Aortic stent placement and the effect on renal function is not well described in the literature. Although approximately 50 aortic stents have been placed in this hospital this is the first case referred to the nephrology unit because of co-existing renal artery stenosis. The patient was a 78-year-old female described as ‘extremely fit for her age’. The serum creatinine at presentation was 200 µmol/l. She had a 5.5 cm abdominal aortic aneurysm suitable for stenting on spiral CT. She also had a right ostial renal artery stenosis (RAS) and a left proximal renal artery occlusion. The blood pressure was ‘160/90’ on bendrofluazide, atenolol and amlodipine. The surgeon wished to know if either of the renal artery lesions should be treated prior to aneurysm treatment. In clinic she was a reasonably fit 78 year old, whose only symptom was occasional ankle oedema. She was a non-smoker who lived alone. There was no other relevant past medical history. Her blood pressure was 188/86 and urinalysis was normal. The serum creatinine was 184 µmol/L. It was suggested that a statin be added to her treatment regime. The case was then discussed with the radiologists and surgeon. A review of the radiology showed bilateral renal artery stenosis (Fig. 1). It was felt that there would be an increased risk of acute renal failure or renal infarction with open surgery but probably not with endovascular aortic stenting. However, aortic stenting might make later renal artery intervention difficult. It was decided that the two best options were either not to intervene with the aneurysm or the renal arteries, or to attempt to stent at least one renal artery prior to aneurysm intervention. As the patient declared that she worried every night about her aneurysm rupturing, the latter course was taken. The patient was warned of a 1-2% immediate death rate after renal artery intervention. The left renal artery was stented. The procedure was technically difficult on the right and stenting could not be achieved at that session. Total contrast dose was 40 ml Iomeron and 40 ml Magnevist. Prior to intervention the serum creatinine was 215 µmol/l. After intervention her blood pressure was 140/64 and the anti-hypertensive medications were reduced and IV fluid given. She experienced some abdominal pain, nausea and pleuritic lower left chest pain. The plasma creatinine peaked at 283 µmol/L post intervention. Two weeks later her blood pressure was 121/68 so the anti-hypertensive medications were further reduced. The plasma creatinine was 290 µmol/L. A renogram showed 62% function in the stented kidney. Four weeks after intervention the blood pressure was 125/72 and serum creatinine was 300 µmol/l. Three months after intervention her blood pressure was 136/71 and serum creatinine 243 µmol/l. The patient felt well for the first time since intervention. The issues are what to do now about the right RAS and the abdominal aortic aneurysm; and whether an alternative strategy should have been pursued initially?

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