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Zhang L, Dong YF, Chen Y, Li XG, Wang YH, Wang Y, Ge ZT, Wang X, Cai S, Yang X, Zhu QL, Li JC. Impact of Microbubble Degradation and Flow Velocity on Subharmonic-aided Pressure Estimation (SHAPE): An Experimental Investigation. ULTRASOUND IN MEDICINE & BIOLOGY 2024; 50:1020-1027. [PMID: 38594125 DOI: 10.1016/j.ultrasmedbio.2024.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE This study aimed to investigate the impact of microbubble degradation and flow velocity on Sub-Harmonic Aided Pressure Estimation (SHAPE), and to explore the correlation between subharmonic amplitude and pressure as a single factor. METHODS We develop an open-loop vascular phantom platform system and utilize a commercial ultrasound machine and microbubbles for subharmonic imaging. Subharmonic amplitude was measured continuously at constant pressure and flow velocity to assess the impact of microbubble degradation. Flow velocity was varied within a range of 4-14 cm/s at constant pressure to investigate its relationship to subharmonic amplitude. Furthermore, pressure was varied within a range of 10-110 mm Hg at constant flow velocity to assess its isolated effect on subharmonic amplitude. RESULTS Under constant pressure and flow velocity, subharmonic amplitude exhibited a continuous decrease at an average rate of 0.221 dB/min, signifying ongoing microbubble degradation during the experimental procedures. Subharmonic amplitude demonstrated a positive correlation with flow velocity, with a variation ratio of 0.423 dB/(cm/s). Under controlled conditions of microbubble degradation and flow velocity, a strong negative linear correlation was observed between pressure and subharmonic amplitude across different Mechanical Index (MI) settings (all R2 > 0.90). The sensitivity of SHAPE was determined to be 0.025 dB/mmHg at an MI of 0.04. CONCLUSION The assessment of SHAPE sensitivity is affected by microbubble degradation and flow velocity. Excluding the aforementioned influencing factors, a strong linear negative correlation between pressure and subharmonic amplitude was still evident, albeit with a sensitivity coefficient lower than previously reported values.
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Affiliation(s)
- Li Zhang
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yi-Fan Dong
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yao Chen
- Department of Ultrasound, GE Healthcare Medical System (China), Shanghai, China
| | - Xiao-Gang Li
- Biobank Facility, National Infrastructures for Translational Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ya-Hong Wang
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Ying Wang
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Zhi-Tong Ge
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xin Wang
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Sheng Cai
- Department of Health Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiao Yang
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Qing-Li Zhu
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Jian-Chu Li
- Department of Diagnostic Ultrasound, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China.
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Huang X, Li XL, Zhou H, Li XM. Assessment of Angiography-Based Renal Quantitative Flow Ratio Measurement in Patients with Atherosclerotic Renal Artery Stenosis. Cardiovasc Ther 2024; 2024:4618868. [PMID: 38234331 PMCID: PMC10791475 DOI: 10.1155/2024/4618868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/19/2024] Open
Abstract
Background Quantitative flow ratio (QFR) is an angiography-based fractional flow reserve measurement without pressure wire or induction of hyperemia. A recent innovation that uses combined geometrical data and hemodynamic boundary conditions to measure QFR from a single angiographic view has shown the potential to measure QFR of the renal artery-renal QFR (rQFR). Objective The aim of this pilot study was to assess the feasibility of rQFR measurement and the contribution of rQFR in selecting patients with atherosclerotic renal artery stenosis (ARAS) undergoing revascularization. Methods This retrospective trial enrolled patients who had ARAS (50-90%) and hypertension. The enrolled patients were treated by optimal antihypertensive medication or revascularization, respectively, and the therapeutic strategies were based on rFFR measurement and/or clinical feature. Results A total of 55 patients underwent rQFR measurement. Among the enrolled patients, 18 underwent optimal antihypertensive medication and 37 underwent revascularization, 19 patients in whom rQFR and rFFR were both assessed. During the 180-day follow-up, 25 patients saw an improvement in their blood pressure among the 37 patients that underwent revascularization. ROC analysis revealed that rQFR had a high diagnostic accuracy for predicting blood pressure improvement (AUCrQFR = 0.932, 95% CI 0.798-0.998). The ideal cut-off value of rQFR for predicting blood pressure improvement after revascularization is ≤0.72 (sensitivity: 72.00%, specificity: 100%). The paired t test and Bland-Altman analyses demonstrated good agreement between rQFR and rFFR (t = 1.887, 95% CI -0.021 to 0.001, 95% limits of agreement: -0.035 to 0.055, p = 0.075). The Spearman correlation test reveals that there was a significant positive correlation between rQFR and rFFR (r = 0.952, 95% CI 0.874 to 0.982, p < 0.001). Conclusion The rQFR has the potential to enhance the ability of angiography to detect functionally significant renal artery stenosis during angiography and to produce results that are comparable to invasive hemodynamic assessment.
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Affiliation(s)
- Xiang Huang
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Xiao-Lan Li
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Heng Zhou
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Xiao-Mei Li
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
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Zhao Y, Shi Y, Jin Y, Cao Y, Song H, Chen L, Li F, Li X, Chen W. Evaluating Short-Term and Long-Term Risks Associated with Renal Artery Stenosis Position and Severity: A Hemodynamic Study. Bioengineering (Basel) 2023; 10:1002. [PMID: 37760104 PMCID: PMC10525140 DOI: 10.3390/bioengineering10091002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/29/2023] Open
Abstract
Background: Moderate renal artery stenosis (50-70%) may lead to uncontrolled hypertension and eventually cause irreversible damage to renal function. However, the clinical criteria for interventional treatment are still ambiguous in this condition. This study investigated the impact of the position and degree of renal artery stenosis on hemodynamics near the renal artery to assess the short-term and long-term risks associated with this disease. Methods: Calculation models with different degrees of stenosis (50%, 60%, and 70%) located at different positions in the right renal artery were established based on the computed tomography angiography (CTA) of a personalized case. And computational fluid dynamics (CFD) was used to analyze hemodynamic surroundings near the renal artery. Results: As the degree of stenosis increases and the stenosis position is far away from the aorta, there is a decrease in renal perfusion. An analysis of the wall shear stress (WSS)-related parameters indicated areas near the renal artery (downstream of the stenosis and the entrance of the right renal artery) with potential long-term risks of thrombosis and inflammation. Conclusion: The position and degree of stenosis play a significant role in judging short-term risks associated with renal perfusion. Moreover, clinicians should consider not only short-term risks but also independent long-term risk factors, such as certain regions of 50% stenosis with adequate renal perfusion may necessitate prompt intervention.
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Affiliation(s)
- Yawei Zhao
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yike Shi
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yusheng Jin
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Yifan Cao
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Hui Song
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China;
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Lingfeng Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Fen Li
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Taiyuan 030024, China;
- Institute of Applied Mechanics, Taiyuan University of Technology, Taiyuan 030024, China
| | - Xiaona Li
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
| | - Weiyi Chen
- College of Biomedical Engineering, Taiyuan University of Technology, Taiyuan 030024, China; (Y.Z.); (Y.S.); (Y.J.); (Y.C.); (X.L.); (W.C.)
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Hebert CA, Rosenthal RL, Schussler JM. Transradial Renal Angioplasty and Stent Placement for Systemic Hypertension Caused by Severe Unilateral Renovascular Stenosis. Cureus 2023; 15:e34781. [PMID: 36909107 PMCID: PMC10005850 DOI: 10.7759/cureus.34781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/11/2023] Open
Abstract
Percutaneous transluminal angioplasty and stent placement for renovascular hypertension is a recognized albeit seldom used therapy. We present a case of severe renovascular hypertension, due to renal artery atherosclerosis, treated successfully with stent placement via the radial artery access approach.
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Affiliation(s)
| | - Robert L Rosenthal
- Cardiology, Baylor University Medical Center, Dallas, USA.,Cardiology, Baylor Scott & White Heart and Vascular Hospital, Dallas, USA
| | - Jeffrey M Schussler
- Cardiology, Baylor University Medical Center, Dallas, USA.,Interventional Cardiology, Baylor Scott & White Heart and Vascular Hospital, Dallas, USA
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Dreyfus I, Zilinyin R, Radhakrishnann J, Parikh SA. Therapy for Renal Artery Stenosis: A Call for Change. J Endovasc Ther 2022:15266028221134884. [PMID: 36415917 DOI: 10.1177/15266028221134884] [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: 02/17/2024]
Abstract
CLINICAL IMPACT We present a brief case description of a patient who benefitted from stenting in ARAS and provide a comprehensive review of ARAS; its prevalence, pathophysiology, clinical manifestations, diagnosis and treatment. We review the evidence for and against stenting in ARAS as well as consensus guidelines for stenting. Our review is valuable as we argue that stenting in ARAS is underutilized and the randomized control data for stenting in those patients who may benefit most is lacking. Our review will provide an important perspective for clinicians faced with decisions of how to treat ARAS.
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Affiliation(s)
- Isaac Dreyfus
- Division of Cardiology, Department of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Robert Zilinyin
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Jai Radhakrishnann
- Division of Nephrology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
| | - Sahil A Parikh
- Division of Cardiology, Department of Medicine, New York-Presbyterian Hospital/Columbia University Irving Medical Center, New York, NY, USA
- Center for Interventional Cardiovascular Care and Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
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Li P, Niu G, Yan Z, Zhang B, Yang M. Case Report: Endovascular Treatment of Chronic Atherosclerotic Renal Artery Total Occlusions with Failed Medical Therapy. Front Surg 2022; 9:843568. [PMID: 36329980 PMCID: PMC9622779 DOI: 10.3389/fsurg.2022.843568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 04/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background Current guidelines generally no longer support revascularization for chronic renal artery occlusive diseases because results from randomized controlled trials favor medical therapy over angioplasty. However, increasing reports indicate that patients with renal artery occlusion (RAO) can benefit from revascularization under certain circumstances. Case summary Here, we present a patient with renal artery stenosis (RAS) who does not have refractory hypertension or fit any clinical trial inclusion criteria by far. Medical therapy failed to prevent the progression of RAS in this patient, leading to total occlusion of his right renal artery. This patient had progressive renal insufficiency but recovered renal function after endovascular treatment. Conclusion This case demonstrates that angioplasty can be beneficial in selected RAO patients, especially those with residual renal function and collateral perfusion.
