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Drieghe B, van Loon G, Stuyvaert S, De Buyzere ML, Bové T, De Backer T. Renal pressure-flow relationship and renin activation in a porcine model comparing unilateral and bilateral renal artery stenosis. Physiol Rep 2024; 12:e70082. [PMID: 39613722 DOI: 10.14814/phy2.70082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 09/30/2024] [Accepted: 09/30/2024] [Indexed: 12/01/2024] Open
Abstract
Because renal artery stenosis (RAS) often presents bilateral, we sought to investigate the renal pressure-flow relationship and its relation to renin release, in the presence of a contralateral significant stenosis. A porcine model of graded unilateral RAS in the presence of a significant contralateral stenosis was created. The severity of the stenosis was expressed as the ratio between distal renal pressure (Pd) and aortic pressure (Pa). Pd and renal flow velocity were continuously measured using a combined pressure-flow wire (Combowire®). Hemodynamic measurements and blood sampling for renin, angiotensin, and aldosterone were performed in baseline conditions and during progressive balloon inflation in the renal artery leading to stepwise 5% Pd decrements. Resistive index (RI) was computed as (1-(End Diastolic V/Maximum Peak Systolic V))*100. A decrease of average peak flow velocity (APV) was observed when distal renal perfusion pressure decreased by 25% and was associated with activation of renin secretion. The RI decreased already for minimal changes in Pd/Pa ratio. In an animal model of unilateral graded RAS in the presence of a significant contralateral stenosis, a 25% decrease in perfusion pressure results in a significant decrease in distal renal flow, causing a more pronounced upregulation of renin secretion when compared to a model of graded unilateral RAS without contralateral significant RAS.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Ghent, Ghent, Belgium
| | - Gunther van Loon
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | - Sabrina Stuyvaert
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Ghent, Belgium
| | | | - Thierry Bové
- Heart Center, University Hospital Ghent, Ghent, Belgium
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Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Catheter Cardiovasc Interv 2024; 104:285-299. [PMID: 38837309 DOI: 10.1002/ccd.31117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Gent, Gent, Belgium
| | | | - Thierry Bové
- Heart Center, University Hospital Gent, Gent, Belgium
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Drieghe B, van Loon G, Decloedt A, Stuyvaert S, De Buyzere ML, Bové T, De Backer T. Defining Hemodynamic Significance of Renal Artery Stenosis: Insights From a Porcine Model of Graded Renal Artery Stenosis. Acad Radiol 2023; 30 Suppl 1:S286-S294. [PMID: 37120404 DOI: 10.1016/j.acra.2023.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 05/01/2023]
Abstract
RATIONALE AND OBJECTIVES To investigate the renal pressure-flow relationship and its relation to renin release, because the renal perfusion pressure below which renal flow starts to decline and renin secretion is upregulated is unclear. MATERIALS AND METHODS A porcine model of graded unilateral renal artery stenosis was created. The severity of the stenosis was expressed as the ratio between distal renal pressure (Pd) and aortic pressure (Pa). Pd and renal flow velocity were continuously measured using a combined pressure-flow wire (Combowire®). Hemodynamic measurements and blood sampling for renin, angiotensin and aldosterone were performed in baseline conditions and during progressive balloon inflation in the renal artery leading to Pd decrease per 5% increment. Resistive index (RI) was computed as (1 - (End Diastolic V/Peak Systolic V))*100. RESULTS For a 5% decrease in renal perfusion pressure (95% of aortic pressure or 5% decrease compared to Pa), peak systolic velocity started to decrease. A significant decrease in average peak flow velocity was observed when distal renal perfusion pressure decreased by 25% and was associated with activation of ipsilateral renin secretion. The RI decreased already for minimal changes in Pd/Pa ratio. CONCLUSION In an animal model of unilateral graded renal artery stenosis, a 25% decrease in perfusion pressure results in a significant decrease in distal renal flow, causing upregulation of renin secretion.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Gunther van Loon
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Annelies Decloedt
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Sabrina Stuyvaert
- Dept of Internal Medicine, Reproduction and Population Medicine, Faculty of Veterinary Medicine, Ghent University, Belgium (G.V.L., A.D., S.S.).
| | - Marc L De Buyzere
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Thierry Bové
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
| | - Tine De Backer
- Heart Center, University Hospital Ghent, Belgium (B.D., M.L.D.B., T.B., T.D.B.).
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Cadour F, Silhol F, Iline N, Giorgi R, Lorthioir A, Amar L, Sapoval M, Rousseau H, Sarlon G, Thony F, Jacquier A. Insights from intravascular pressure measurement of renal artery revascularization in patients with fibromuscular dysplasia: the DYSART study. J Vasc Surg 2021; 75:939-949.e1. [PMID: 34601043 DOI: 10.1016/j.jvs.2021.09.023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/04/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The indication of percutaneous renal transluminal angioplasty (PTRA) in fibromuscular dysplasia (FMD) is mainly based on renal artery stenosis (RAS) due to atherosclerosis criteria, which are not specific to FMD. Consequently, the selection of patients who could benefit from this treatment and its effectiveness remain uncertain. The aims of this study were to: (1) report the effects of PTRA guided by trans-stenotic pressure measurements on hypertension 7 months after treatment; (2) assess the impact of pressure measurement to guide treatment efficacy in comparison to visual angiographic parameters; and (3) evaluate the reproducibility and accuracy of the stenosis measurement using a 4F catheter in comparison to a pressure guidewire. METHODS This prospective multi-centric study analyzed 24 patients with hypertension with RAS due to FMD that required PTRA. Clinical, duplex ultrasound, and angiographic indices were collected, and patients were followed up for 7 months (±1 month). Angiographic indices were measured twice both by a pressure guidewire and a 4F catheter. Assessment of procedural and clinical success of angioplasty was performed for all patients. RESULTS Twenty-three patients (96%) had procedural success (considered as a post-PTRA translesional systolic gradient ≤10 mmHg or reduced by at least 80%) with a significant decrease in the systolic gradient after angioplasty (26.50 mmHg; [interquartile range, 16.75-38.75] vs 0.00 [interquartile range, 0.00-2.00]; P < .01). Three patients (12%) had complications, including two renal artery dissections and one partial renal infarction. Twenty-one patients (88%) were clinical responders to angioplasty at follow-up. Visual stenosis assessment showed a poor correlation with systolic gradient measurement before and after PTRA (R from -0.05 to 0.41; P = 0.06-0.82). High correlations were found between pressure measurements made by a 4F catheter and guidewire (R from 0.64 to 0.89; P ≤ .003). CONCLUSIONS In patients selected by clinical indicators and duplex ultrasound, reaching a translesional systolic gradient ≤10 mmHg or reduced by at least 80% after angioplasty, promotes a high success rate for PTRA in hypertension due to FMD RAS.
