SCAI appropriate use criteria for peripheral arterial interventions: An update

Lessons Learned from Coronary Revascularization Appropriateness Statements for Application to Peripheral Artery Disease

Appropriate Use Criteria (AUC) are evidence-based criteria developed in a methodologically robust manner with the input of expert providers across a wide range of disciplines and practice settings. AUC have been successfully implemented in the diagnosis and management of a wide range of cardiovascular disease processes. AUC have demonstrated clear potential for influencing meaningful change in practice patterns with regards to high-value, high-quality care in cardiovascular pathologies. Potential for similar impact in the management of peripheral artery disease, specifically for patients presenting with intermittent claudication (IC), may be limited due to unique challenges. These challenges include multidisciplinary interventionalists, variability in existing AUC across specialties, and financial incentives influencing physician behavior. AUC serve to benefit patients by improving outcomes, and adoption of AUC is a critical step toward improving the quality of care provided to patients with IC. Societal support is necessary for effective AUC implementation.

Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome

Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.

Device regulation and surveillance in vascular care: Challenges and opportunities

Cardiovascular devices are essential for the treatment of cardiovascular diseases including cerebrovascular, coronary, valvular, congenital, peripheral vascular and arrhythmic diseases. The regulation and surveillance of vascular devices in real-world practice, however, presents challenges during each individual product's life cycle. Four examples illustrate recent challenges and questions regarding safety, appropriate use and efficacy arising from FDA approved devices used in real-world practice. We outline potential pathways wherein providers, regulators and payors could potentially provide high-quality cardiovascular care, identify safety signals, ensure equitable device access, and study potential issues with devices in real-world practice.

A systematic review of existing appropriate use criteria in cardiovascular disease from the last 15 years

Appropriate use criteria (AUC) aim to impact the provision of high-value care. This scoping review identified AUC regarding the procedural and operative treatment of cardiovascular disease and described the evolution of AUC in this space over time, including changes in the focus, strategy, and language of AUC. The summative presentation of these AUC identifies elements of AUC that may lead to successes in, and barriers to, implementation across disease processes, specialties, and societies. AUC topics include coronary artery disease, peripheral artery disease, valvular disease, venous disease, renal artery stenosis, and mesenteric ischemia, among others.

Below-the-Knee Endovascular Revascularization: A Position Statement

Patients with chronic limb-threatening ischemia, the terminal stage of peripheral artery disease, are frequently afflicted by below-the-knee disease. Although all patients should receive guideline-directed medical therapy, restoration of inline flow is oftentimes necessary to avoid limb loss. Proper patient selection and proficiency in endovascular techniques for below-the-knee revascularization are intended to prevent major amputation and promote wound healing. This review, a consensus among an international panel of experienced operators, provides guidance on these challenges from an endovascular perspective and offers techniques to navigate this complex disease process.

Endovascular treatment of renal artery stenosis in Germany: a retrospective analysis of the DEGIR registry 2018-2021

PURPOSE

 To provide an overview of endovascular treatment of renal artery stenosis (RAS) using the data of the Deutsche Gesellschaft für interventionelle Radiologie (DeGIR) quality management system.

MATERIALS AND METHODS

 A retrospective analysis was performed. Pre-, peri- and postprocedural data, technical success rates, complication rates, and clinical success rates at dismissal were examined.

RESULTS

 Between 2018 and 2021, 2134 angiography examinations of the renal arteries were performed: diagnostic angiography in 70 patients (3 %), balloon angioplasty in 795 (37 %), stent implantation in 1166 (55 %) and miscellaneous procedures in 103 (5 %). The lesion length was less than or equal to 5 mm in 1837 patients (87 %), between 5 and 10 mm in 197 (9 %), and between 10 and 20 mm in 62 (3 %). The degree of stenosis was less than 50 % in 156 patients (7 %), greater than 50 % in 239 (11 %), and greater than 70 % in 1472 (70 %). Occlusion was treated in 235 patients (11 %). Symptoms at discharge resolved in 600 patients (29 %), improved in 1012 (49 %), were unchanged in 77 (4 %), and worsened in 5 (0.2 %). Complications were reported in 51 patients (2.5 %) and the mortality rate was 0.15 %.

CONCLUSION

 A substantial number of patients with RAS and occlusions were treated by radiologists in Germany, with high technical success rates and low complication rates. The indication should be determined carefully as the current European guidelines for the treatment of RAS suggest that only carefully selected groups of patients will benefit from recanalizing treatment.

