Multivasküler Fibromüsküler Displazide Bireyselleştirilmiş Endovasküler Yaklaşım
Özet
Yirmi yedi yaşında kadın hasta, genç yaşta başlayan ve medikal tedaviye dirençli hipertansiyon nedeniyle sekonder hipertansiyon açısından değerlendirildi. Ayrıntılı vasküler değerlendirme, renal arter hastalığına karotis ve intrakraniyal tutulumun eşlik ettiği sistemik fibromüsküler displazi fenotipini gösterdi. Sağ internal karotis arter proksimal segmentinde yaklaşık %50 stenoza yol açan fibromüsküler displazi, sol internal karotis arter oftalmik segmentinde ise sakküler anevrizma saptandı. Renal anjiyografide sağ renal arter orta segmentinde yaklaşık %80, sol renal arter orta segmentinde yaklaşık %95 darlık izlendi. İlk girişimde bilateral balon anjiyoplasti uygulandı ve işlem sonunda rezidüel darlık saptanmadı. Ancak dört ay sonraki kontrol anjiyografide her iki renal arterde yeniden ciddi akım kısıtlayıcı darlık gelişmesi üzerine sol renal artere 4.0×23 mm, sağ renal artere 3.5×16 mm ilaç salınımlı stent implante edildi. Üç yıllık takipte stentlerin açık olduğu, böbrek fonksiyonlarının stabil seyrettiği ve kan basıncı kontrolünün sağlandığı izlendi. Bu olgu, renal arter fibromüsküler displazisinde balon anjiyoplastinin temel endovasküler yaklaşım olduğunu; ancak başarılı ilk işleme rağmen erken dönemde ciddi restenoz gelişen seçilmiş hastalarda stentlemenin bireyselleştirilmiş bir revaskülarizasyon seçeneği olarak değerlendirilebileceğini göstermektedir. Eşlik eden karotis ve intrakraniyal vasküler tutulum, fibromüsküler displazide tedavi planının tek bir damar yatağı ile sınırlı kalmaması ve sistemik vasküler değerlendirme ile yönlendirilmesi gerektiğini vurgulamaktadır.
A 27-year-old female patient was assessed for secondary hypertension due to hypertension that had begun at a young age and was resistant to medical treatment. A detailed vascular assessment revealed a phenotype of systemic fibromuscular dysplasia, in which renal artery disease was accompanied by carotid and intracranial involvement. Fibromuscular dysplasia causing approximately 50 percent stenosis was detected in the proximal segment of the right internal carotid artery, whilst a saccular aneurysm was detected in the ophthalmic segment of the left internal carotid artery. Renal angiography revealed a stenosis of approximately 80 percent in the mid-segment of the right renal artery and approximately 95 percent in the middle segment of the left renal artery. During the initial angiography, bilateral balloon angioplasty was performed and no residual stenosis was detected at the end of the procedure. However, following the follow-up angiography four months later, which revealed the recurrence of severe flow-limiting stenosis in both renal arteries, a 4.0×23 mm drug-eluting stent was implanted in the left renal artery and a 3.5×16 mm drug-eluting stent in the right renal artery. During the three-year follow-up, it was observed that the stents remained patent, renal function remained stable and blood pressure was well controlled. This case demonstrates that balloon angioplasty is the primary endovascular approach in renal artery fibromuscular dysplasia; however, in selected patients who develop severe restenosis in the early period despite a successful initial procedure, stenting may be considered as an individualised revascularisation option. The associated carotid and intracranial vascular involvement emphasises that the treatment plan for fibromuscular dysplasia should not be limited to a single vascular bed. A systemic vascular assessment is warranted.
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