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Affiliation(s)
- Farah Cadour
- Department of Radiology, La Timone Hospital, Marseille, France.
| | - François Silhol
- Department of Hypertension and Vascular Medicine, La Timone Hospital, Marseille, France
| | - Nicolas Iline
- Department of Biostatistiques et Technologies de l'Information et de la Communication, APHM, Hop Timone, BioSTIC, Marseille, France
| | - Roch Giorgi
- Aix Marseille Univ, APHM, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Hop Timone, BioSTIC, Biostatistique et Technologies de l'Information et de la Communication, Marseille, France
| | - Aurélien Lorthioir
- Hypertension Unit, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Laurence Amar
- Hypertension Unit, AP-HP, Hôpital Européen Georges-Pompidou, Paris, France
| | - Marc Sapoval
- Department of Interventional Radiology, Hôpital Européen Georges Pompidou, AP-HP, Université de Paris-Descartes Paris 5, Paris, France
| | | | - Gabrielle Sarlon
- Department of Hypertension and Vascular Medicine, La Timone Hospital, Marseille, France
| | - Frederic Thony
- Department of Imaging and Interventional Radiology, Grenoble-Alpes University Hospital, Grenoble, France
| | - Alexis Jacquier
- Department of Radiology, La Timone Hospital, Marseille, France
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The Japanese Society of Hypertension Guidelines for the Management of Hypertension (JSH 2019). Hypertens Res 2020; 42:1235-1481. [PMID: 31375757 DOI: 10.1038/s41440-019-0284-9] [Citation(s) in RCA: 1207] [Impact Index Per Article: 241.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Boutari C, Georgianou E, Sachinidis A, Katsimardou A, Christou K, Piperidou A, Karagiannis A. Renovascular Hypertension: Novel Insights. Curr Hypertens Rev 2020; 16:24-29. [DOI: 10.2174/1573402115666190416153321] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 03/31/2019] [Accepted: 04/01/2019] [Indexed: 11/22/2022]
Abstract
Renovascular hypertension (RVH) remains among the most prevalent and important, but
also potentially reversible, causes of secondary hypertension. The predominant causes of renal artery
stenosis (RAS) are atherosclerotic renovascular arterial stenosis (ARAS) and renal fibromuscular
dysplasia. This condition can lead to progressive renal injury, cardiovascular complications and
‘flash pulmonary edema’. Duplex Doppler ultrasonography, computed tomographic angiography
and magnetic resonance angiography are the most commonly used diagnostic methods. There are
three therapeutic options available: medical therapy including renin-angiotensin-aldosterone system
antagonists, lipid-lowering agents, and antiplatelet therapy, percutaneous angioplasty with or without
stent placement and surgical revascularization. Three large trials failed to demonstrate the superiority
of renal artery revascularization over pharmaceutical therapy in controlling blood pressure
and preserving renal function. For this reason, today revascularization is only recommended for
patients with progressive worsening of renal function, recurrent ‘flash pulmonary edema’ and rapid
increase in antihypertensive requirement in patients with previously well-controlled hypertension.
However, more properly designed trials are needed in order to identify which patient populations
would probably benefit from renal revascularization.
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Affiliation(s)
- Chrysoula Boutari
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Eleni Georgianou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexandros Sachinidis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexandra Katsimardou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Konstantinos Christou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Alexia Piperidou
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
| | - Asterios Karagiannis
- Second Propedeutic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, Hippocration Hospital, 49 Konstantinoupoleos, Thessaloniki, 54642, Greece
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Abstract
Renovascular disease (RVD) is a major cause of secondary hypertension. Atherosclerotic renal artery stenosis is the most common type of RVD followed by fibromuscular dysplasia. It has long been recognized as the prototype of angiotensin-dependent hypertension. However, the mechanisms underlying the physiopathology of hypertensive occlusive vascular renal disease are complex and distinction between the different causes of RVD should be made. Recognition of these distinct types of RVD with different degrees of renal occlusive disease is important for management. The greatest challenge is to individualize and implement the best approach for each patient in the setting of widely different comorbidities.
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Affiliation(s)
- Sandra M Herrmann
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA.
| | - Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55902, USA
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8
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Chothia MY, Davids MR, Bhikoo R. Awakening the sleeping kidney in a dialysis-dependent patient with fibromuscular dysplasia: A case report and review of literature. World J Nephrol 2018; 7:143-147. [PMID: 30510913 PMCID: PMC6259034 DOI: 10.5527/wjn.v7.i7.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 09/06/2018] [Accepted: 10/10/2018] [Indexed: 02/06/2023] Open
Abstract
Renal artery stenosis is a common cause of secondary hypertension and chronic kidney disease. We present here a case of fibromuscular dysplasia that was treated with surgical revascularization, resulting in recovery of kidney function with eventual cessation of chronic dialysis. The case involves a 25-year-old female with coincidentally discovered hypertension, who underwent further investigations revealing a diagnosis of renal artery stenosis due to fibromuscular dysplasia. She subsequently developed two episodes of malignant hypertension, with flash pulmonary oedema and worsening renal failure that resulted in dialysis dependence. After evidence was obtained that the right kidney was still viable, a revascularization procedure was performed, improving blood pressure control and restoring kidney function, thereby allowing dialysis to be stopped. This case highlights the importance of evaluating patients with renal artery stenosis for revascularization before committing them to a life of chronic dialysis.
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Affiliation(s)
- Mogamat-Yazied Chothia
- Renal Unit, Tygerberg Hospital, Cape Town 7505, South Africa
- Division of Nephrology, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town 7505, South Africa
| | - Mogamat Razeen Davids
- Division of Nephrology, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town 7505, South Africa
| | - Raisa Bhikoo
- Division of Nephrology, Department of Medicine, Tygerberg Hospital and Stellenbosch University, Cape Town 7505, South Africa
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9
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Factors Associated with Outcomes of Percutaneous Transluminal Renal Angioplasty in Patients with Renal Artery Stenosis: A Retrospective Analysis of 50 Consecutive Cases. Int J Hypertens 2018. [PMID: 29535868 PMCID: PMC5817381 DOI: 10.1155/2018/1952685] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Background The results of recent trials have brought some confusion to the treatment strategy for renal artery stenosis (RAS). To evaluate the applicability of percutaneous transluminal renal angioplasty (PTRA) for RAS, we extracted the factors that may affect the effectiveness of PTRA from cases experienced at a hypertension center. Methods and Results We retrospectively assessed the blood pressure (BP) lowering effects and renoprotective effects in 50 consecutive patients that had hemodynamically significant RAS and had undergone PTRA and stenting during 2001–2005. Subjects were diagnosed with atherosclerotic RAS (42), fibromuscular dysplasia (6), or Takayasu disease (2). After PTRA, BP significantly lowered from 152.3/80.3 mmHg to 132.6/73.2 mmHg (p < 0.05), but the estimated glomerular filtration rate (eGFR) did not change significantly. There were no factors associated with the BP lowering effects of PTRA. The baseline resistive index (RI) was negatively correlated with the change in eGFR (p < 0.05). After correction for age, sex, BMI, and the dose of contrast medium, the association of RI with change in eGFR remained significant. Conclusion In cases with hemodynamically significant RAS, PTRA lowered BP but was not effective in improving renal function. Higher baseline RI may be a factor for predicting poor clinical course of renal function after PTRA.