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Society for Vascular Surgery Appropriate Use Criteria for Management of Intermittent Claudication. J Vasc Surg 2022; 76:3-22.e1. [PMID: 35470016 DOI: 10.1016/j.jvs.2022.04.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 04/09/2022] [Indexed: 12/28/2022]
Abstract
The Society for Vascular Surgery (SVS) Appropriate Use Criteria (AUC) for Management of Intermittent Claudication were created using the RAND appropriateness method (RAM) which is a validated and standardized methodology that combines best-available evidence from medical literature with expert opinion, using a modified-Delphi process. These criteria serve as a framework upon which individualized patient and clinician shared decision-making can grow. These criteria are not absolute. AUC should not be interpreted as a requirement to administer treatments rated as appropriate (benefit outweighs risk). Nor should AUC be interpreted as a prohibition on treatments rated as inappropriate (risk outweighs benefit). There will be clinical situations in which moderating factors, not included in these AUC, will shift the appropriateness level of a treatment for an individual patient. Proper implementation of AUC calls for a description of those moderating patient factors. For scenarios with an indeterminate rating, clinician judgement combined with best available evidence should determine treatment strategy. Importantly, these are scenarios in need of mechanisms to track treatment decisions and outcomes. AUC should be revisited on a periodic basis to ensure that these criteria remain relevant. The panelists rated 2280 unique scenarios for the treatment of intermittent claudication (IC) in the aortoiliac, common femoral and femoropopliteal segment in Round 2 rating. Of these, only 9 (0.4%) had disagreement according to the IPRAS formula, indicating an exceptionally high degree of consensus among the panelists. [Note, post-hoc, the term, "inappropriate," was replaced with the term "R>B" (risk outweighs benefit). The term "appropriate" was also replaced with "B>R" (benefit outweighs risk)]. The key principles for the management of intermittent claudication reflected within these AUC are: (1) Exercise therapy is a preferred initial management strategy for all patients with IC. (2) For patients who have not completed exercise therapy, invasive therapy may provide net benefit in selected patients with IC who are non-smokers, are taking optimal medical therapy, are considered low physiologic and technical risk, and who are experiencing severe lifestyle limitation and/or short walking distance. (3) Considering the long-term durability of currently available technology, invasive interventions for femoropopliteal disease should be reserved for patients with severe lifestyle limitation and short walking distance. (4) In the common femoral segment, open common femoral endarterectomy provides greater net benefit than endovascular intervention for the treatment of IC. (5) In the infrapopliteal segment, invasive intervention for the treatment of intermittent claudication is of unclear benefit and may be harmful.
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Li Y, Ma N, Zhang Y, Wang S, Sun Y, Li M, Ai H, Zhu H, Wang Y, Li P, Guo F, Li Y, Ren J. Development and Validation of a Prognostic Nomogram for Prognosis in Patients With Renal Artery Stenosis. Front Med (Lausanne) 2022; 9:783994. [PMID: 35479955 PMCID: PMC9035536 DOI: 10.3389/fmed.2022.783994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 03/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Objective Renal artery stenosis (RAS) is associated with an increased risk of renal function deterioration (RFD). Our previous study showed that renal cortical blood perfusion assessed by contrast-enhanced ultrasound (CEUS) was an important related factor for RFD in RAS patients. Based on several conventional related factors confirmed by previous studies, we aimed to establish and verify a CEUS+ scoring system to evaluate the risk of RFD at 1 year of follow-up in RAS patients. Methods This study was a single-center retrospective study. A total of 497 elderly RAS patients (247 in the training group and 250 in the verification group) admitted to the Beijing Hospital from January 2016 to December 2019 were included. The baseline characteristics of the patients on admission (including general conditions, previous medical history, blood pressure, blood creatinine, RAS, and cortical blood perfusion in the affected kidney) and renal function [glomerular filtration rate (GFR)] at 1-year of follow-up were collected. We used the univariate and multivariate logistic regressions to establish a CEUS+ scoring system model, the receiver operating characteristic (ROC) curve and area under the curve (AUC) to evaluate prediction accuracy, and the decision curve analysis and nomogram to evaluate the clinical application value of CEUS+ scoring system model. Results Among the 497 patients enrolled, 266 (53.5%) were men, with an average age of (51.7 ± 19.3) years. The baseline clinical-radiomic data of the training group and the verification group were similar (all p > 0.05). Multivariate logistic regression analysis results showed that age [Odds ratio (OR) = 1.937, 95% confidence interval (CI): 1.104–3.397), diabetes (OR = 1.402, 95% CI: 1.015–1.938), blood pressure (OR = 1.575, 95% CI: 1.138–2.182), RAS (OR = 1.771, 95% CI: 1.114–2.816), and area under ascending curve (AUCi) (OR = 2.131, 95% CI: 1.263–3.596) were related factors for the renal function deterioration after 1 year of follow-up (all p < 0.05). The AUC of the ROC curve of the CEUS+ scoring system model of the training group was 0.801, and the Youden index was 0.725 (specificity 0.768, sensitivity 0.813); the AUC of the ROC curve of the validation group was 0.853, Youden index was 0.718 (specificity 0.693, sensitivity 0.835). There was no significant difference in ROC curves between the two groups (D = 1.338, p = 0.325). In addition, the calibration charts of the training and verification groups showed that the calibration curve of the CEUS+ scoring system was close to the standard curve (p = 0.701, p = 0.823, both p > 0.10). Conclusion The CEUS+ scoring system model is helpful in predicting the risk of worsening renal function in elderly RAS patients.
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Affiliation(s)
- Yan Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Ma
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yuewei Zhang
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Siyu Wang
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Youjing Sun
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengpu Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Ai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hui Zhu
- Department of Nuclear Medicine, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, National Center for Cardiovascular Diseases and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Peng Li
- Beijing Institute of Geriatrics, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Fajin Guo
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Junhong Ren
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Junhong Ren,
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Nabil AA, Lesya K, Margarita K, Eliezer J. H, Uri R, Dganit D, Pazit B. Treatment of severe renal artery stenosis with acute kidney injury requiring hemodialysis by percutaneous transluminal renal angioplasty and stent implantation. J Vasc Interv Radiol 2022; 33:707-714.e2. [DOI: 10.1016/j.jvir.2022.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 01/29/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022] Open
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Li Y, Sun Y, Wang S, Ma N, Li M, Ren J, Li Y, Ai H, Zhu H, Wang Y, Guo F. Clinical and Renal Cortical Blood Perfusion Characteristics in Patients with Severe Atherosclerotic Renal Artery Stenosis Who Underwent Stent Implantation: A Single-center Retrospective Cohort Study. BIO INTEGRATION 2022. [DOI: 10.15212/bioi-2021-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective This study aimed to observe the clinical imaging features of patients with severe atherosclerotic renal artery stenosis (ARAS) receiving stent implantation, and to evaluate the associations between baseline clinical and imaging factors and renal-function deterioration at a 1-year follow-up.Methods This study was a single-center retrospective cohort study. A total of 159 patients with unilateral severe ARAS who underwent stent implantation at Beijing Hospital between July 2017 and December 2020 were consecutively enrolled. According to the renal glomerular filtration rate (GFR), detected by radionuclide renal imaging at 1-year follow-up, all patients were divided into a poor-prognosis group (with a ≥30% decrease in renal GFR; n=32 cases) and a control group (127 cases). Clinical imaging data, including the renal cortical blood perfusion pre- and post-sent implantation, were analyzed. Univariate and multivariate logistic regression analysis was used to evaluate the associations between clinical and imaging factors and renal-function deterioration.Results Of the 159 patients enrolled, 83 (52.2%) were men, with an average age of (57.2±14.7) years. The patient age, rate of diabetes, and systolic blood and diastolic blood pressure in the poor-prognosis group were significantly higher than those in the control group (all P<0.05). Before stent treatment, patients in the poor-prognosis group, compared with the control group, had a significantly smaller area under the ascending curve (AUC1), area under the descending curve (AUC2), and peak intensity (PI), and a longer time to peak intensity (TTP) and mean transit time (MTT) (all P<0.05). After stent treatment, patients in the poor-prognosis group, compared with the control group, showed significantly smaller AUC1, AUC2, and PI, and longer MTT (all P<0.05). Multivariate logistic regression analysis indicated that age (OR=1.251, 95%CI: 1.113–1.406, P=0.0002), diabetes (OR=1.472, 95%CI: 1.110–1.952, P=0.007), systolic blood pressure (OR=1.339, 95%CI: 1.082–1.657, P=0.007), renal GFR (OR=2.025, 95%CI: 1.217–3.369, P=0.006), and AUC1 post-stent (OR=2.173, 95%CI: 1.148–4.113, P=0.017) were the factors associated with renal deterioration at the 1-year follow-up.Conclusions Patients with severe RAS with renal-function deterioration after stent implantation were older, and often had diabetes, hypertension, and impaired renal cortical perfusion. Age, diabetes, systolic blood pressure, renal GFR, and AUC1 after stent implantation were independent factors associated with short-term renal deterioration.
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Affiliation(s)
- Yan Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Youjing Sun
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Siyu Wang
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Na Ma
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Mengpu Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Junhong Ren
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yongjun Li
- Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hu Ai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Hui Zhu
- Department of Nuclear Medicine, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Yang Wang
- Department of Medical Research & Biometrics Center, National Center for Cardiovascular Diseases and Fuwai Hospital, CAMS and PUMC, Beijing 100037, China
| | - Fajin Guo
- Department of Sonography, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China
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Al-Musawi M, Yuser A, AlOmaishi S, Kareem O, Rubay D. The Use of Systematic Clinical Approach in Diagnosing Rare Cases of Secondary Hypertension: A Case Report of Mid Aortic Syndrome in a Young Patient. Cureus 2021; 13:e19215. [PMID: 34745787 PMCID: PMC8562992 DOI: 10.7759/cureus.19215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2021] [Indexed: 11/05/2022] Open
Abstract
Mid aortic syndrome (MAS) is a rare disease that occurs in children and young adults. The most important clinical feature reflecting vascular involvement is the presence of systemic hypertension. The diagnosis is usually made during the imaging assessment of secondary hypertension when routine echocardiography fails to identify the characteristic morphological or Doppler flow patterns associated with thoracic arch coarctation in the presence of the clinical features of aortic vascular obstruction. In this report, we present a case of a 22-year-old male who presented with systemic hypertension not responding to medical treatment, and whose systematic diagnostic workup revealed the diagnosis of MAS involving both renal arteries.
