冠攣縮性狭心症を合併し，経皮的腎血管形成術に血管内超音波とステントが有用であった入口部狭窄腎血管性高血圧症の1例

Successful Treatment of Renovascular Hypertension with Ostial Stenosis Treated by Intravascular Ultasound guided Stenting in a Patient Complicated with Coronary Vascular Spasm

　58歳，男性．190／104mmHgの高血圧と胸部絞扼感を主訴に入院した．冠動脈造影およびアセチルコリン負荷試験で冠攣縮性狭心症と診断された．血漿レニン活性，アルドステロンは高値でフロセミド負荷試験は陽性であった．腎動脈造影にて左腎動脈を2本認め，そのうち1本の入口部に90％狭窄を認めた．腎静脈採血にて患側のレニン活性は健側の1.6倍と有意に上昇しており，腎血管性高血圧症と診断した．経皮的腎血管形成術を施行し，造影上は25％狭窄まで開大したが，血管内超音波所見では内腔に突出するプラークを認め，内腔開大も不十分であったためPalmazステントを留置し，内腔は十分開大された．6ヵ月後の再検査では再狭窄を認めず，冠攣縮性狭心症に対するカルシウム拮抗薬の投薬のみで血圧は安定した．

A 58-year-old male was admitted to our hospital withchest oppression and a high blood pressure of 190/104mmHg. Coronary angiogram and an acetylcholine pro-vocation test revealed vasospastic angina pectoris.Serum renin and aldosteron at rest were elevated and afurosemide-loading test was positive. Renal arteriogra-phy revealed 90% ostial stenosis of the left renal artery.Venous sampling showed renin activity in the left renalvein 1.6 times greater than that in the right renal vein.Renovascular hypertension was diagnosed and per-cutaneous transluminal renal angioplasty was perfor-med. The angiogram showed reduction of the stenosis to25% with haziness. However, intrayscular ultrasoundrevealed the protrusion of a large plaque in the lumenand incomplete dilatation of the vessel. To preventacute occlusion and restenosis, a Palmaz stent wasdeployed ensuring sufficiet dilatation of the lumen. Sixmonths later, renal angiography and intravascular ultra-sound showed no restenosis. Minimal dosage of calciumantagonist controlled the vasospasm and there was norecurrence of hypertension. We had thus encountered acase of renovascular hypertension, in which intravas-cular ultrasound was useful in indicating the need forstent implantation which proved an effective device fordealing with ostial stenosis.