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10
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Zheng T, Zhu S, Ou JF, Fang WG, Qiao ZY, Qi RD, Chen L, Chen L, Li CN, Pan LL, Zhu Q, Chen D, Sun XJ, Zhu JM. Treatment with Corticosteroid and/or Immunosuppressive Agents before Surgery can Effectively Improve the Surgical Outcome in Patients with Takayasu's Arteritis. J INVEST SURG 2018; 32:220-227. [PMID: 29313449 DOI: 10.1080/08941939.2017.1408718] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Tie Zheng
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China, Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing Engineering Research Center for Vascular Prostheses, Beijing, China
| | - Shuai Zhu
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jia-Fu Ou
- Cardiology Division, Department of Internal Medicine, Washington University, St. Louis, USA
| | - Wei-Gang Fang
- General Internal Medicine Unit, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Zhi-Yu Qiao
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Rui-Dong Qi
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Li Chen
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Lei Chen
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Cheng-Nan Li
- Department of Cardiovascular Surgery, Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Li-Li Pan
- Department of Rheumatology and Immunology Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China; Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Qing Zhu
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dong Chen
- Department of Pathology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xue-Jun Sun
- Department of Cardiovascular Surgery, Beijing Anzhen Hospital of Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, and Beijing Engineering Research Center of Vascular Prostheses, Beijing, China; Fu Wai Hospital and Cardiovascular Institute, Chinese Academy of Medical Sciences, Beijing, China
| | - Jun-Ming Zhu
- Department of General Surgery, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
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11
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Karanikola E, Karaolanis G, Galyfos G, Barbaressos E, Palla V, Filis K. Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm? Vasc Specialist Int 2017; 33:1-15. [PMID: 28377906 PMCID: PMC5374954 DOI: 10.5758/vsi.2017.33.1.1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Revised: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/25/2022] Open
Abstract
Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.
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Affiliation(s)
- Evridiki Karanikola
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Georgios Karaolanis
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - George Galyfos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Emmanuel Barbaressos
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
| | - Viktoria Palla
- Vascular Surgery Unit, 1st Department of Surgery, University of Athens Medical School, Laikon General Hospital, Athens, Greece
| | - Konstantinos Filis
- Division of Vascular Surgery, 1st Department of Propaedeutic Surgery, University of Athens Medical School, Hippocration General Hospital, Athens, Greece
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12
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Wholey MH, Wholey MH. Percutaneous Endovascular Therapy of Renal Artery Stenosis: Technical and Clinical Developments in the past Decade. J Endovasc Ther 2016; 11 Suppl 2:II43-61. [PMID: 15760247 DOI: 10.1177/15266028040110s612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Renal artery stenosis may initiate or exacerbate arterial hypertension and/or renal insufficiency. During the last decade, technical improvements of diagnostic and interventional endovascular tools have led to more widespread use of endoluminal renal artery revascularization and broader indications for this type of therapy. Since the first renal artery angioplasties performed by Felix Mahler and Andreas Grüntzig in 1978, numerous single-center studies have documented the benefits of percutaneous renal revascularization. In the early 1990s, stent implantation was added to the interventionist's armamentarium for treating renal artery stenosis due to atherosclerosis or fibromuscular dysplasia. The metaanalysis of 3 randomized studies comparing balloon angioplasty with best medical therapy found intervention to be beneficial for blood pressure control but not for preservation of renal function. Despite the absence of randomized studies, there is mounting evidence that stenting of hemodynamically relevant atherosclerotic renal artery stenosis has a positive impact on blood pressure control and renal function. This article summarizes the technical improvements in these endovascular tools during the last decade and gives an overview concerning their clinical impact on renal artery revascularization.
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Affiliation(s)
- Mark H Wholey
- University of Pittsburgh Medical Center-Shadyside, Pittsburgh, Pennsylvania 15232, USA.
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13
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Zeller T, Frank U, Müller C, Bürgelin K, Schwarzwälder U, Sinn L, Horn B, Roskamm H, Neumann FJ. Technological Advances in the Design of Catheters and Devices Used in Renal Artery Interventions: Impact on Complications. J Endovasc Ther 2016; 10:1006-14. [PMID: 14656167 DOI: 10.1177/152660280301000526] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Purpose: To analyze the impact of technical improvements in stent devices and guiding catheters (e.g., reduced device diameter, increased flexibility) on the complication rates associated with percutaneous renal artery interventions. Methods: During a 5-year period (1997–2001), 268 consecutive patients (178 men; mean age 67±9 years) had 370 atherosclerotic renal artery stenoses (RAS) ≥70% treated with angioplasty/stenting in 320 procedures. The guiding catheter technique was used routinely until 2000; in 2001, a guiding sheath was used in 29% of cases. From 1997 to 2000, sealing devices were frequently used for sheath removal; during the last year, the sheaths were removed using the Femostop device. Results: In 320 interventions, 32 (10%) complications occurred, with a decreasing frequency during the last 2 years (1996/97: 13% [7/53]; 1998: 16% [9/57]; 1999: 15% [11/74]; 2000: 4% [3/70]; 2001: 3% [2/66]). There were 21 (6.6%) local complications, including 4 cases requiring permanent hemodialysis after the intervention and 11 (3.4%) access site complications. No procedure-related death occurred. During the study period, the average sheath diameter was reduced from 8.15±0.76 F to 6.15±0.63 F (p<0.05). Mean procedural time was reduced from 42±13 minutes to 23±11 minutes (p<0.05). The initial heparin dose was reduced from 10,000 to 5000 units. Conclusions: In parallel with the use of more flexible catheters and premounted stents of lower profile, the complication rate of renal angioplasty/stenting of atherosclerotic RAS has been reduced significantly during a 5-year period.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Herz-Zentrum Bad Krozingen, Germany.
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14
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Ralapanawa DMPUK, Jayawickreme KP, Ekanayake EMM. A case of treatable hypertension: fibromuscular dysplasia of renal arteries. BMC Res Notes 2016; 9:6. [PMID: 26724918 PMCID: PMC4698323 DOI: 10.1186/s13104-015-1835-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 12/21/2015] [Indexed: 11/10/2022] Open
Abstract
Background Renovascular hypertension accounts for 51–52 % of all cases of hypertension in the general population, but plays a major role in treatable causes for hypertension in the young. This entity consists of renal vascular atherosclerosis (90 %), commonly seen among the elderly population, and renal fibro muscular dysplasia (FMD) (10 %), predominantly seen in the young. The prevalence of clinically significant renal artery fibromuscular dysplasia is 0.4 %. Case presentation We present a case of treatable young hypertension in a 29 year old female, who was diagnosed with renovascular hypertension due to fibromuscular dysplasia of the left renal artery. Computed tomographic angiogram revealed significant stenosis of the left main renal artery. Diethylene triamine penta acetic acid renogram showed a small left kidney due to renal artery stenosis. She underwent left sided nephrectomy, and histology revealed features of FMD, after which she achieved full recovery with normalization of blood pressure, and did not require antihypertensive drug treatment. Conclusions Fibromuscular dysplasia causing renal artery stenosis, though a rare cause of renovascular hypertension, is essential to be considered in young hypertensives, even in the absence of family history of hypertension. A high index of suspicion is necessary in early diagnosis and prompt treatment, which can result in rapid and complete recovery.