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Affiliation(s)
| | - Akeel Yuser
- Cardiovascular Surgery, Ibn AlNafees Center for Thoracic and Cardiovascular Surgery, Baghdad, IRQ
| | - Suhad AlOmaishi
- Internal Medicine, Life Alliance Organ Recovery Agency, University of Miami, Miami, USA
| | - Oula Kareem
- Department of Surgery, University of Colorado, Aurora, USA
| | - David Rubay
- Trauma and Surgical Critical Care, University of Florida College of Medicine, Gainesville, USA
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12
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Aksenova AV, Sivakova OA, Blinova NV, Danilov NM, Elfimova EM, Kisliak OA, Litvin AY, Oshchepkova EV, Fomin VV, Chikhladze NM, Shelkova GV, Chazova IE. Russian Medical Society for Arterial Hypertension expert consensus. Resistant hypertension: detection and management. TERAPEVT ARKH 2021; 93:1018-1029. [DOI: 10.26442/00403660.2021.09.201007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 10/08/2021] [Indexed: 01/04/2023]
Abstract
The diagnosis of resistant arterial hypertension allows us to single out a separate group of patients in whom it is necessary to use special diagnostic methods and approaches to treatment. Elimination of reversible factors leading to the development of resistant arterial hypertension, such as non-adherence to therapy, inappropriate therapy, secondary forms of arterial hypertension, leads to an improvement in the patient's prognosis. Most patients with resistant hypertension should be evaluated to rule out primary aldosteronism, renal artery stenosis, chronic kidney disease, and obstructive sleep apnea. The algorithm for examining patients, recommendations for lifestyle changes and a step-by-step therapy plan can improve blood pressure control. It is optative to use the most simplified treatment regimen and long-acting combined drugs. For a separate category of patients, it is advisable to perform radiofrequency denervation of the renal arteries.
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13
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Dregoesc MI, Bolboacă SD, Dorolțan PM, Istrate M, Marc MC, Iancu AC. Long-Term Mortality After Renal Artery Stenting in Patients With Severe Atherosclerotic Renal Artery Stenosis and High-Risk Clinical Manifestations. Am J Hypertens 2021; 34:880-887. [PMID: 33530094 DOI: 10.1093/ajh/hpab027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 10/19/2020] [Accepted: 01/27/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Atherosclerotic renal artery stenosis is a risk factor for cardiovascular death. Observational studies support the benefit of renal revascularization on outcomes in patients with high-risk clinical manifestations. In this context, we evaluated the factors associated with long-term mortality after renal artery stenting in patients with severe renal artery stenosis, impaired kidney function, and/or uncontrolled hypertension. METHODS The medical records of patients undergoing renal artery stenting between 2004 and 2014 were extracted. Blood pressure and creatinine were recorded at baseline, 24 hours poststenting and in the 1-month to 1-year interval that followed revascularization. Long-term follow-up was performed in March 2020. RESULTS The cohort consisted of 65 patients. Median follow-up was 120 months. In the first year after stenting, less patients had chronic kidney disease (CKD) class 3b-5 as compared with baseline (35.3% vs. 56.9%, P = 0.01). The number of patients with controlled blood pressure after revascularization increased with 69.2% (P < 0.001). Long-term all-cause mortality reached 44.6%. Age (odds ratio (OR) 1.1; 95% confidence interval (CI) 1.0-1.2; P = 0.01), male gender (OR 7.9; 95% CI 1.9-43.5; P = 0.008), poststenting CKD class 3b-5 (OR 5.8; 95% CI 1.5-27.9; P = 0.01), and postrevascularization uncontrolled hypertension (OR 8.9; 95% CI 1.7-63.5; P = 0.01) were associated with long-term mortality independent of diabetes mellitus and coronary artery disease. CONCLUSIONS Improved CKD class and blood pressure were recorded in the first year after renal artery stenting in patients with severe renal artery stenosis and high-risk clinical manifestations. The lack of improvement in kidney function and blood pressure was independently associated with long-term mortality.
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Affiliation(s)
- Mihaela Ioana Dregoesc
- “Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Cardiology, Cluj-Napoca, Romania
| | - Sorana Daniela Bolboacă
- “Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Medical Informatics and Biostatistics, Cluj-Napoca, Romania
| | - Patricia Mirela Dorolțan
- “Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Cardiology, Cluj-Napoca, Romania
| | - Mihnea Istrate
- “Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Cardiology, Cluj-Napoca, Romania
| | | | - Adrian Corneliu Iancu
- “Iuliu Hațieganu” University of Medicine and Pharmacy, Department of Cardiology, Cluj-Napoca, Romania
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14
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Inocian EP, Batoctoy BZ, Chio FL, Polito ES, Porsuelo-Torres HB. Renal endovascular stenting of a non-atherosclerotic renal artery stenosis secondary to Takayasu arteritis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40S:174-178. [PMID: 34176765 DOI: 10.1016/j.carrev.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 06/16/2021] [Accepted: 06/16/2021] [Indexed: 11/03/2022]
Abstract
Non-atherosclerotic renal artery stenosis (RAS) secondary to Takayasu arteritis (TA) is rarely cited in the literature. Although stenting has been well-described in atherosclerotic RAS, it's role in non-atherosclerotic, Takayasu arteritis-induced renal artery stenosis (TARAS) has not been fully established. We report a 38-year old, Filipino, woman who presented with an incidental finding of small left kidney and hypertension. On CT aortogram, complete total occlusion of the left kidney, and significant stenosis of the right renal artery, and several aortic branches were demonstrated, consistent with Takayasu arteritis. After initiating immunosuppressive agents and undergoing renal endovascular stenting, the patient's blood pressure dramatically improved. Restenosis of the right renal artery was not observed after 6 months. Kidney function was also preserved 2 years after the procedure.
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Affiliation(s)
- Elrey P Inocian
- Perpetual Succour Hospital, Gorordo Avenue, Cebu City 6000, Philippines.
| | - Brett Z Batoctoy
- Perpetual Succour Hospital, Gorordo Avenue, Cebu City 6000, Philippines; University of Cebu Medical Center, Ouano Ave., Subangdaku, Mandaue City, Cebu 6014, Philippines
| | - Francisco L Chio
- Perpetual Succour Hospital, Gorordo Avenue, Cebu City 6000, Philippines; University of Cebu Medical Center, Ouano Ave., Subangdaku, Mandaue City, Cebu 6014, Philippines; Chong Hua Hospital, Don Mariano Cui Street, Fuente Osmeña, Cebu City 6000, Philippines
| | | | - Hariett B Porsuelo-Torres
- Perpetual Succour Hospital, Gorordo Avenue, Cebu City 6000, Philippines; University of Cebu Medical Center, Ouano Ave., Subangdaku, Mandaue City, Cebu 6014, Philippines
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15
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Abstract
Renal artery stenosis is the most common secondary cause of hypertension and predominantly caused by atherosclerosis. In suspected patients, a non-invasive diagnosis with ultrasound is preferred. Asymptomatic, incidentally found RAS does not require revascularization. In symptomatic patients requiring revascularization, renal artery stenting is the preferred therapy. Selecting appropriate patients for revascularization requires careful consideration of lesion severity and is optimized with a multidisciplinary team. All patients with atherosclerotic RAS should be treated with guideline-directed medical therapy, including hypertension control, diabetes control, statins, antiplatelet therapy, smoking cessation and encouraging activity.
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16
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Xiong Z, Yuan D, Wang J, Zheng T, Fan Y. Influence of renal artery stenosis morphology on hemodynamics. Comput Methods Biomech Biomed Engin 2021; 24:1294-1301. [PMID: 33565336 DOI: 10.1080/10255842.2021.1883592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Currently, the clinical classification of the severity of renal artery stenosis (RAS) solely depends on the degree of stenosis. In addition, when the stenosis degree is between 50% and 70%, the clinical strategy is decided based on whether the RAS is hemodynamically significant. In this study, the influence of RAS morphological parameters on hemodynamics was numerically analyzed to provide a theoretical basis for clinical treatment. METHODS Idealized RAS models were established to investigate the hemodynamic effects of the stenosis length, asymmetric stenosis, and direction of the opening of the renal artery. RESULTS The longer the stenosis length, the greater is the ratio of the low time-averaged wall shear stress (WSS) and high oscillatory shear index (OSI) area distal stenosis (when the stenosis area is the same). In addition, asymmetric stenosis leads to a significant increase in the ratio of the renal artery peak systolic velocity (R-PSV) and the abdominal aorta peak systolic velocity (A-PSV) when the stenosis area is 60-70%. Furthermore, the fraction flow reserve (FFR) of the RAS model with 12 mm stenosis length, upward eccentricity and upward direction of renal artery opening was approximately equal to the cumulative value of the influence of different stenosis morphologies on FFR. CONCLUSION An assessment of the severity of RAS should consider the stenosis area and other morphological parameters, including the length and asymmetry of RAS as well as the direction of the opening of renal artery, particularly when the stenosis degree of RAS is between 50% and 70%.
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Affiliation(s)
- Zhuxiang Xiong
- Department of Applied Mechanics, Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tinghui Zheng
- Department of Applied Mechanics, Sichuan University, Chengdu, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Beihang University, Beijing
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17
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Sasaki Y, Mishima E, Kikuchi K, Toyohara T, Suzuki T, Ota H, Seiji K, Miyazaki M, Harigae H, Ito S, Takase K, Abe T. Treatment of Refractory Hypertension with Timely Angioplasty in Total Renal Artery Occlusion with Atrophic Kidney. Intern Med 2021; 60:287-292. [PMID: 32830180 PMCID: PMC7872794 DOI: 10.2169/internalmedicine.5290-20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Angioplasty for cases of chronic total occlusion of renal artery with/without atrophic kidney is generally not recommended. We herein report a 57-year-old man who presented with renin-mediated refractory hypertension caused by occlusion of a unilateral renal artery leading to kidney atrophy (length: 69 mm). Angioplasty favorably achieved blood pressure control with normalized renin secretion and enlargement of the atrophic kidney to 85 mm. Timely angioplasty can be beneficial in select patients, even with an atrophic kidney and total occlusion, especially in cases with deterioration of hypertension within six months and the presence of collateral perfusion to the affected kidney.