KEY POINTS

  · Carefully selected patient groups may benefit from endovascular treatment of renal artery stenosis.. · Analysis of the DEGIR quality management database shows that treatment of renal artery stenosis was performed by radiologists in Germany with high technical success rates and low complication rates.. · Recanalization even led to symptom improvement in a large proportion of patients with occlusions..

Atherosclerotic renovascular disease: a clinical practice document by the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and the Working Group Hypertension and the Kidney of the European Society of Hypertension (ESH)

Atherosclerotic renovascular disease (ARVD) is the most common type of renal artery stenosis. It represents a common health problem with clinical presentations relevant to many medical specialties and carries a high risk for future cardiovascular and renal events, as well as overall mortality. The available evidence regarding the management of ARVD is conflicting. Randomized controlled trials failed to demonstrate superiority of percutaneous transluminal renal artery angioplasty (PTRA) with or without stenting in addition to standard medical therapy compared with medical therapy alone in lowering blood pressure levels or preventing adverse renal and cardiovascular outcomes in patients with ARVD, but they carried several limitations and met important criticism. Observational studies showed that PTRA is associated with future cardiorenal benefits in patients presenting with high-risk ARVD phenotypes (i.e. flash pulmonary oedema, resistant hypertension or rapid loss of kidney function). This clinical practice document, prepared by experts from the European Renal Best Practice (ERBP) board of the European Renal Association (ERA) and from the Working Group on Hypertension and the Kidney of the European Society of Hypertension (ESH), summarizes current knowledge in epidemiology, pathophysiology and diagnostic assessment of ARVD and presents, following a systematic literature review, key evidence relevant to treatment, with an aim to support clinicians in decision making and everyday management of patients with this condition.

Safety of Retrograde Tibial-Pedal Access and Intervention in Patients with Single Remaining Non-Occluded Infra-Popliteal Runoff Artery

BACKGROUND

The adaptation of retrograde tibial-pedal access for peripheral angiogram and intervention is limited by the lack of operator experience and concern for small distal vessel injury. This study evaluates the safety of the retrograde tibial-pedal access for peripheral angiogram and intervention in patients with two vessel infra-popliteal artery chronic total occlusions, where the access point is the sole remaining non-occluded infra-popliteal artery.

METHODS

A retrospective analysis of 5687 consecutive patients who underwent peripheral angiograms by retrograde tibial-pedal access via the single remaining non-occluded infra-popliteal artery was performed. Patients who had retrograde tibial-pedal access at the sole remaining infra-popliteal artery confirmed by angiography were included. Clinical and ultrasound data of the accessed infra-popliteal vessel up to 6 months were collected.

RESULTS

The cohort consisted of 314 patients (152 males; mean age 77.9 years). At 6 months, access vessel complications occurred in 15 patients (4.8%). Access vessel occlusion occurred in 9 out of 314 patients (2.9%), arteriovenous fistula in 4 (1.3%), with spontaneous resolution in 2, pseudoaneurysm requiring thrombin injection in 2 (0.6%) and non-cardiovascular death in 1 (0.3%). No uncontrolled bleeding, procedure-related hospitalizations or limb amputations occurred.

CONCLUSIONS

Routine primary retrograde tibial-pedal access for lower extremity peripheral artery diagnostic angiography and intervention in patients with single infra-popliteal artery runoff can be safety performed in an outpatient setting with infrequent and manageable complications.

Severe acute kidney injury in a patient with renal artery stenosis of a single-functioning kidney: A case report of rapid normalisation of the renal function after percutaneous transluminal angioplasty with stent placement

Revascularisation of renal arterial stenosis in acute settings, such as uncontrolled arterial hypertension, flash pulmonary oedema and/or acute renal failure, has shown controversial results in observational and prospective studies. Current guidelines do not recommend revascularisation in the occurrence of renal failure as revascularisation and best medical treatment have shown similar long-term outcomes on renal function. We describe a case of acute degradation of the renal function (with oligo-anuria and a peak creatinine of 462 µmol/L) after the re-introduction of an angiotensin-II receptor blocker (irbesartan) in a 66-year-old Caucasian diabetic male patient with bilateral renal stenosis and a right-sided single-functioning kidney, with a rapid improvement of the renal function which normalized 5 days after percutaneous angioplasty and stenting of the right renal artery.

