He followed an uneventful hospital course and was consequently discharged on the next day. The total irradiation time was 140 minutes and the volume of contrast medium used was 122.2 mL. The patient safely tolerated the entire procedure, and we successfully completed the treatment. After inflating balloons sequentially with 2- and 4-mm diameters ( Figure 4B), we deployed 2 Palmatz Genesis (Cordis Corp., CA, USA) balloon-expandable stents (5.0/18 and 5.0/15 mm) ( Figure 4C), and achieved favorable dilation of the target artery ( Figure 4D). We successfully penetrated the proximal hard calcification with a Naveed4 Hard 50 guidewire and passed it distally ( Figure 4A). To overcome this problem, we inserted a guide catheter extension catheter, the “GuideLiner catheter”, near the ostium of the left renal artery through the JR4 guide catheter, and achieved a sufficient back-up force against the contralateral aortic wall ( Figure 3C arrows). ( C) We inserted a guide catheter extension device near the ostium of the left renal artery through the JR4 guide catheter, and achieved a sufficient back-up force against the contralateral aortic wall (arrows). ( B) The JR4 guide catheter disengaged backward from the left renal artery by pushing the guidewire (arrows). ( A) The JR4 guide catheter via the left brachial artery achieved good coaxiality to the left renal artery. However, because the JR4 guide catheter disengaged backward from the left renal artery on pushing the guidewires, none of those guidewires could pass the severely calcified proximal cap ( Figure 3B). We tried to penetrate the proximal tight calcified lesion with several guidewires: Cruise (ASAHI INTECC Co., Ltd., Aichi, Japan), Athlete Wizard PV3 (Japan Lifeline Co., Ltd., Tokyo, Japan), Treasure XS (ASAHI INTECC), Naveed4 Hard15 (Terumo Corp., Tokyo, Japan), and Naveed4 Hard50 (Terumo Corp., Tokyo, Japan). Therefore, we switched to a left brachial approach and could achieve good coaxiality between the JR4 guide catheter and left renal artery ( Figure 3A). However, this system could not provide sufficient coaxial support for guidewire manipulation, and we could not advance the guidewire any further into the lesion ( Figure 2). We used 6-Fr JR4 and RDC1 guide catheters and approached the lesion with a microcatheter. We initially attempted percutaneous transluminal renal angioplasty (PTRA) via the right femoral artery. Antero-posterior view of the upper column. ( B) A 3-dimensional image of MR angiography showing severe stenosis at the ostium of the left renal artery (arrow). ( A) An axial section of plain abdominal CT showing the calcified orifice of the left renal artery (arrow).
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