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Affiliation(s)
| | - Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Koichi Kikuchi
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Takafumi Toyohara
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hideki Ota
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Japan
| | - Kazumasa Seiji
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Japan
| | - Mariko Miyazaki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
| | - Hideo Harigae
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Department of Hematology and Rheumatology, Tohoku University Graduate School of Medicine, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Department of Medicine, Katta Public General Hospital, Japan
| | - Kei Takase
- Department of Diagnostic Radiology, Tohoku University Graduate School of Medicine, Japan
| | - Takaaki Abe
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Japan
- Division of Medical Science, Tohoku University Graduate School of Biomedical Engineering, Japan
- Department of Clinical Biology and Hormonal Regulation, Tohoku University Graduate School of Medicine, Japan
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18
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Wang X, Wang S, Pang YP, Jiang T, Yu C, Li Y, Shi B. Contrast-Enhanced Ultrasound Assessment of Renal Parenchymal Perfusion in Patients with Atherosclerotic Renal Artery Stenosis to Predict Renal Function Improvement After Revascularization. Int J Gen Med 2020; 13:1713-1721. [PMID: 33408509 PMCID: PMC7781108 DOI: 10.2147/ijgm.s293316] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 12/15/2020] [Indexed: 12/29/2022] Open
Abstract
Background Identifying patients with atherosclerotic renal artery stenosis (ARAS) who will be improved in renal function after percutaneous transluminal renal artery stenting (PTRAS) is crucial since most patients show no worthwhile benefit of PTRAS. Although the assessment of renal parenchymal perfusion is useful for the identification, few studies predict the renal functional improvement by evaluating the characteristics of renal perfusion. Objective The aim of this study was to assess the renal parenchymal perfusion in ARAS patients with contrast-enhanced ultrasonography (CEUS) and predict the benefits of renal function after PTRAS utilizing time-intensity curve (TIC) parameters. Methods Thirty-eight kidneys in 30 ARAS patients received PTRAS in this study. They were divided into moderate stenosis group (n=25) and severe stenosis group (n=13) and mild dysfunction group (n=14) and moderate dysfunction group (n=24) according to the degree of renal stenosis and radioisotope glomerular filtration rate (rGFR). The baseline assessment of renal function and renal parenchymal perfusion were performed for all patients. rGFR was repeated to evaluate the renal outcome at 4 months after PTRAS. The outcome of PTRAS was classified as improved, stable, or deteriorated compared to the baseline. Time-intensity curve (TIC) parameters obtained from CEUS were analyzed to evaluate the predictive accuracy. Results TIC parameters (AUC and PI) were positively correlated with renal function (r=0.617, 0.663; P<0.05) but weakly and negatively correlated with the stenosis (r=−0.360, −0.435; P<0.05). Baseline rGFR was not accurate in predicting improved renal function after PTRAS (0.670). The accuracy of the combined prediction model of baseline AUC and PI (0.889) was higher than the individual indicators (baseline AUC: 0.855 and PI: 0.782). Conclusion CEUS could accurately assess renal parenchymal perfusion and identify ARAS patients with potential benefit after PTRAS. The combination of TIC parameters (AUC and PI) is valuable in the prediction of improved renal function after PTRAS.
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Affiliation(s)
- Xiuyan Wang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Shuo Wang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Yan-Ping Pang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Tian Jiang
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Chen Yu
- Department of Nephrology, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Yuan Li
- Department of Ultrasonography, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
| | - Baomin Shi
- Department of General Surgery, Tongji Hospital of Tongji University, Shanghai, People's Republic of China
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Pastroma A, Spiliopoulos S, Palialexis K, Reppas L, Brountzos E. Revascularization of a single-kidney occluded stent for renal salvage complicated by guide wire distal artery perforation and reperfusion injury. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2020. [DOI: 10.1186/s43055-020-00284-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
The complexity of the case, including the rarefied simultaneous occurrence of complications—iatrogenic, as well as reperfusion injury, invite reporting and publication.
Case presentation
A 39-year-old woman with a single-functioning left kidney, previous left renal artery stenting (RAS), and known hypercoagulopathy was hospitalized for flash pulmonary edema, elevated serum creatinine (9.7 mg/dl), and refractory hypertension. She was subsequently referred to our center [2] for endovascular treatment of acute renal ischemia (AKI) due to RAS occlusion.
Periprocedural complications of guide-wire arterial perforation and reperfusion injury resulted in life-threatening hemorrhage.
Conclusions
Following more than 48 h of hypoperfusion of the left kidney, revascularization of the thrombosed RAS was successfully attempted with selective, trans-catheter thrombolysis, and balloon angioplasty. Ultra-selective, nephron-sparing coil embolization was successfully performed. The patient’s creatinine level decreased to 2.8 mg/dl at 12 days and to 1.5 mg/dl at 3 months. After 1 year of follow-up, the stent remains patent, and the patient is asymptomatic with stable renal function.
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20
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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: 982] [Impact Index Per Article: 245.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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21
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Kidney enlargement effect of angioplasty for nonatherosclerotic renovascular disease: reversibility of ischemic kidney. Hypertens Res 2020; 43:1214-1221. [PMID: 32444857 DOI: 10.1038/s41440-020-0473-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/08/2020] [Accepted: 04/24/2020] [Indexed: 11/08/2022]
Abstract
Renal artery stenosis causes kidney ischemia, reducing the size of the affected kidney, which eventually results in atrophy. Although renal atrophy is considered irreversible, resolution of the ischemia occasionally restores kidney size when the cause is renal artery stenosis. Angioplasty is effective in patients with nonatherosclerotic renovascular diseases (non-ARVDs). Nevertheless, renal enlargement after angioplasty has not been fully examined. We conducted a retrospective study to examine this phenomenon in non-ARVD patients. Ten patients with a <100-mm pole-to-pole length of the poststenotic kidney were treated with angioplasty. Data were collected up to 12 months after angioplasty. The mean age was 28 years; the estimated glomerular filtration rate was 92 ± 7 mL/min/1.73 m2 (mean ± SEM); blood pressure was 150/99 mmHg; 80% were women; and fibromuscular dysplasia was present in 90% of the patients. All patients had hypertension. The lengths of the poststenotic and contralateral kidney before angioplasty were 91 ± 1 and 111 ± 3 mm, respectively. After angioplasty, the length of the poststenotic kidney gradually increased during the 3 months after treatment (+5.4 mm) and that of the contralateral kidney decreased over the same time course (-3.7 mm). Enlargement was also found in the moderate atrophy subgroup (length < 92 mm), and it was greater in the <30 years old group. In a noteworthy case, renal size in the poststenotic kidney recovered from 87 to 102 mm after angioplasty. Our findings demonstrated that reduced renal size can be reversed after optimal angioplasty in non-ARVD patients, especially young patients, suggesting reversibility of the ischemic kidney.
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22
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Mishima E, Suzuki T, Ito S. Selection of Patients for Angioplasty for Treatment of Atherosclerotic Renovascular Disease: Predicting Responsive Patients. Am J Hypertens 2020; 33:391-401. [PMID: 31996895 DOI: 10.1093/ajh/hpaa016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 01/22/2023] Open
Abstract
Atherosclerotic renal artery stenosis (ARAS) can cause secondary hypertension, progressive decline in renal function, and cardiac complications. Recent randomized controlled trials including the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study have not reported the benefit of renal artery stenting compared with medical therapy alone to improve renal function or reduce cardiovascular and renal events in the enrolled patients with ARAS. However, observational evidence indicating the benefits of angioplasty in the selected high-risk patients with ARAS has been increasing. Thus, the timely correction of stenosis through angioplasty may have a beneficial effect in selected patients. However, optimal patient selection for angioplasty has been debated and can be challenging at times. Clinicians must identify the responsive patients who would benefit from angioplasty through risk stratification and the prediction of outcomes. Efforts have been made for the determination of predictors that can identify the subgroups of patients who would benefit from angioplasty. Lower age, more severe stenosis, preserved renal perfusion, and absence of diabetes or generalized atherosclerosis have been reported as the predictors for the improvement of hypertension after angioplasty. Global renal ischemia, rapidly declining renal function over 6-12 months, progressive shrinkage of the affected kidney, lower resistive index, and lower levels of albuminuria have been reported as predictors of improved or preserved renal function after angioplasty. This review discusses the identification of ARAS patients who will potentially respond well to angioplasty.
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Affiliation(s)
- Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sadayoshi Ito
- Department of Medicine, Katta General Hospital, Shiroishi, Japan
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23
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The Demystification of Secondary Hypertension: Diagnostic Strategies and Treatment Algorithms. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2019; 21:90. [DOI: 10.1007/s11936-019-0790-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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24
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Abstract
PURPOSE OF REVIEW To discuss the current definition as well as recommendations for diagnosis and treatment of resistant hypertension (RH) based on the 2018 American Heart Association (AHA) guidelines and recent literature. RECENT FINDINGS RH is defined as uncontrolled blood pressure (BP) on ≥ 3 anti-hypertensives, one of which should be a diuretic, prescribed at maximally tolerated doses and appropriate dosing frequency. The diagnosis of RH requires exclusion of white coat effect and medication non-adherence, underscoring the importance of out-of-office BP measurements. Secondary causes of hypertension must be excluded in all patients with RH. A step-wise approach to treatment focusing on lifestyle modifications and medication optimization can be effective in > 50% of the patients with RH. Device-based interventional therapies for RH are currently investigational. Out-of-office BP measurements are central to the diagnosis of RH. Medication optimization is successful in most patients. Further studies are needed to define the role of device-based interventions.
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Affiliation(s)
- Irene Chernova
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA
| | - Namrata Krishnan
- Yale School of Medicine/Section of Nephrology, New Haven, CT, USA. .,Veterans Affairs Medical Center, 950 Campbell Ave., West Haven, CT, 06516, USA.
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Sens F, Normand G, Fournier T, Della-Schiava N, Luong S, Pelletier C, Robinson P, Lemoine S, Rouvière O, Juillard L. Blood pressure decreases after revascularization in atherosclerotic renal artery disease: A cohort study based on a multidisciplinary meeting. PLoS One 2019; 14:e0218788. [PMID: 31233539 PMCID: PMC6590822 DOI: 10.1371/journal.pone.0218788] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 06/10/2019] [Indexed: 01/22/2023] Open
Abstract
Background In atherosclerotic renal artery disease, the benefit of revascularization is controversial. A clinical decision-making process based on a multidisciplinary meeting was formalized in the Lyon university hospital. Objectives To investigate whether this decisional process ensured a clinical benefit to patients assigned to renal revascularization. Methods Single-centre retrospective cohort study, including patients diagnosed from April 2013 to February 2015 with an atherosclerotic renal artery disease with a peak systolic velocity >180cm/s. For each patient, the decision taken in multidisciplinary meeting (medical treatment or revacularization) was compared to the one guided by international guidelines. Blood pressure values, number of antihypertensive medications, presence of an uncontrolled or resistant hypertension, and glomerular filtration rate at one-year follow-up were compared to baseline values. Safety data were collected. Results Forty-nine patients were included: 26 (53%) were assigned to a medical treatment and 23 (47%) to a renal revascularization. Therapeutic decision was in accordance with the 2013 American Health Association guidelines and with the 2017 European Society of Cardiology guidelines for 78% and 22% of patients who underwent revascularization, respectively. Patients assigned to revascularization presented a significant decrease in systolic blood pressure (-23±34mmHg, p = 0.007), diastolic blood pressure (-12±18mmHg, p = 0.007), number of antihypertensive medications (-1.00±1.03, p = 0.001), and number of uncontrolled or resistant hypertension (p = 0.022 and 0.031) at one-year follow-up. Those parameters were not modified among patients assigned to medical treatment alone. There was no grade 3 adverse event. Conclusion Based on a multidisciplinary selection of revascularization indications, patients on whom a renal revascularization was performed exhibited a significant improvement of blood pressure control parameters with no severe adverse events.