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Böhlke M, Barcellos FC. From the 1990s to CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial results and beyond: does stenting have a role in ischemic nephropathy? Am J Kidney Dis 2015; 65:611-22. [PMID: 25649878 DOI: 10.1053/j.ajkd.2014.11.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 11/02/2014] [Indexed: 01/07/2023]
Abstract
The prevalence of atherosclerotic renal artery stenosis is high, ∼7% in individuals older than 65 years and ∼50% in patients with diffuse arterial disease, and it is increasingly frequent in an aging population. About 10% to 15% of atherosclerotic renal artery stenosis cases lead to the development of resistant hypertension and/or ischemic nephropathy. The management of ischemic nephropathy may include medical therapy and/or revascularization. In the past, revascularization required surgical bypass or endarterectomy, accompanied by the morbidity and mortality associated with a major surgical procedure. During the last few decades, less invasive endovascular procedures such as percutaneous transluminal renal artery angioplasty with stent placement have become available. At the same time, new antihypertensive and cardiovascular drugs have been developed, which may preclude revascularization, at least in some cases. The indications of each of these therapeutic options have changed over time. This review offers a temporal perspective on the course of technical and scientific advances and the accompanying change in clinical practice for the treatment of ischemic nephropathy. The latest randomized clinical trials, including the CORAL (Cardiovascular Outcomes in Renal Atherosclerotic Lesions) trial, the largest on the subject, as well as a meta-analysis of these studies, have indicated that the best approach is medical therapy alone. There is evidence that revascularization brings no additional benefit, at least in low-risk and stable atherosclerotic renal artery stenosis. High-risk patients, especially those with recurrent flash pulmonary edema, could benefit from percutaneous transluminal renal artery angioplasty and stent placement, but there is no definitive evidence and the treatment choice should take into account the risks and potential benefits of the procedure.
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Affiliation(s)
- Maristela Böhlke
- Dialysis and Transplantation Center, São Francisco de Paula University Hospital, Catholic University of Pelotas, Rio Grande do Sul, Brazil.
| | - Franklin Correa Barcellos
- Dialysis and Transplantation Center, São Francisco de Paula University Hospital, Catholic University of Pelotas, Rio Grande do Sul, Brazil
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16
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Abstract
Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory angiopathy of unknown cause affecting medium-sized (most commonly renal) arteries and causing renovascular hypertension. The most common medial multifocal type of FMD (with the “string of beads” appearance) is more than four times more prevalent in females than in males. FMD accounts for up to 10% of cases of renovascular hypertension. Compared with patients with atherosclerotic renal artery stenosis, patients with FMD are younger, have fewer risk factors for atherosclerosis, and a lower occurrence of atherosclerosis in other vessels. The etiology is multifactorial, including vessel wall ischemia and smoking, as well as hormonal and genetic factors. Intra-arterial digital subtraction angiography is still the gold standard for exclusion or confirmation of renal artery stenosis caused by FMD, at least in young patients, who more often have lesions in branches of the renal artery. For FMD patients with atherosclerosis and those who are older (>50–55 years), significant renal artery stenosis may be confirmed or excluded with ultrasonography. The FMD lesion is typically truncal or distal, whereas atherosclerotic lesions are more often proximal or ostial. Treatment options are medical, endovascular (percutaneous transluminal renal angioplasty [PTRA]), and surgical. Invasive treatment should be considered when hypertension cannot be controlled with antihypertensive drugs and in patients with impaired renal function or ischemic nephropathy. PTRA has become the treatment of choice and normally yields good results, especially in unifocal disease and young patients. Pressure gradients are normally completely abolished, and there is no indication for stent placement. Surgical revascularization is indicated after PTRA complications; thrombosis, perforation, progressive dissection, repeated PTRA failure or restenosis. Centralization of handling is recommended.
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Affiliation(s)
- Anders Gottsäter
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - Bengt Lindblad
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
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17
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Chrysant GS, Bates MC, Sullivan TM, Bachinsky WB, Popma JJ, Peng L, Omran HL, Jaff MR. Proper Patient Selection Yields Significant and Sustained Reduction in Systolic Blood Pressure Following Renal Artery Stenting in Patients With Uncontrolled Hypertension: Long-Term Results From the HERCULES Trial. J Clin Hypertens (Greenwich) 2014; 16:497-503. [PMID: 24909590 DOI: 10.1111/jch.12341] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/25/2014] [Accepted: 04/02/2014] [Indexed: 11/28/2022]
Affiliation(s)
| | - Mark C. Bates
- West Virginia University School of Medicine; Charleston WV
| | | | | | | | | | | | - Michael R. Jaff
- VasCore; The Vascular Ultrasound Core Laboratory; Massachusetts General Hospital; Boston MA
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18
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Crimmins GM, Madder RD, Marinescu V, Safian RD. Validity of Estimated Glomerular Filtration Rates for Assessment of Renal Function After Renal Artery Stenting in Patients With Atherosclerotic Renal Artery Stenosis. JACC Cardiovasc Interv 2014; 7:543-9. [DOI: 10.1016/j.jcin.2013.11.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2013] [Revised: 11/13/2013] [Accepted: 11/21/2013] [Indexed: 11/30/2022]
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20
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Olin JW, Gornik HL, Bacharach JM, Biller J, Fine LJ, Gray BH, Gray WA, Gupta R, Hamburg NM, Katzen BT, Lookstein RA, Lumsden AB, Newburger JW, Rundek T, Sperati CJ, Stanley JC. Fibromuscular dysplasia: state of the science and critical unanswered questions: a scientific statement from the American Heart Association. Circulation 2014; 129:1048-78. [PMID: 24548843 DOI: 10.1161/01.cir.0000442577.96802.8c] [Citation(s) in RCA: 292] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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21
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Blood pressure and renal function before and after percutaneous transluminal renal angioplasty in fibromuscular dysplasia. J Hypertens 2013; 31:1183-8. [DOI: 10.1097/hjh.0b013e32836044b2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Renal artery stenosis and abdominal aorta aneurysm in patients with pseudoexfoliation syndrome. Eye (Lond) 2013; 27:735-41. [PMID: 23579404 DOI: 10.1038/eye.2013.56] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE To evaluate the renal arteries and abdominal aorta in patients with pseudoexfoliation syndrome (PEX). DESIGN Prospective, case-control study. METHODS The study involved 49 patients with PEX and 42 control subjects. Abdominal aorta and renal arteries were examined by Doppler ultrasonography. In both renal arteries (proximal and distal portions) and abdominal aorta, the peak systolic velocity (PSV) was measured. Renal artery stenosis (RAS) was defined as the renal artery PSV >150 cm/s or renal-to-aortic ratio (RAR) >3.0. Patients who had an abdominal aortic diameter >3 cm were recorded. Computed tomographic angiography was performed to confirm these findings in patients with RAS and/or abdominal aorta aneurysm. RESULTS The mean PSV in the proximal renal artery was 88.3 cm/s in PEX group and 79.5 cm/s in control group (P=0.314); in distal renal artery was 91.7 cm/s in PEX group and 93.0 cm/s in control group (P=0.794); in abdominal aorta was 76.0 cm/s in PEX group and 65.2 cm/s in control group (P=0.046). RAS was observed in nine patients with PEX and in only one patient without PEX (P=0.017). Seven out of 10 patients with RAS (six patients in PEX group; one patient in control group) had hypertension. Abdominal aorta aneurysm was observed in four patients in PEX group but not in control group (P=0.061). CONCLUSIONS Our study has demonstrated that there is a significant association between PEX and RAS. The abdominal aorta aneurysm may be seen in patients with PEX.
