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Figure 4g. Renovascular hypertension in a patient with type B aortic dissection who presented with uncontrollable hypertension, reduced lower extremity pulses, and a rising creatinine level 2 weeks after dissection occurred. (a) CT scan shows the right renal artery arising from the false lumen (arrow) and near occlusion of the left renal artery by extension of the dissection flap (arrowhead). (b) Aortogram shows a common celiac artery-SMA origin, aortic obstruction, and faint filling of the obstructed left renal artery (arrow). (c) Angiogram demonstrates a right lower renal artery (arrow) arising from a very narrow true lumen of the infrarenal aorta, which was compressed by the posterior false lumen. Intravascular US-guided puncture of the flap was performed, and fenestration with a 20-mm balloon equalized lumen pressures. (d) Aortogram shows no obstruction of the right renal artery (arrow) but near occlusion of the left renal artery (cf a, b). (e) Selective left renal arteriogram shows narrowing of the true lumen by extension of the false lumen (arrow). A long, self-expanding Wallstent was deployed. (f) Digital image shows the Wallstent (arrow), which was effective in compressing the false lumen. (g) Digital image shows persistent obstruction of both iliac arteries. "Kissing" Wallstents were placed at the aortic bifurcation, and a third Wallstent was placed in the right external iliac artery. (h) Aortogram shows relief of the iliac artery obstruction. (i) On a CT angiogram obtained 9 months later, the stents are patent; after 15 months, the patient remains active and is taking two blood pressure medications.