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Affiliation(s)
- Florence Sens
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
- FCRIN INI-CRCT, Nancy, France
- * E-mail:
| | - Gabrielle Normand
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
| | - Thomas Fournier
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Nellie Della-Schiava
- Department of Vascular Surgery, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Stéphane Luong
- Department of Urinary and Vascular Imaging, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Caroline Pelletier
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
| | - Philip Robinson
- Direction de la Recherche Clinique et de l’Innovation, Hospices Civils de Lyon, Lyon, France
| | - Sandrine Lemoine
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
- FCRIN INI-CRCT, Nancy, France
| | - Olivier Rouvière
- Lyon 1 Claude Bernard University, Villeurbanne, France
- Department of Urinary and Vascular Imaging, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Laurent Juillard
- Department of Nephrology, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
- Lyon 1 Claude Bernard University, Villeurbanne, France
- FCRIN INI-CRCT, Nancy, France
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26
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Green D, Vassallo D, Handley K, Ives N, Wheatley K, Chrysochou C, Hegarty J, Wright J, Moss J, Patel RK, Deighan C, Webster J, Rowe P, Carr S, Cross J, O'Driscoll J, Sharma R, Mark P, Kalra PA. Cardiac structure and function after revascularization versus medical therapy for renal artery stenosis: the ASTRAL heart echocardiographic sub-study. BMC Nephrol 2019; 20:220. [PMID: 31200662 PMCID: PMC6570952 DOI: 10.1186/s12882-019-1406-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/30/2019] [Indexed: 01/20/2023] Open
Abstract
Background The ASTRAL trial showed no difference in clinical outcomes between medical therapy and revascularization for atherosclerotic renal vascular disease (ARVD). Here we report a sub-study using echocardiography to assess differences in cardiac structure and function at 12 months. Methods ASTRAL patients from 7 participating centres underwent echocardiography at baseline and 12 months after randomisation. Changes in left ventricular ejection fraction (LVEF), left ventricular mass (LVM), left atrial diameter (LAD), aortic root diameter (AoRD), E:A, and E deceleration time (EDT) were compared between study arms. Analyses were performed using t-tests and multivariate linear regression. Results Ninety two patients were included (50 medical versus 42 revascularization). There was no difference between arms in any baseline echocardiographic parameter. Comparisons of longitudinal changes in echocardiographic measurements were: δLVEF medical 0.8 ± 8.7% versus revascularization − 2.8 ± 6.8% (p = 0.05), δLVM − 2.9 ± 33 versus − 1.7 ± 39 g (p = 0.9), δLAD 0.1 ± 0.4 versus 0.01 ± 0.5 cm (p = 0.3), δAoRD 0.002 ± 0.3 versus 0.06 ± 0.3 cm (p = 0.4), δE:A − 0.0005 ± 0.6 versus 0.03 ± 0.7 (p = 0.8), δEDT − 1.1 ± 55.5 versus − 9.0 ± 70.2 ms (p = 0.6). In multivariate models, there were no differences between treatment groups for any parameter at 12 months. Likewise, change in blood pressure did not differ between arms (mean δsystolic blood pressure medical 0 mmHg [range − 56 to + 54], revascularization − 3 mmHg [− 61 to + 59], p = 0.60). Conclusions This sub-study did not show any significant differences in cardiac structure and function accompanying renal revascularization in ASTRAL. Limitations include the small sample size, the relative insensitivity of echocardiography, and the fact that a large proportion of ASTRAL patient population had only modest renal artery stenosis as described in the main study.
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Affiliation(s)
- Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK.
| | - Diana Vassallo
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | | | | | | | - Constantina Chrysochou
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Janet Hegarty
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | | | | | | | | | | | | | - Sue Carr
- University Hospitals of Leicester, Leicester, UK
| | | | | | | | - Patrick Mark
- Institute of Cardiovascular and Medical Science, University of Glasgow, Glasgow, UK
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
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Carey RM, Calhoun DA, Bakris GL, Brook RD, Daugherty SL, Dennison-Himmelfarb CR, Egan BM, Flack JM, Gidding SS, Judd E, Lackland DT, Laffer CL, Newton-Cheh C, Smith SM, Taler SJ, Textor SC, Turan TN, White WB. Resistant Hypertension: Detection, Evaluation, and Management: A Scientific Statement From the American Heart Association. Hypertension 2019; 72:e53-e90. [PMID: 30354828 DOI: 10.1161/hyp.0000000000000084] [Citation(s) in RCA: 550] [Impact Index Per Article: 110.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Resistant hypertension (RH) is defined as above-goal elevated blood pressure (BP) in a patient despite the concurrent use of 3 antihypertensive drug classes, commonly including a long-acting calcium channel blocker, a blocker of the renin-angiotensin system (angiotensin-converting enzyme inhibitor or angiotensin receptor blocker), and a diuretic. The antihypertensive drugs should be administered at maximum or maximally tolerated daily doses. RH also includes patients whose BP achieves target values on ≥4 antihypertensive medications. The diagnosis of RH requires assurance of antihypertensive medication adherence and exclusion of the "white-coat effect" (office BP above goal but out-of-office BP at or below target). The importance of RH is underscored by the associated risk of adverse outcomes compared with non-RH. This article is an updated American Heart Association scientific statement on the detection, evaluation, and management of RH. Once antihypertensive medication adherence is confirmed and out-of-office BP recordings exclude a white-coat effect, evaluation includes identification of contributing lifestyle issues, detection of drugs interfering with antihypertensive medication effectiveness, screening for secondary hypertension, and assessment of target organ damage. Management of RH includes maximization of lifestyle interventions, use of long-acting thiazide-like diuretics (chlorthalidone or indapamide), addition of a mineralocorticoid receptor antagonist (spironolactone or eplerenone), and, if BP remains elevated, stepwise addition of antihypertensive drugs with complementary mechanisms of action to lower BP. If BP remains uncontrolled, referral to a hypertension specialist is advised.
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28
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Kawarada O, Kume T, Zen K, Nakamura S, Hozawa K, Akimitsu T, Asano H, Ando H, Yamamoto Y, Yamashita T, Shinozaki N, Odashiro K, Sato T, Yuba K, Sakanoue Y, Uzu T, Okada K, Fitzgerald PJ, Honda Y, Yasuda S. Cardiac function response to stenting in atherosclerotic renal artery disease with and without heart failure: results from the Carmel study. ESC Heart Fail 2019; 6:319-327. [PMID: 30614643 PMCID: PMC6437431 DOI: 10.1002/ehf2.12391] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 09/30/2018] [Accepted: 11/05/2018] [Indexed: 01/20/2023] Open
Abstract
Aims Consensus‐derived guidelines recommend renal stenting for patients with atherosclerotic renal artery disease (ARAD) and heart failure (HF). The aim of this prospective multi‐centre observational study was to verify our hypothesis that changes in E/e′, an echocardiographic correlate of left ventricular (LV) filling pressure, following renal stenting may differ between ARAD patients with and without HF. Methods and results This study enrolled de novo ARAD patients undergoing renal stenting at 14 institutions. The primary endpoint was the difference in E/e′ change between ARAD patients with and without HF. Clinical and echocardiographic data were prospectively collected at baseline, the day following renal stenting, and 1 month and 6 months afterwards. ARAD patients with HF were defined as patients with New York Heart Association (NYHA) Class 2 and more, or a history of HF hospitalization. A total of 76 patients were included, and 39% were ARAD patients with HF. ARAD patients with HF had significantly lower estimated glomerular filtration rate (P = 0.028) and higher NYHA functional class (P < 0.001) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (P = 0.001) than ARAD patients without HF. Also, ARAD patients with HF had significantly lower LV ejection fraction (P = 0.003) and e′‐velocity (P = 0.003) and higher E/e′ ratio (P = 0.001), left atrial volume index (LAVI) (P = 0.046), LV end‐diastolic volume (LVEDV) (P = 0.001), LV end‐systolic volume (LVESV) (P = 0.001), and LV mass index (P = 0.009) than ARAD patients without HF. All procedures were successful. In contrast to blood pressure and renal function, there was a significant interaction in E/e′ (Pinteraction < 0.001) between time and HF, and ARAD patients with HF showed a significant (P < 0.001) decrease in E/e′ albeit those without HF. By the same token, there was a significant interaction in NYHA class (Pinteraction < 0.001), MLHFQ score (Pinteraction = 0.018), E‐velocity (Pinteraction = 0.002), LAVI (Pinteraction = 0.001), LVEDV (Pinteraction = 0.003), and LVESV (Pinteraction = 0.001) between time and HF with a significant improvement in all these variables in ARAD patients with HF (NYHA class, P = 0.001; MLHFQ score, P = 0.002; E‐velocity, P = 0.005; LAVI, P = 0.001; LVEDV, P = 0.017; and LVESV, P = 0.011). Conclusions Change in LV filling pressure after renal stenting differed between ARAD patients with and without HF, with a significant improvement in LV filling pressure in patients with HF‐ARAD. These unique findings might support clinical cardiac benefits of renal stenting in ARAD patients with HF.