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23
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Koivuviita N, Liukko K, Kudomi N, Oikonen V, Tertti R, Manner I, Vahlberg T, Nuutila P, Metsärinne K. The effect of revascularization of renal artery stenosis on renal perfusion in patients with atherosclerotic renovascular disease. Nephrol Dial Transplant 2012; 27:3843-8. [PMID: 22785108 DOI: 10.1093/ndt/gfs301] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Only a small fraction of patients with atherosclerotic renovascular disease (ARVD) treated with revascularization have improved renal function after the procedure. It has been suggested that this may be due to effects of renal microvascular disease. Our aim was to measure the effect of renal artery stenosis (RAS) revascularization on renal perfusion in patients with renovascular disease. METHODS Seventeen renovascular disease patients were treated by dilatation of unilateral (N = 8) or bilateral (N = 9) RAS (N = 23 kidneys), mainly because of uncontrolled or refractory hypertension. The patients were studied before and after (103 ± 29 days) the procedure. Renal perfusion was measured using quantitative positron emission tomography (PET) perfusion imaging. RESULTS Although renal perfusion correlated inversely with the degree of RAS in patients with renovascular disease, it did not change after revascularization. CONCLUSIONS Our data support the notion of former clinical trials that angiographic severity of RAS does not determine the response to revascularization. Quantitative PET perfusion imaging is a promising tool to noninvasively measure renal perfusion for the assessment of physiological impact of RAS.
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Affiliation(s)
- Niina Koivuviita
- Department of Medicine, Turku University Hospital, Turku, Finland.
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24
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Krug KB, Rehder O, Bovenschulte H, Schwabe H, Burst V, Engelmann U, Thul R, Mönig S, Hellmich M. [Effects of endovascular therapy for renal artery stenosis on blood pressure and renal function: retrospective analysis of an unselected patient collective from 1994 to 2007]. Urologe A 2012; 51:1562-71. [PMID: 22743982 DOI: 10.1007/s00120-012-2952-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND A retrospective analysis of the long-term success rates of endoluminal therapy of renal artery stenosis in a university hospital was carried out. MATERIAL AND METHODS Preinterventional and postinterventional data contained in the clinical records of all 104 patients who underwent percutaneous transluminal angioplasty (PTA, 25 patients) or stent PTA (79 patients) from 01 January 1994 to 31 December 2007, were documented using an electronically structured questionnaire and a time period classification. Subgroup analyses and statistical calculations were done using t-tests for joint random samples. RESULTS At day 1 postintervention all patients showed a statistically significant decrease in mean systolic blood pressure (all patients: p=0.002, stent PTA group: p=0.023, PTA group: p=0.022). The significant decrease in mean systolic blood pressure persisted in years 1 and 2 postintervention (all patients: p=0.009 and 0.007, stent PTA group: p=0.039 and 0.015, respectively). Mean blood pressure values remained constant during the other time periods analyzed. In patients with a stent PTA carried out between 2001 and 2007 there was no significant reduction of prescribed antihypertonic drugs (p=0.023 and p=0.046, respectively). Mean serum creatinine concentrations decreased during years 1 and 2 postintervention and increased starting in year 3. In patients with elevated serum creatinine levels prior to the intervention the increase in mean serum creatinine level started in year 5. CONCLUSIONS Endoluminal therapy of arteriosclerotic renal artery stenosis delays further deterioration of renal function and stabilizes blood pressure as well as the number of prescribed antihypertonic drugs. This can be considered a response to treatment in view of the mostly chronic progressive course of the disease.
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Affiliation(s)
- K B Krug
- Institut und Poliklinik für Radiologische Diagnostik, Universität zu Köln, Josef-Stelzmann-Straße 9, 50924 Köln, Deutschland.
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25
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Ebrahimi B, Li Z, Eirin A, Zhu XY, Textor SC, Lerman LO. Addition of endothelial progenitor cells to renal revascularization restores medullary tubular oxygen consumption in swine renal artery stenosis. Am J Physiol Renal Physiol 2012; 302:F1478-85. [PMID: 22419692 PMCID: PMC3378175 DOI: 10.1152/ajprenal.00563.2011] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2011] [Accepted: 03/08/2012] [Indexed: 01/12/2023] Open
Abstract
Renal artery stenosis (RAS) promotes microvascular rarefaction and fibrogenesis, which may eventuate in irreversible kidney injury. We have shown that percutaneous transluminal renal angioplasty (PTRA) or endothelial progenitor cells (EPC) improve renal cortical hemodynamics and function in the poststenotic kidney. The renal medulla is particularly sensitive to hypoxia, yet little is known about reversibility of medullary injury on restoration of renal blood flow. This study was designed to test the hypothesis that PTRA, with or without adjunct EPC delivery to the stenotic kidney, may improve medullary remodeling and tubular function. RAS was induced in 21 pigs using implantation of irritant coils, while another group served as normal controls (n = 7 each). Two RAS groups were then treated 6 wk later with PTRA or both PTRA and EPC. Four weeks later, medullary hemodynamics, microvascular architecture, and oxygen-dependent tubular function of the stenotic kidneys were examined using multidetector computed tomography, microcomputed tomography, and blood oxygenation level-dependent MRI, respectively. Medullary protein expression of vascular endothelial growth factor, endothelial nitric oxide synthase, hypoxia-inducible factor-1α, and NAD(P)H oxidase p47 were determined. All RAS groups showed decreased medullary vascular density and blood flow. However, in RAS+PTRA+EPC animals, EPC were engrafted in tubular structures, oxygen-dependent tubular function was normalized, and fibrosis attenuated, despite elevated expression of hypoxia-inducible factor-1α and sustained downregulation of vascular endothelial growth factor. In conclusion, EPC delivery, in addition to PTRA, restores medullary oxygen-dependent tubular function, despite impaired medullary blood and oxygen supply. These results support further development of cell-based therapy as an adjunct to revascularization of RAS.
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Affiliation(s)
- Behzad Ebrahimi
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First St. SW, Rochester, MN 55905, USA
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26
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27
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Hegde U, Rajapurkar M, Gang S, Khanapet M, Durugkar S, Gohel K, Aghor N, Ganju A, Dabhi M. Fifteen Years’ Experience of Treating Atherosclerotic Renal Artery Stenosis by Interventional Nephrologists in India. Semin Dial 2011; 25:97-104. [DOI: 10.1111/j.1525-139x.2011.00962.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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28
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Rossi GP, Seccia TM, Miotto D, Zucchetta P, Cecchin D, Calò L, Puato M, Motta R, Caielli P, Vincenzi M, Ramondo G, Taddei S, Ferri C, Letizia C, Borghi C, Morganti A, Pessina AC. The Medical and Endovascular Treatment of Atherosclerotic Renal Artery Stenosis (METRAS) study: rationale and study design. J Hum Hypertens 2011; 26:507-16. [DOI: 10.1038/jhh.2011.62] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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29
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Madder RD, Hickman L, Crimmins GM, Puri M, Marinescu V, McCullough PA, Safian RD. Validity of Estimated Glomerular Filtration Rates for Assessment of Baseline and Serial Renal Function in Patients With Atherosclerotic Renal Artery Stenosis. Circ Cardiovasc Interv 2011; 4:219-25. [DOI: 10.1161/circinterventions.110.960971] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Despite routine use of estimated glomerular filtration rates (GFRs) as major renal end points in clinical trials of renal revascularization, serial GFR estimates have never been validated in patients with renal artery stenosis (RAS). The purpose of this study was to evaluate the validity of GFR estimates in patients with atherosclerotic RAS.
