surgery and its possible complications&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">CASE STUDY</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Female patient aged 67 years with multiple risk factors&#58; HBP&#44; hypercholesterolaemia&#44; dysglycaemia&#44; obesity&#44; acute coronary syndrome&#44; etc&#46;</p><p class="elsevierStylePara">Patient with a solitary left kidney and stenosis due to stage 3 chronic kidney disease &#40;KDOQI Guidelines&#41; secondary to ischaemic renal disease with preserved diuresis&#46;</p><p class="elsevierStylePara">An angiography revealed critical stenosis of the left renal artery and uncontrolled hypertension despite triple drug therapy &#40;angiotensin converting enzyme inhibitors&#44; beta blockers&#44; calcium channel blockers&#44; diuretics and alpha blockers&#41;&#46; Preliminary tests revealed creatinine levels of 1&#46;9-2&#46;4mg&#47;dl and intractable HBP&#46;</p><p class="elsevierStylePara">Anaesthesia risk was moderate&#44; and the patient underwent scheduled surgery to place a stent in the left renal artery under locoregional anaesthesia&#44; with blood pressure under constant monitoring&#46; During surgery&#44; the patient remained haemodynamically stable with preserved diuresis&#46;</p><p class="elsevierStylePara">During the postoperative period&#44; she experienced sudden intense pain in the left renal fossa&#44; accompanied by hypotension&#44; vertigo and weakness and rapid-onset oligoanuria&#46; She then experienced chest pain radiating to the back with no alterations on the electrocardiogram and no elevated cardiac markers&#46; In any case&#44; treatment for ischaemic heart disease was initiated&#46; As stent thrombosis was suspected&#44; angiography was performed via the left femoral artery&#44; confirming thrombosis in the renal artery &#40;doctors attempted thrombolysis without success&#41; and also confirming migration of the stent&#44; which could not be returned to its location&#46; The patient was haemodynamically unstable during the procedure and required vasoactive drugs and a blood transfusion&#46; She also experienced anuria&#44; increased urea and creatinine levels&#44; so a dialysis catheter was placed&#46; She required high doses of vasoactive drugs to control the HBP&#44; haemodiafiltration for the anuria&#44; with increasing levels of urea and creatinine&#44; and echocardiography to rule out cardiogenic causes&#46; She presented blood clotting disorders with no signs of active haemorrhage&#44; and rapid deterioration of general health with respiratory failure that required use of mechanical ventilation&#46; An abdominal CT revealed a retroperitoneal haematoma and urgent laparotomy was performed&#46; The patient&#8217;s condition was complicated by the onset of distributive shock refractory to vasoactive drugs&#44; systemic inflammatory response syndrome and anuric renal failure&#46; It resulted in multiple organ dysfunction syndrome secondary to complications from the vascular surgery to correct renal ischaemia in a patient with a single kidney&#46; The outcome was death&#44; directly caused by shock refractory to treatment&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The strategy for treating atherosclerotic renal vascular disease has undergone significant changes in recent years&#46; Initially&#44; renal revascularisation procedures were intended to control HBP resistant to pharmacological treatment&#46; Evidence suggesting that the progression of vascular stenoses of renal arteries could lead to progressive loss of renal parenchyma and parenchymal function changed this approach to treating the disease&#46; At present&#44; the main goal is to protect or improve renal function&#44; whether by surgical or percutaneous methods of revascularisation&#46;</p><p class="elsevierStylePara">Angioplasty has a high incidence rate of technical failure&#44; and much effort has been spent in improving stent placement results&#46; According to the most recently published studies&#44; results seem to be better with 94&#37;-100&#37; of cases having improved renal function&#46; In the studies we reviewed&#44; survival rates after renal stent placement were high&#44; blood pressure and renal function were better up to 5 years after surgery&#46;</p><p class="elsevierStylePara">The indication of percutaneous renal angioplasty in renal vascular disease is a matter for debate&#44; as it is known that creatinine levels above 3mg&#47;dl are associated with low kidney survival rates&#46;</p><p class="elsevierStylePara">In patients with a single kidney&#44; the indication for revascularisation is even more controversial&#59; some studies advocating medical treatment&#46; The studies that we reviewed reported no significant differences in morbidity and mortality among patients with solitary kidneys and those with only one working kidney out of the two&#46; We found differences in long term survival&#44; with higher survival rates among patients with a normal contralateral kidney&#46; Predictors of a favourable long-term clinical outcome include GFR above 30ml&#47;min&#47;1&#46;73m<span class="elsevierStyleSup">2</span>&#44; kidney larger than 9cm and no immediate decrease in renal function following the endovascular process&#46; Surgery in solitary kidney patients is a safe process which improves or stabilises renal function in 87&#37; of patients&#46; Its clinical benefits depend on preoperative eGFR&#44; kidney size and renal failure following the procedure&#44; provided that no complications occur&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the content of this article&#46;</p>"
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