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Affiliation(s)
- Osami Kawarada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan.,Department of Cardiovascular Medicine, Ikuwakai Memorial Hospital, Osaka, Japan
| | - Teruyoshi Kume
- Department of Cardiology, Kawasaki Medical School Hospital, Okayama, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | | | - Koji Hozawa
- Department of Cardiology, New Tokyo Hospital, Chiba, Japan
| | | | - Hiroshi Asano
- Department of Cardiology, Tosei General Hospital, Aichi, Japan
| | - Hiroshi Ando
- Department of Cardiology, Kasukabe Chuo General Hospital, Saitama, Japan
| | - Yoshito Yamamoto
- Department of Cardiology, Iwaki Kyoritsu Hospital, Fukushima, Japan
| | - Takehiro Yamashita
- Department of Cardiology, Hokkaido Ohno Memorial Hospital, Hokkaido, Japan
| | | | - Keita Odashiro
- Department of Cardiovascular Medicine, Kyushu University Hospital, Fukuoka, Japan
| | - Tadaya Sato
- Department of Cardiology, Saka General Hospital, Miyagi, Japan
| | - Kenichiro Yuba
- Department of Cardiology, Tokushima Red Cross Hospital, Tokushima, Japan
| | - Yuji Sakanoue
- Department of Cardiology, Higashisumiyoshi Morimoto Hospital, Osaka, Japan
| | - Takashi Uzu
- Division of Nephrology, Nippon Life Hospital, Osaka, Japan
| | - Kozo Okada
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Peter J Fitzgerald
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Yasuhiro Honda
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1 Fujishiro-dai, Suita, Osaka, 565-8565, Japan
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The cardiovascular phenotype of childhood hypertension: a cardiac magnetic resonance study. Pediatr Radiol 2019; 49:727-736. [PMID: 31053874 PMCID: PMC6614159 DOI: 10.1007/s00247-019-04393-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 01/07/2019] [Accepted: 02/21/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The cardiovascular phenotype is poorly characterized in treated pediatric hypertension. Cardiovascular magnetic resonance imaging (MRI) can be used to better characterize both cardiac and vascular phenotype in children with hypertension. OBJECTIVE To use MRI to determine the cardiac and vascular phenotypes of different forms of treated hypertension and compare the results with those of healthy children. MATERIALS AND METHODS Sixty children (15 with chronic renal disease with hypertension, 15 with renovascular hypertension, 15 with essential hypertension and 15 healthy subjects) underwent MRI with noninvasive blood pressure measurements. Cardiovascular parameters measured include systemic vascular resistance, total arterial compliance, left ventricular mass and volumetric data, ejection fraction and myocardial velocity. Between-group comparisons were used to investigate differences in the hypertension types. RESULTS Renal hypertension was associated with elevated vascular resistance (P≤0.007) and normal arterial compliance. Conversely, children with essential hypertension had normal resistance but increased compliance (P=0.001). Renovascular hypertension was associated with both increased resistance and compliance (P≤0.03). There was no difference in ventricular volumes, mass or cardiac output between groups. Children with renal hypertension also had lower systolic and diastolic myocardial velocities. CONCLUSION Cardiovascular MRI may identify distinct vascular and cardiac phenotypes in different forms of treated childhood hypertension. Future studies are needed to investigate how this may inform further optimisation of blood pressure treatment in different types of hypertension.
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30
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Mandaltsi A, Grytsan A, Odudu A, Kadziela J, Morris PD, Witkowski A, Ellam T, Kalra P, Marzo A. Non-invasive Stenotic Renal Artery Haemodynamics by in silico Medicine. Front Physiol 2018; 9:1106. [PMID: 30174610 PMCID: PMC6107783 DOI: 10.3389/fphys.2018.01106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 07/23/2018] [Indexed: 11/20/2022] Open
Abstract
Background: Measuring the extent to which renal artery stenosis (RAS) alters renal haemodynamics may permit precision medicine by physiologically guided revascularization. This currently requires invasive intra-arterial pressure measurement with associated risks and is rarely performed. The present proof-of-concept study investigates an in silico approach that uses computational fluid dynamic (CFD) modeling to non-invasively estimate renal artery haemodynamics from routine anatomical computed tomography (CT) imaging of RAS. Methods: We evaluated 10 patients with RAS by CT angiography. Intra-arterial renal haemodynamics were invasively measured by a transducing catheter under resting and hyperaemic conditions, calculating the translesional ratio of distal to proximal pressure (Pd/Pa). The diagnostic and quantitative accuracy of the CFD-derived virtual Pd/Pa ratio (vPd/Pa) was evaluated against the invasively measured Pd/Pa ratio (mPd/Pa). Results: Hyperaemic haemodynamics was infeasible and CT angiography in 4 patients had insufficient image resolution. Resting flow data is thus reported for 7 stenosed arteries from 6 patients (one patient had bilateral RAS). The comparison showed a mean difference of 0.015 (95% confidence intervals of ± 0.08), mean absolute error of 0.064, and a Pearson correlation coefficient of 0.6, with diagnostic accuracy for a physiologically significant Pd/Pa of ≤ 0.9 at 86%. Conclusion: We describe the first in silico estimation of renal artery haemodynamics from CT angiography in patients with RAS, showing it is feasible and diagnostically accurate. This provides a methodological framework for larger prospective studies to ultimately develop non-invasive precision medicine approaches for studies and interventions of RAS and resistant hypertension.
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Affiliation(s)
- Aikaterini Mandaltsi
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom.,Mechanical Engineering Department, University of Sheffield, Sheffield, United Kingdom
| | - Andrii Grytsan
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom.,Mechanical Engineering Department, University of Sheffield, Sheffield, United Kingdom
| | - Aghogho Odudu
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.,Salford Royal Hospital NHS Foundation Trust, Salford, United Kingdom
| | - Jacek Kadziela
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Paul D Morris
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom.,Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
| | - Adam Witkowski
- Department of Interventional Cardiology and Angiology, Institute of Cardiology, Warsaw, Poland
| | - Timothy Ellam
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Philip Kalra
- Division of Cardiovascular Sciences, University of Manchester, Manchester, United Kingdom.,Salford Royal Hospital NHS Foundation Trust, Salford, United Kingdom
| | - Alberto Marzo
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom.,Mechanical Engineering Department, University of Sheffield, Sheffield, United Kingdom
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31
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Petrov I, Tasheva I, Garvanski I, Marzyanov M, Adam G. Recanalization and stenting of total occlusions of the renal arteries for blood pressure control in resistant to treatment hypertension. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018:S1553-8389(18)30275-6. [PMID: 30121219 DOI: 10.1016/j.carrev.2018.06.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 06/27/2018] [Accepted: 06/27/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate whether percutaneous recanalization and stenting of totally occluded renal arteries is feasible and might be justified as effective in reducing the blood pressure (BP) in some patients with preserved collateral renal flow. PATIENTS AND METHODS Seven consecutive patients (3 women, 4 men) at average age of 42.8 years (range, 15-67 years) with resistant hypertension, high renin activity, renal artery occlusion and preserved subsegmental flow were included. RESULTS Endovascular recanalization was successful in 6 of 7 attempted cases. One month after the procedure the 24-h ABPM in the successfully recanalized renal CTO patients showed impressive decrease in the BP average of 138.5/81.7 mm Hg compared to 167.1/95.1 mm Hg before the procedure. Significant decrease in the drug medication was achieved. During the 6-month follow-up, two of the patients had in-stent restenosis- both successfully treated with endovascular reintervention. Secondary patency was 100% for 18 months thereafter and the BP control was excellent without medication increase. CONCLUSIONS The recanalization of total renal artery occlusions resulted feasible and safe in the described group of patients with resistant hypertension and high plasma rennin activity. The renal artery recanalization had a positive effect on lowering the plasma renin activity and BP control.
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Affiliation(s)
- Ivo Petrov
- Acibadem City Clinic University Hospital Sofia, Bulgaria.
| | - Iveta Tasheva
- Acibadem City Clinic University Hospital Sofia, Bulgaria
| | | | | | - Gloria Adam
- Acibadem City Clinic University Hospital Sofia, Bulgaria
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32
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Khan Z, Tolia S, Sanam K, Gholkar G, Zughaib M, Naik S, Zughaib M. Is there still a role for renal artery stenting in the management of renovascular hypertension - A single-center experience and where do we stand? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:202-206. [PMID: 29934065 DOI: 10.1016/j.carrev.2018.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/20/2018] [Accepted: 06/08/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Renal artery (RA) stenosis has been implicated in the pathophysiological mechanism for resistant hypertension. Despite the increasingly diagnosed frequency of hemodynamically significant lesions, the value of RA revascularization remains controversial. Our group had previously demonstrated significant blood pressure (BP) reduction in a retrospective cohort of appropriately selected patients undergoing RA stenting up to 18-months of follow-up. We herein present long-term clinical outcomes data 5-years post revascularization on 26 subjects who continued follow-up at our institution. METHODS Retrospective analysis was performed on subjects who underwent RA stenting at our institution for hemodynamically significant (≥70%) RA stenosis and systolic hypertension on ≥3 antihypertensive agents. Clinical outcome data for systolic blood pressure (SBP), diastolic blood pressure (DBP), creatinine level and number of antihypertensive drugs was assessed prior to and then later at 6-12 months and 3-5 years post RA stenting. RESULTS Mean age was 69 ± 9 years; 27% (7/26) were male. Median follow-up was 5.1 years. Blood pressure reduction was sustained at long-term follow-up (135/70 ± 18/11 mmHg) compared to initial reduction noted at 6-months (136/69 ± 16/8 mmHg; p ≤0.01 for both) and from baseline (162/80 ± 24/18 mmHg; p ≤0.001 for both). The number of antihypertensive agents also decreased from 4.1 ± 1.0 to 2.7 ± 2.1 (p = 0.002) at 6-months and was sustained at long-term follow-up, 3.4 ± 1.2 (p = 0.03) with no difference in renal function between short- and long-term follow-up compared to baseline. CONCLUSIONS This study shows sustained benefit of RA stenting in BP reduction in an appropriately selected cohort with significant stenosis ≥70% and uncontrolled hypertension on multiple medications on long-term follow-up.
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Affiliation(s)
- Zubair Khan
- Providence-Providence Park Hospital, Southfield, Michigan, USA.
| | - Sunit Tolia
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Kumar Sanam
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Gunjan Gholkar
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marc Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Sunil Naik
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marcel Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
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33
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Salahia MG, White RD, Gordon AC, Williams IM. Hepatorenal Bypass for Renal Salvage: A Forgotten Option in the Endovascular Era. Vasc Endovascular Surg 2018; 52:629-632. [DOI: 10.1177/1538574418779468] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: In this era of rapidly expanding endovascular techniques, the use of hepatorenal bypass as treatment for a critically compromised renal perfusion has largely been forgotten. This article highlights the benefits of the technique both as a bailout strategy following complications from angioplasty and as a primary treatment in cases deemed unsuitable for endovascular intervention. Materials and Methods: Two patients are described whose renal viability was threatened by vascular compromise. One patient had a single functioning kidney with significant renal artery stenosis secondary to severe atherosclerotic disease and developed acute renal function deterioration following unsuccessful angioplasty. The second patient developed renal artery occlusion 3 years following open thoracoabdominal aortic aneurysm surgery. Both patients underwent successful hepatorenal bypass surgery and remain off dialysis 6 months after admission. Results: Both cases demonstrated the success of hepatorenal bypass with significant improvement in their renal function following open surgical repair. Conclusion: Hepatorenal bypass, although now seldom used because of available endovascular alternatives, remains an effective method of treating complicated cases of threatened kidney secondary to vascular insult.