Methods and Results—
Serum creatinine (SCr) and
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I-iothalamate GFR (I-GFR) were measured in patients with RAS. GFR estimates were calculated from Modification of Diet in Renal Disease (MDRD), Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI), and Cockroft-Gault (CG) formulas. Using I-GFR as the reference standard, the sensitivity, specificity, and receiver operating characteristic area under the curve (AUC) were determined for MDRD, CKD-EPI, CG, and reciprocal SCr for identifying I-GFR <60 mL/min per 1.73 m
2
and a 20% change in I-GFR over time. Between 1998 and 2007, 541 I-GFR measurements were performed in 254 consecutive patients with RAS. MDRD, CKD-EPI, and CG GFR estimates demonstrated good sensitivity (86% to 95%), modest specificity (67% to 71%), and good reliability (AUC, 0.86 to 0.94) for identifying I-GFR <60 mL/min per 1.73 m
2
. GFR estimates had good specificity (87% to 95%), poor sensitivity (0% to 45%), and poor reliability (AUC, 0.61 to 0.65) for detecting 20% changes in I-GFR over follow-up.
Conclusions—
In patients with RAS, GFR estimates demonstrate good sensitivity and modest specificity for identifying I-GFR <60 mL/min per 1.73 m
2
but poor sensitivity and reliability for detecting 20% changes in I-GFR. GFR estimates should not be used in clinical trials as major end points to assess serial GFR after renal revascularization.
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Affiliation(s)
- Ryan D. Madder
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Leaden Hickman
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Geoffrey M. Crimmins
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Mohammad Puri
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Victor Marinescu
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Peter A. McCullough
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
| | - Robert D. Safian
- From the Department of Cardiovascular Medicine, William Beaumont Hospital, Royal Oak, MI
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30
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Olin JW, Sealove BA. Diagnosis, management, and future developments of fibromuscular dysplasia. J Vasc Surg 2011; 53:826-36.e1. [DOI: 10.1016/j.jvs.2010.10.066] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2010] [Revised: 10/07/2010] [Accepted: 10/07/2010] [Indexed: 10/18/2022]
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Uchino Y, Watanabe M, Hirata Y, Shigematsu K, Miyata T, Nagai R. Efficacy of renal revascularization in a patient with fibromuscular renal artery stenosis and heart failure. Int Heart J 2010; 51:432-5. [PMID: 21173521 DOI: 10.1536/ihj.51.432] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
We report the case of a 65-year-old woman with a solitary kidney who developed hypertension due to renal artery stenosis caused by fibromuscular dysplasia. In addition, an echocardiogram revealed severe left ventricular systolic and diastolic dysfunction. Despite antihypertensive drug treatment that included diuretics, her serum concentration of brain natriuretic peptide was persistently elevated and associated with progressive worsening of renal function. She underwent iliac artery to renal artery bypass grafting. After the surgery, blood pressure control was good, the serum concentration of brain natriuretic peptide decreased, and left ventricular diastolic function improved. This case exemplifies the efficacy of renal revascularization in patients with fibromuscular renal artery stenosis and heart failure.
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Affiliation(s)
- Yuichi Uchino
- Department of Cardiovascular Medicine, Division of Surgery, Graduate School of Medicine, The University of Tokyo, Japan
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Abstract
The detrimental link between cardiac and renal pathophysiology in atherosclerotic renovascular disease (ARVD) is well described. Patients with ARVD usually have significant atherosclerotic disease in other vascular beds including the coronary circulation, and structural and functional cardiac changes are highly prevalent. This excess cardiovascular burden probably contributes to the increased cardiac morbidity and mortality seen in these patients. In this review we describe the associations of cardiovascular disease and ARVD and treatment thereof. The clinical debate of which patients are offered any additional advantage by revascularisation over medications alone remains to be answered. The close link between cardiac and renal pathophysiology in ARVD raises the possibility that renal revascularisation might confer a benefit to cardiac morphology and function. This is the subject of ongoing randomised controlled trials.
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Use of B-Type Natriuretic Peptide to Predict Blood Pressure Improvement after Percutaneous Revascularisation for Renal Artery Stenosis. Eur J Vasc Endovasc Surg 2010; 40:599-607. [DOI: 10.1016/j.ejvs.2010.07.013] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Accepted: 07/19/2010] [Indexed: 11/21/2022]
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Affiliation(s)
- Mira T. Keddis
- Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo Clinic, Rochester, MN
| | - Vesna D. Garovic
- Adviser to resident and Consultant in Nephrology and Hypertension, Mayo Clinic, Rochester, MN
- Individual reprints of this article are not available. Address correspondence to Vesna D. Garovic, MD, Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Van den Driessche A, Van Hul E, Ichiche M, Verpooten GA, Bosmans JL. Fibromuscular dysplasia presenting as a renal infarction: a case report. J Med Case Rep 2010; 4:199. [PMID: 20591148 PMCID: PMC2905432 DOI: 10.1186/1752-1947-4-199] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2009] [Accepted: 06/30/2010] [Indexed: 11/10/2022] Open
Abstract
Introduction Fibromuscular dysplasia is a non-atherosclerotic, non-inflammatory disease that most commonly affects the renal and internal carotid arteries. Case presentation We present the case of a 44-year-old Caucasian man who was admitted with complaints of loin pain and hypertension. A computed tomography scan of the abdomen revealed a right renal infarction with a nodular aspect of the right renal artery. Subsequent renal angiography revealed a typical 'string of beads' pattern of the right renal artery with thrombus formation. Oral anticoagulation was started and the secondary hypertension was easily controlled with anti-hypertensive drugs. At follow-up, our patient refused percutaneous transluminal renal angioplasty as a definitive treatment. Conclusions Fibromuscular dysplasia is the most common cause of renovascular hypertension in patients under 50 years of age. Presentation with renal infarction is rare. In fibromuscular dysplasia, angioplasty has been proven to have, at least for some indications, an advantage over anti-hypertensive drugs. Therefore, hypertension secondary to fibromuscular dysplasia is the most common cause of curable hypertension.
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Technical and Clinical Results After Percutaneous Angioplasty in Nonmedial Fibromuscular Dysplasia: Outcome After Endovascular Management of Unifocal Renal Artery Stenoses in 30 Patients. Cardiovasc Intervent Radiol 2010; 33:270-7. [DOI: 10.1007/s00270-010-9818-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2009] [Accepted: 12/17/2009] [Indexed: 11/27/2022]
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Kalra PA, Guo H, Gilbertson DT, Liu J, Chen SC, Ishani A, Collins AJ, Foley RN. Atherosclerotic renovascular disease in the United States. Kidney Int 2010; 77:37-43. [DOI: 10.1038/ki.2009.406] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Cheung CM, Chrysochou C, Shurrab AE, Buckley DL, Cowie A, Kalra PA. Effects of renal volume and single-kidney glomerular filtration rate on renal functional outcome in atherosclerotic renal artery stenosis. Nephrol Dial Transplant 2009; 25:1133-40. [PMID: 20028827 DOI: 10.1093/ndt/gfp623] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renal functional outcome is unpredictable after revascularization of high-grade atherosclerotic renal artery stenosis (RAS). 'Hibernating' parenchyma describes acute parenchymal injury where renal dysfunction is potentially reversible with treatment of the stenosis. We analysed renal parenchymal volume (PV) and single-kidney glomerular filtration rate (SK-GFR) characteristics to identify kidneys with hibernating parenchyma and hence determine renal functional outcome after revascularization. METHODS Fifty patients with > or =50% RAS underwent baseline analyses: (i) PV using magnetic resonance imaging; (ii) radioisotopic SK-GFR. Twenty-one patients (27 kidneys) underwent renal revascularization and 29 medical therapy alone. RESULTS Patients with revascularized kidneys manifesting high PV:SK-GFR showed improvement in global estimated GFR compared to conservatively managed counterparts at 6 months and 1 year (6 months: 6.2 +/- 2.9 versus -3.7 +/- 6.8, P = 0.038; 1 year: 3.5 +/- 3.0 versus -5.1 +/- 5.1 ml/min/1.73 m(2), P = 0.021). Twelve revascularized patients (16 kidneys) underwent repeat SK-GFR 4 months post-revascularization. Six of 16 revascularized kidneys had high baseline PV:SK-GFR and showed improved SK-GFR compared to kidneys with low or normal PV:SK-GFR (6.3 +/- 2.0 versus -0.9 +/- 4.2 ml/min, P = 0.002). CONCLUSIONS Our data suggest that, after revascularization, GFR improvement is likely if there is a disproportionately higher baseline PV:SK-GFR in the RAS kidney. Analysing these parameters can potentially identify these 'hibernating' kidneys and aid determination of renal functional outcome in RAS.