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Affiliation(s)
- M. Ghali Salahia
- Department of Clinical Radiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Richard D. White
- Department of Clinical Radiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Andrew C. Gordon
- Department of Clinical Radiology, University Hospital of Wales, Cardiff, United Kingdom
| | - Ian M. Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, United Kingdom
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Abugroun A, Gonzalez M, Vilchez D. Recurrent Pleural Effusion as a Result of Bilateral Renal Artery Stenosis. Does Renal Revascularization Help? CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2018. [PMID: 29531478 PMCID: PMC5843098 DOI: 10.1177/1179547618761378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Renal artery stenosis (RAS) is the leading cause of secondary hypertension. Renal artery stenosis can result in various cardiopulmonary complications mostly through activation of neurohormonal pathways that result in fluid overload and systemic hypertension. We herein describe a 72-year-old man with recurrent rapidly accumulating transudative pleural effusion in a patient with severe bilateral RAS. Patient pleural effusion resolved following stent placement with revascularization of the left renal artery despite absence of improvement of renal function. Patient renal function continued to decline and ultimately treated with fixed hemodialysis.
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Affiliation(s)
- Ashraf Abugroun
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Marion Gonzalez
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
| | - Daniel Vilchez
- Department of Internal Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL, USA
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35
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Nakajima Y, Kawarada O, Higashimori A, Yokoi Y, Zen K, Anzai H, Doi H, Hokimoto S, Ito S, Kato T, Kume T, Shintani Y, Tanimoto S, Tsubakimoto Y, Utsunomiya M, Nishimura K, Yasuda S. Predictors of cardiac benefits of renal artery stenting from a multicentre retrospective registry. HEART ASIA 2018; 9:e010934. [PMID: 29469905 DOI: 10.1136/heartasia-2017-010934] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 08/18/2017] [Accepted: 08/19/2017] [Indexed: 01/20/2023]
Abstract
OBJECTIVES There have been limited data regarding the prediction of cardiac benefits after renal artery stenting for patients with atherosclerotic renal artery disease (ARAD). The aim of this multicentre retrospective study was to identify clinical or echocardiographic factors associated with improvements of cardiac symptoms after renal artery stenting. METHODS We enrolled 58 patients with de novo ARAD undergoing successful renal artery stenting for heart failure, angina or both between January 2000 and August 2015 at 13 hospitals. RESULTS Improvement of cardiac symptoms was observed in 86.2% of patients during a mean follow-up of 6.0±2.7 months. Responders demonstrated significantly lower New York Heart Association functional class, higher estimated glomerular filtration rate, lower serum creatinine and lower interventricular septal wall thickness (IVS), lower left ventricular mass index, lower left atrial dimension and lower E-velocity than non-responders. Backward stepwise multivariate analysis identified IVS as an independent predictor of improvement of cardiac symptoms (OR 0.451, 95% CI 0.209 to 0.976; p=0.043). According to receiver operating characteristic curve analysis, an IVS cut-off of 11.9 mm provided the best predictive value, with sensitivity of 71.4%, specificity of 75.5% and accuracy of 73.5%. The positive predictive value was 74.5% and the negative predictive value was 72.5%. CONCLUSIONS This multicentre retrospective study shows that the echocardiographic index of IVS is an independent predictor for improvement of cardiac symptoms after renal artery stenting.
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Affiliation(s)
- Yuri Nakajima
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Osami Kawarada
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan.,Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | | | - Yoshiaki Yokoi
- Department of Cardiology, Kishiwada Tokushukai Hospital, Osaka, Japan
| | - Kan Zen
- Department of Cardiology, Omihachiman Community Medical Center, Shiga, Japan
| | - Hitoshi Anzai
- Department of Cardiology, Ota Memorial Hospital, Gunma, Japan
| | - Hideki Doi
- Department of Cardiology, Kumamoto Rosai Hospital, Kumamoto, Japan
| | - Seiji Hokimoto
- Department of Cardiology, Kumamoto University Hospital, Kumamoto, Japan
| | - Shigenori Ito
- Department of Cardiology, Nagoya City East Medical Center, Aichi, Japan
| | - Taku Kato
- Department of Cardiology, Nantan General Hospital, Kyoto, Japan
| | - Teruyoshi Kume
- Department of Cardiology, Kawasaki Medical School Hospital, Okayama, Japan
| | | | - Shuzou Tanimoto
- Department of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | | | | | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
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36
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Qiu C, Shao J, Liu X, Liu B. Utilizing flat-panel detector parenchymal blood volume imaging (FD-PBV) for quantitative kidney perfusion analysis during the process of percutaneous transluminal renal angioplasty (PTRA): A case report. Medicine (Baltimore) 2017; 96:e8654. [PMID: 29381939 PMCID: PMC5708938 DOI: 10.1097/md.0000000000008654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Traditional digital subtraction angiography (DSA) provides lumen morphology of renal artery as indicators for vascular patency in patients with renal artery stenosis (RAS). It, however, lacks hemodynamic information toward target kidney. To solve this shortcoming, a novel technique, flat-panel detector parenchymal blood volume imaging (FD-PBV), is introduced, which is able to evaluate hemodynamic changes of target kidney intraoperatively. PATIENTS CONCERNS A 77-year-old female presented with hypertension, intermittent dizziness, nausea, and fatigue. DIAGNOSES Ninety-nine percent stenosis of left RAS was found. INTERVENTIONS Percutaneous transluminal renal angioplasty was performed, along with FD-PBV acquisition protocol. OUTCOMES Her symptoms relieved gradually after procedure. Intuitive FD-PBV maps showed her renal perfusion improved remarkably. Quantitative analysis of FD-PBV showed her kidney volume was 47.02 and 75.61 cm with average density of contrast medium (CM) 58.1 HU and 311.5 HU before and after stenting. Follow-up at 6 months showed patency of the stent and stable kidney blood perfusion. LESSONS FD-PBV technique possesses a remarkable value in quantitatively assessing the changes of kidney blood perfusion and can be a useful auxiliary technique for DSA.
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Atherosclerotic renovascular disease - epidemiology, treatment and current challenges. ADVANCES IN INTERVENTIONAL CARDIOLOGY 2017; 13:191-201. [PMID: 29056991 PMCID: PMC5644037 DOI: 10.5114/aic.2017.70186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Accepted: 09/16/2017] [Indexed: 12/30/2022] Open
Abstract
The neutral results of recent large randomized controlled trials comparing renal revascularization with optimal medical therapy in patients with atherosclerotic renovascular disease (ARVD) have cast doubt on the role of revascularization in the management of unselected patients with this condition. However, these studies have strengthened the evidence base for the role of contemporary intensive medical vascular protection therapy and aggressive risk factor control in improving clinical outcomes in ARVD. Patients presenting with ‘high-risk’ clinical features such as uncontrolled hypertension, rapidly declining renal function or flash pulmonary oedema are underrepresented in these studies; hence these results may not be applicable to all patients with ARVD. In this ‘high-risk’ subgroup, conservative management may not be sufficient in preventing adverse events, and indeed, observational evidence suggests that this specific patient subgroup may gain benefit from timely renal revascularization. Current challenges include the development of novel diagnostic techniques to establish haemodynamic significance of a stenosis, patient risk stratification and prediction of post-revascularization outcomes to ultimately facilitate patient selection for revascularization. In this paper we describe the epidemiology of this condition and discuss treatment recommendations for this condition in light of the results of recent randomized controlled trials while highlighting important clinical unmet needs and challenges faced by clinicians managing this condition.
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Deoker A, Mukherjee D. Renal artery revascularisation: can we predict who benefits? HEART ASIA 2017; 9:e010951. [PMID: 29470560 PMCID: PMC5818045 DOI: 10.1136/heartasia-2017-010951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Revised: 08/16/2017] [Accepted: 08/18/2017] [Indexed: 11/03/2022]
Affiliation(s)
- Abhizith Deoker
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, Texas, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, Texas, USA
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Zeller T, Krankenberg H, Erglis A, Blessing E, Fuss T, Scheinert D, Weser R, Doerr BB, Yollo WD, Radermacher J. A randomized, multi-center, prospective study comparing best medical treatment versus best medical treatment plus renal artery stenting in patients with hemodynamically relevant atherosclerotic renal artery stenosis (RADAR) - one-year results of a pre-maturely terminated study. Trials 2017; 18:380. [PMID: 28807045 PMCID: PMC5556660 DOI: 10.1186/s13063-017-2126-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The indications for conservative "best medical treatment" (BMT) versus additional renal artery stenting are a matter of ongoing debate. The RADAR study aimed to evaluate the impact of percutaneous renal artery stenting on the impaired renal function in patients with hemodynamically significant atherosclerotic renal artery stenosis (RAS). METHODS RADAR is an international, prospective, randomized (1:1) controlled study comparing BMT alone versus BMT plus renal artery stenting in patients with duplex sonographic hemodynamically relevant RAS. Follow-up assessments were at 2, 6, and 12 months and at 3 years. The primary endpoint was change in estimated glomerular filtration rate (eGFR) at 12 months. RESULTS Due to slow enrollment, RADAR was terminated early after inclusion of 86 of the scheduled 300 patients (28.7%). Change in eGFR between baseline and 12 months was 4.3 ± 15.4 ml/min/1.73 m2 (stent group) and 3.0 ± 14.9 ml/min/1.73 m2 (BMT group), p > 0.999. Clinical event rates were low with a 12-month composite of cardiac death, stroke, myocardial infarction, and hospitalization for congestive heart failure of 2.9% in the stent and 5.3% in the BMT group, p = 0.526, and a 3-year composite of 14.8% and 12.0%, p = 0.982. At 3 years, target vessel (re-)vascularization occurred in one patient (3.0%) in the stent group and in 8 patients (29.4%) in the BMT group. CONCLUSION In RADAR, outcomes of renal artery stenting were similar to BMT. These results have to be interpreted with the caveat that the study did not reach its statistically based sample size. TRIAL REGISTRATION Clinicaltrials.gov, NCT00640406. Registered on 17 March 2008.
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Affiliation(s)
- Thomas Zeller
- Department of Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen, Südring 15, 79189, Bad Krozingen, Germany.
| | - Hans Krankenberg
- Department of Angiology, Asklepios Klinik Hamburg, Hamburg, Germany
| | - Andrejs Erglis
- Latvian Center of Cardiology, P. Stradins Clinical University Hospital, Riga, Latvia
| | - Erwin Blessing
- Department of Internal Medicine, SRH Klinikum Karlsbad-Langensteinbach, Karlsbad, Germany
| | - Torsten Fuss
- Zentralklinikum Suhl, Suhl, Germany.,Department Internal Medicine, Elblandkliniken, Radebeul, Germany
| | - Dierk Scheinert
- Department of Internal, Neurological and Dermatological Medicine, Division of Interventional Angiology, Universitätsklinikum Leipzig, Leipig, Germany
| | - Ralf Weser
- Abt. Kardiologie und Angiologie, Herzzentrum Coswig, Coswig, Anhalt, Germany
| | - Beatrix B Doerr
- Coriuvar Clinical Research & Medical Writing, Moosburg, Germany
| | | | - Joerg Radermacher
- Center for Internal Medicine/Nephrology, Klinikum I, Johannes Wesling Klinikum Minden, Minden, Germany
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Textor SC, Herrmann SM. Evidence and Renovascular Disease: Trials and Mistrials? Am J Kidney Dis 2017; 70:160-163. [PMID: 28535904 PMCID: PMC5848211 DOI: 10.1053/j.ajkd.2017.04.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 04/07/2017] [Indexed: 11/11/2022]
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Klein AJ, Jaff MR, Gray BH, Aronow HD, Bersin RM, Diaz-Sandoval LJ, Dieter RS, Drachman DE, Feldman DN, Gigliotti OS, Gupta K, Parikh SA, Pinto DS, Shishehbor MH, White CJ. SCAI appropriate use criteria for peripheral arterial interventions: An update. Catheter Cardiovasc Interv 2017; 90:E90-E110. [PMID: 28489285 DOI: 10.1002/ccd.27141] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | - Kamal Gupta
- University of Kansas Medical Center, Kansas City, KS
| | - Sahil A Parikh
- Columbia University Medical Center/NY Presbyterian Hospital, New York, NY
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Radvany MG. Use of Embolic Protection Devices in Peripheral Interventions. Interv Cardiol 2017; 12:31-35. [PMID: 29588727 PMCID: PMC5808701 DOI: 10.15420/icr.2016:23:2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 12/07/2016] [Indexed: 12/12/2022] Open
Abstract
The use of embolic protection devices (EPDs) when treating coronary saphenous vein bypass grafts, performing carotid arterial stenting and treating acute coronary syndromes is well accepted. We will review currently available devices and approaches to reduce distal embolisation, first discussing their uses in carotid interventions and then in vertebral and peripheral vascular interventions.
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Affiliation(s)
- Martin G Radvany
- Chief of Interventional Neuroradiology, WellSpan Radiology and Neurosciences, York, PA, USA
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Vassallo D, Ritchie J, Green D, Chrysochou C, Kalra PA. The effect of revascularization in patients with anatomically significant atherosclerotic renovascular disease presenting with high-risk clinical features. Nephrol Dial Transplant 2017; 33:497-506. [DOI: 10.1093/ndt/gfx025] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/28/2017] [Indexed: 12/21/2022] Open
Affiliation(s)
- Diana Vassallo
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - James Ritchie
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | - Darren Green
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal NHS Foundation Trust, Salford, UK
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Abstract
Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension; it can also cause progressive renal insufficiency and cardiovascular complications such as refractory heart failure and flash pulmonary edema. Medical therapy including risk factor modification, renin-angiotensin-aldosterone system antagonists, lipid lowering agents, and antiplatelet therapy is the first line of treatment in all patients. Patients with uncontrolled renovascular hypertension despite optimal medical therapy, ischemic nephropathy, and cardiac destabilization syndromes who have severe renal artery stenosis are likely to benefit from renal artery revascularization. Screening for renal artery stenosis can be done with Doppler ultrasonography, computed tomographic angiography and magnetic resonance angiography. Invasive physiologic measurements are useful to confirm the severity of renal hypoperfusion and therefore improve the selection patients likely to respond to renal artery revascularization. Primary patency exceeds 80% at 5 years and surveillance for in-stent restenosis can be done with periodic clinical, laboratory, and imaging follow-up.
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Abstract
PURPOSE OF REVIEW Atherosclerotic renovascular disease remains highly prevalent and presents an array of clinical syndromes. Recent prospective trials have dampened enthusiasm for revascularization generally, but clinicians recognize the need to identify patients likely to benefit from vascular intervention. RECENT FINDINGS This article highlights the inflammatory nature of vascular occlusive disease and the limits of the kidney to adapt to reduced blood flow. Although moderate reductions can be tolerated, severe impairment of renal perfusion leads to tissue hypoxia and activates inflammatory injury within the kidney. Hence, assessment of kidney viability and potential tools to modify mitochondrial and inflammatory damage may be important to identify patients for whom clinical intervention should be undertaken. SUMMARY Clinicians must recognize clinical syndromes that identify 'high-risk' groups and apply revascularization in those likely to benefit. Future efforts to protect the kidney (e.g., mitochondrial protection) or cell-based therapy may amplify clinical recovery when combined with restoring renal blood flow.
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Kawarada O, Kitajima R, Sugano Y, Noguchi T, Anzai T, Ogawa H, Yasuda S. Improvement of left ventricular filling and pulmonary artery pressure following unilateral renal artery total occlusion stenting in a patient with recurrent congestive heart failure complicated by renovascular hypertension and renal failure. ESC Heart Fail 2016; 2:160-163. [PMID: 27774260 PMCID: PMC5057347 DOI: 10.1002/ehf2.12069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 08/23/2015] [Accepted: 08/26/2015] [Indexed: 11/15/2022] Open
Abstract
Recurrent congestive heart failure related to renal artery disease is an important clinical entity that is typically observed in bilateral renal artery stenosis or solitary functioning kidney. However, the relationship between heart failure and unilateral renal artery disease, especially that with total occlusion, remains unclear. We report a successful management by unilateral renal artery total occlusion stenting with an evidence of improvement of left ventricular filling and pulmonary artery pressure in case of a patient suffering from medical therapy resistant recurrent congestive heart failure with preserved ejection fraction.
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Affiliation(s)
- Osami Kawarada
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Ryota Kitajima
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Yasuo Sugano
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
| | - Hisao Ogawa
- Department of Cardiovascular MedicineNational Cerebral and Cardiovascular CenterOsakaJapan; Department of Cardiovascular Medicine, Graduate School of Medical SciencesKumamoto UniversityKumamotoJapan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan
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Jiang X, Peng M, Li B, Dong H, Che W, Zou Y, Yang Y, Gao R. The efficacy of renal artery stent combined with optimal medical therapy in patients with severe atherosclerotic renal artery stenosis. Curr Med Res Opin 2016; 32:3-7. [PMID: 27779455 DOI: 10.1080/03007995.2016.1218833] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVE To evaluate the efficacy of renal artery stent combined with optimal medical therapy as treatment for renal artery stenosis. RESEARCH DESIGN AND METHODS A prospective cohort study was conducted. Patients with severe atherosclerotic renal artery stenosis received percutaneous renal artery stent because of poorly controlled hypertension or preservation of renal function. The patients also received optimal medical therapy to achieve the blood pressure, lipid and blood glucose targets. MAIN OUTCOME MEASURES All patients underwent a 12 month follow-up to observe the effect of the procedure on blood pressure control, number of antihypertensive medications and creatinine level. RESULTS Stents were placed in 185 renal arteries of 149 patients. Mean stenosis was 83.1 ± 7.0%. The success rate of renal artery stent was 99.3%. At 12 months, estimated glomerular filtration rate increased significantly compared with baseline (84.1 ± 28.8 vs. 76.5 ± 22.50 ml/min ×1.73 m2, p < 0.05). Both office blood pressure and 24 hour blood pressure significantly decreased compared with baseline (from 153/83 mmHg to 134/73 mmHg and from 143/80 mmHg to 124/69 mmHg, respectively; p < 0.05), and less antihypertensive medication was taken compared with baseline (1.5 ± 0.8 vs. 2.2 ± 0.9; p < 0.05). CONCLUSIONS Renal artery stent combined with optimal medical therapy as a treatment has a beneficial effect on blood pressure control and estimated glomerular filtration rate in selected patients with atherosclerotic renal artery stenosis. Larger studies with a longer follow-up appear necessary to further confirm these intriguing findings.
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Affiliation(s)
- Xiongjing Jiang
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Meng Peng
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Bin Li
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Hui Dong
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Wuqiang Che
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yubao Zou
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Yuejin Yang
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
| | - Runlin Gao
- a Department of Cardiology , Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College , Beijing , China
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Patel SM, Li J, Parikh SA. Renal Artery Stenosis: Optimal Therapy and Indications for Revascularization. Curr Cardiol Rep 2016; 17:623. [PMID: 26238738 DOI: 10.1007/s11886-015-0623-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Atherosclerotic renal artery stenosis (ARAS) is associated with increased cardiovascular risk and overall mortality. Manifestations of ARAS include resistant or malignant hypertension, progressive deterioration of renal function, and cardiac dysfunction syndromes of flash pulmonary edema and angina. Diagnosis rests upon non-invasive studies such as duplex ultrasonography and is confirmed using invasive renal arteriography. Regardless of the severity of ARAS, management of this entity has been a topic of contentious debate. For over two decades, the use of percutaneous revascularization to treat ARAS has been studied with various clinical trials. Though case series seem to demonstrate favorable clinical response to revascularization, the overwhelming majority of randomized clinical trials have not mirrored a robust outcome. In these trials, poor correlation is noted between the reduction of stenosis and the improvement of renovascular hypertension and glomerular filtration rate, and decrease in cardiovascular outcomes and mortality. With dichotomizing results, the explanation for these discrepant findings has been attributed to improper trial design and inappropriate patient selection. An overview of the treatment options available will be provided, with a focus on the methodology and design of clinical trials investigating the efficacy of percutaneous revascularization. Emphasis is placed on appropriate patient selection criteria, which may necessitate the use of hemodynamic lesion assessment and clinical correlation based on individualized care. When clinical equipoise exists between optimal medical therapy and revascularization, the current paradigm supports ongoing medical therapy as the treatment of choice. However, renal artery stenting remains a viable therapeutic option for those who continue to have clinical syndromes consistent with renal hypoperfusion while adequately treated with optimal medical therapy. Despite observational studies suggesting clinical benefit for this specific patient population, there remains a paucity of randomized clinical trial data. Further trials targeting the patients who are inadequately treated with optimal medical therapy need to be undertaken to confirm the efficacy of revascularization.
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Affiliation(s)
- Sandeep M Patel
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Affiliation(s)
| | - Sanjay Misra
- Interventional Radiology, Mayo Clinic, Rochester, Minnesota
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