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Affiliation(s)
- Ching M Cheung
- Department of Renal Medicine and Radiology, Salford Royal Hospital, Stott Lane, Salford M6 8HD, UK.
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Anchala PR, Resnick SA. The current state of endovascular therapy in the evaluation and management of renovascular disease. Semin Intervent Radiol 2009; 26:333-44. [PMID: 21326543 DOI: 10.1055/s-0029-1242202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Hypertension is the most common reason for physician office visits among nonpregnant adults in the United States; up to one-third of Americans over the age of 18 have been diagnosed with hypertension. Patients with physiologically significant renal artery stenosis often go unnoticed because hypertension can often be well controlled with antihypertensive medications. As a result, screening for renovascular causes of hypertension is rarely done. However, the likelihood of renovascular disease increases in patients with acute, severe, or refractory hypertension and should be explored in patients who fall into these categories. Renovascular disease is a crucial consideration in the management of hypertension due to its increasing incidence and its potential for reversibility. Although renovascular disease accounts for less than 1% of patients with mild hypertension, it is estimated that between 10 and 45% of white patients with severe or malignant hypertension have renal artery stenosis (RAS). In this population, diagnosing and treating RAS can have a profound and long-lasting effect on the treatment of hypertension.
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Affiliation(s)
- Praveen R Anchala
- Department of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Wheatley K, Ives N, Gray R, Kalra PA, Moss JG, Baigent C, Carr S, Chalmers N, Eadington D, Hamilton G, Lipkin G, Nicholson A, Scoble J. Revascularization versus medical therapy for renal-artery stenosis. N Engl J Med 2009; 361:1953-62. [PMID: 19907042 DOI: 10.1056/nejmoa0905368] [Citation(s) in RCA: 706] [Impact Index Per Article: 44.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Percutaneous revascularization of the renal arteries improves patency in atherosclerotic renovascular disease, yet evidence of a clinical benefit is limited. METHODS In a randomized, unblinded trial, we assigned 806 patients with atherosclerotic renovascular disease either to undergo revascularization in addition to receiving medical therapy or to receive medical therapy alone. The primary outcome was renal function, as measured by the reciprocal of the serum creatinine level (a measure that has a linear relationship with creatinine clearance). Secondary outcomes were blood pressure, the time to renal and major cardiovascular events, and mortality. The median follow-up was 34 months. RESULTS During a 5-year period, the rate of progression of renal impairment (as shown by the slope of the reciprocal of the serum creatinine level) was -0.07x10(-3) liters per micromole per year in the revascularization group, as compared with -0.13x10(-3) liters per micromole per year in the medical-therapy group, a difference favoring revascularization of 0.06x10(-3) liters per micromole per year (95% confidence interval [CI], -0.002 to 0.13; P=0.06). Over the same time, the mean serum creatinine level was 1.6 micromol per liter (95% CI, -8.4 to 5.2 [0.02 mg per deciliter; 95% CI, -0.10 to 0.06]) lower in the revascularization group than in the medical-therapy group. There was no significant between-group difference in systolic blood pressure; the decrease in diastolic blood pressure was smaller in the revascularization group than in the medical-therapy group. The two study groups had similar rates of renal events (hazard ratio in the revascularization group, 0.97; 95% CI, 0.67 to 1.40; P=0.88), major cardiovascular events (hazard ratio, 0.94; 95% CI, 0.75 to 1.19; P=0.61), and death (hazard ratio, 0.90; 95% CI, 0.69 to 1.18; P=0.46). Serious complications associated with revascularization occurred in 23 patients, including 2 deaths and 3 amputations of toes or limbs. CONCLUSIONS We found substantial risks but no evidence of a worthwhile clinical benefit from revascularization in patients with atherosclerotic renovascular disease. (Current Controlled Trials number, ISRCTN59586944.)
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Schwarzwälder U, Zeller T. Critical review of indications for renal artery stenting: do randomized trials give the answer? Catheter Cardiovasc Interv 2009; 74:251-6. [PMID: 19434748 DOI: 10.1002/ccd.22073] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Significant renal artery stenosis (RAS) is a well accepted cause of deterioration of arterial hypertension and of renal insufficiency. Just recently, more interest has been focused on the impact of RAS on structural heart disease and patient survival. Technical improvements of diagnostic and interventional endovascular tools have lead to a more widespread use of endoluminal renal artery revascularization and extension of the indications for this type of therapy during the past 2 decades. Since the first renal artery angioplasties performed by Felix Mahler and Andreas Grüntzig, numerous single centre studies have reported the beneficial effect of percutaneous transluminal renal angioplasty, and since the early 1990's stenting of renal artery stenosis caused either by atherosclerosis or fibromuscular dysplasia. However, none of the so far published or presented randomized controlled trials (RCT) could prove a beneficial outcome of RAS revascularization compared with medical management. As a result of these negative trials including the recently presented ASTRAL trial, referrals to endovascular renal artery revascularization went down and moreover, reimbursement of these procedures became a matter of debate. This article summarizes the background and the limitations of the so far published and still ongoing controlled trials. Moreover, we discuss why well-designed registries might give important insight on the impact of endovascular revascularization of hemodynamically relevant atherosclerotic RAS.
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Affiliation(s)
- Uwe Schwarzwälder
- Department of Angiology, Heart Centre Bad Krozingen, Bad Krozingen, Germany
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Thatipelli M, Huettl E, McKusick M, Misra S. Angioplasty for Renal Artery Fibromuscular Dysplasia in Older Hypertensive Patients. Angiology 2009; 60:714-8. [DOI: 10.1177/0003319709335512] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aim: To describe the outcomes of treating patients with angioplasty who are older than 40 years with symptomatic/labile/refractory hypertension (HTN). Methods: Between1999 and 2005, 28 patients underwent angioplasty for renal fibromuscular dysplasia (FMD). Patients were excluded if they had concomitant atherosclerotic renal artery stenosis (n = 4) or less than 1 month follow-up (n = 8). Results: The study group included 16 Caucasians (21 procedures; mean age 65.5 10.8 years; females = 88%). The cardiovascular risk factors include HTN (n = 13), smoking (n = 1), diabetes (n = 2), dyslipidemia (n = 8). The HTN was characterized as refractory (n = 15, 12 were symptomatic) and new-onset in 1 patient. The technical success rate was 100%. Over a median period of 12.8 months (range: 1.0-85.8), 18 (95%) procedures ‘‘failed,’’ of which 8 (42%) within 1 month and the rest in 1 year. Conclusions: Angioplasty in symptomatic renal FMD in patients >40 years is associated with poor outcomes possibly due to early restenosis.
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Affiliation(s)
| | - E.A. Huettl
- Department of Vascular & Interventional, Radiology Rochester, Minnesota
| | - M.A. McKusick
- Department of Vascular & Interventional Radiology, Rochester, Minnesota
| | - S. Misra
- Department of Vascular & Interventional Radiology, Rochester, Minnesota,
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Endovascular Treatment of Renal Artery Aneurysm Secondary to Fibromuscular Dysplasia: A Case Report. Ann Vasc Surg 2009; 23:536.e9-12. [DOI: 10.1016/j.avsg.2008.11.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 11/10/2008] [Accepted: 11/13/2008] [Indexed: 11/17/2022]
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Karagiannis A, Tziomalos K, Anagnostis P, Gossios T, Athyros VG. Atherosclerotic renal artery stenosis: medical therapy alone or in combination with revascularization? Angiology 2009; 60:397-402. [PMID: 19505885 DOI: 10.1177/0003319709334262] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Jensen G, Annerstedt M, Klingenstierna H, Herlitz H, Aurell M, Hellström M. Survival and quality of life after renal angioplasty: a five-year follow-up study. SCANDINAVIAN JOURNAL OF UROLOGY AND NEPHROLOGY 2009; 43:236-41. [PMID: 19337882 DOI: 10.1080/00365590902833606] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Renal percutaneous transluminal angioplasty (PTA) treatment of renal artery stenosis has been performed worldwide since 1978, but it is still a matter of debate as to what extent the patients benefit from the procedure in terms of quality of life and long-term survival. MATERIAL AND METHODS Of 139 patients referred for renal angioplasty owing to hypertension or pending uraemia, 105 were subsequently treated with PTA. Eighty-eight patients survived for 5 years. Fifty-nine patients were re-examined according to a protocol including physical examination, blood pressure, drug therapy, glomerular filtration rate and quality of life assessment, and an additional 29 patients were interviewed by telephone regarding quality of life. PTA was not conducted in 34 patients owing to high risks as decided at joint radiology-nephrology conferences. RESULTS The 5-year survival was 83% for PTA-treated patients with arteriosclerotic renovascular disease, 100% for patients with fibromuscular vascular disease and 47% for the non-PTA-treated patients. The main causes of death were cardiovascular and cerebrovascular events in both groups. Reduced blood pressure and reduced need for antihypertensive drug treatment were observed in the PTA-treated patients. The renal function was stable. A majority of the PTA-treated patients stated that they had "unrestricted" physical activity, and the physical, mental and social well-being was self-rated as level 4-5 (mostly good and very good) on a five-grade scale by 53%, 67% and 75% of the patients, respectively, at the follow-up investigation. The untreated patients were not interviewed. CONCLUSION The study showed a high survival rate, improved blood pressure control and stable renal function 5 years after renal PTA, and a vast majority of the patients rated their physical, mental and social well-being favourably.
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Affiliation(s)
- Gert Jensen
- Department of Nephrology, Sahlgrenska University Hospital, Göteborg, Sweden.
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Chrysochou C, Cheung CM, Durow M, Middleton RJ, Solomon LR, Craig A, Venning M, Kalra PA. Proteinuria as a predictor of renal functional outcome after revascularization in atherosclerotic renovascular disease (ARVD). QJM 2009; 102:283-8. [PMID: 19202165 DOI: 10.1093/qjmed/hcp007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Renal revascularization is performed in 16% of newly diagnosed patients with atherosclerotic renovascular disease (ARVD). Although there may be some improvement in hypertension control as a result of intervention, renal functional outcomes are known to vary. Pre-existing renal parenchymal injury, as manifested by proteinuria, is associated with poor functional outcome in conservatively managed ARVD patients, but this association has not been investigated in patients undergoing revascularization. METHODS Retrospective case note review of 83 ARVD patients who underwent renal revascularization in four centres within a renal network between 1998 and 2003 was undertaken. Amongst other parameters, baseline proteinuria was correlated with renal functional outcome post revascularization. Renal functional outcome was determined over a mean follow up of 22 months by rate of change of estimated glomerular filtration rate (eGFR) over time. RESULTS Univariate analysis showed that proteinuria >0.6 g/day was the only significant predictor of poor outcome after revascularization. The relationship persisted with multivariate analysis, and linear regression showed a correlation between baseline proteinuria and decline in eGFR with time (r(2) = 0.058, P = 0.039). CONCLUSION This study confirms that prior renal parenchymal injury, here reflected by proteinuria at baseline, is a major arbiter of renal functional outcome after renal revascularization in ARVD.
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Affiliation(s)
- C Chrysochou
- Department of Renal Medicine, Salford Royal Hospital, Salford, UK.
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Davies MG, Saad WE, Peden EK, Mohiuddin IT, Naoum JJ, Lumsden AB. The long-term outcomes of percutaneous therapy for renal artery fibromuscular dysplasia. J Vasc Surg 2008; 48:865-71. [DOI: 10.1016/j.jvs.2008.05.030] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2008] [Revised: 05/08/2008] [Accepted: 05/11/2008] [Indexed: 10/21/2022]
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Kim HJ, Do YS, Shin SW, Park KB, Cho SK, Choe YH, Choo SW, Choo IW, Kim DK. Percutaneous transluminal angioplasty of renal artery fibromuscular dysplasia: mid-term results. Korean J Radiol 2008; 9:38-44. [PMID: 18253074 PMCID: PMC2627178 DOI: 10.3348/kjr.2008.9.1.38] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective To evaluate mid-term imaging, clinical follow-up, and restenosis rates from patients that had undergone percutaneous transluminal renal artery angioplasty (PTRA) for symptomatic renal artery fibromuscular dysplasia (FMD). Materials and Methods Between March 1999 and July 2006, 16 consecutive renal artery FMD patients underwent PTRA for poorly controlled hypertension. The patients were enrolled into this retrospective study after receiving 19 primary and four secondary PTRAs in 19 renal artery segments. Follow-up monitoring of blood pressure, use of antihypertensive medication, and the serum creatinine level after PTRA were assessed at 1, 3, 6, 9, 12 months, and each following year. The degree of restenosis was evaluated with computed tomographic angiography (CTA) after PTRA at 6, 12 months, and every year if possible. Technical and clinical success rates for the treatment of FMD, and restenosis rates for the renal artery were evaluated. Results The technical success rate for primary PTRA was 79% (15/19) and the complication rate was 16% (3/19). Hypertension improved in 80% (12/15) of the patients after four weeks follow-up, and was finally cured or improved in 93% (14/15) during the mean follow-up period of 23.6 months. There was a cumulative 22% (4/18) restenosis rate during the follow-up period. All of the patients were treated with a second PTRA without complications and all of the patients were cured of hypertension after the second PTRA. Conclusion Percutaneous transluminal renal artery angioplasty for clinically symptomatic renal FMD is technically and clinically successful and safe to perform. For all patients with restenosis, there was a good response after undergoing a second PTRA.
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Affiliation(s)
- Hyo Jin Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Kangnam-Gu, Seoul, Korea
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