Endovascular Interventions for Peripheral Artery Disease: A Contemporary Review

PURPOSE OF REVIEW

Peripheral artery disease (PAD) is an increasingly prevalent but frequently underdiagnosed condition that can be associated with high rates of morbidity and mortality. While an initial noninvasive approach is the cornerstone of management, revascularization is often pursued for patients with treatment-refractory claudication or chronic limb-threatening ischemia (CLTI). In this review, we discuss the current state of endovascular interventions for PAD and explore the many new emerging technologies.

RECENT FINDINGS

The last decade has resulted in numerous advances in PAD interventions including the ongoing evolution of drug-coated devices, novel approaches to complex lesions, and contemporary evidence from large clinical trials for CLTI. Advances in endovascular management have allowed for increasingly complex lesions to be tackled percutaneously. Future directions for the field include the continued evolution in device technology, continued development of state-of-the-art techniques to revascularization of complex lesions, and increased collaboration between a largely multidisciplinary field.

Lack of patient-centered evaluation of outcomes in intermittent claudication literature

BACKGROUND

Peripheral arterial disease, characterized as arterial atherosclerotic disease, can lead to insufficient flow in the lower extremities and ischemia, with the most common clinical manifestation being intermittent claudication (IC). In 2022, the Society for Vascular Surgery (SVS) developed appropriate use criteria for the management of IC that used this systematic review as a source of evidence. The objective of this study is to synthesize the findings of the systematic review and identify evidence gaps.

METHODS

A comprehensive search of literature databases including MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus was conducted from January 1, 2000, to November 30, 2022. Noncomparative and comparative observational studies and randomized controlled trials were included. Included studies evaluated exercise therapy, endovascular or open revascularization for the treatment of IC. Outcomes of interest (freedom from major adverse limb event, health-related quality of life, and walking distance) were compared in various subgroups (age, sex, diabetes, smoking status, anatomical location of disease, and optimal medical therapy).

RESULTS

Twenty-six studies reported the outcomes of interest for the evidence map. The general conclusions of the studies that reported freedom from major adverse limb events were that reintervention rates for endovascular therapy at ≥2 years were >20%, major amputation rates were often not reported, and, after endovascular therapy, the 1-month mortality was low (<2%). Quality of life and walking distance data were sparse, limited to only endovascular intervention, and insufficient to make any strong conclusions.

CONCLUSIONS

IC in patients with peripheral arterial disease poses a significant socioeconomic and health care burden. Major, consequential gaps exist in the IC literature with respect to the assessment of patient reported outcome measures, standardized measures of walking distance and the comparative effectiveness of initial exercise therapy vs invasive intervention. The evidence gaps identified by the Society for Vascular Surgery appropriate use criteria on IC systematic review serve as a guide for future research efforts to optimize care for this patient population.

Evaluating Short-Term and Long-Term Risks Associated with Renal Artery Stenosis Position and Severity: A Hemodynamic Study

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.

Association of Clinical Setting With Sociodemographics and Outcomes Following Endovascular Femoropopliteal Artery Revascularization in the United States

BACKGROUND

After the Centers for Medicare and Medicaid Services modified reimbursement rates for outpatient peripheral vascular intervention in 2008 with the intent of improving access to care, providers began to increasingly perform peripheral vascular interventions in privately owned office-based clinics. Little is known about the characteristics of patients treated in this setting and their long-term outcomes as compared with those treated in hospital-based centers.

METHODS

In this retrospective cohort study, Medicare beneficiaries ≥66 years undergoing outpatient femoropopliteal peripheral vascular interventions in office-based clinics and hospital-based centers from 2015 to 2017 were identified. Sociodemographics, comorbidities, and institutional characteristics were compared across sites. Multivariable Cox proportional hazards models were used to estimate the adjusted associations between practice site location and outcomes. The primary outcome was the composite of major amputation or death analyzed through the end of follow-up.

RESULTS

Among 134 869 patients, 29.9% were treated in office-based clinics and 70.1% in hospital-based centers. Patients treated in office-based clinics were more often Black (16.9% versus 11.9%), dually enrolled in Medicaid (26.3% versus 19.6%), and residents of lower-resourced regions (32.6% versus 25.6%). Over a median follow-up time of 800 days (interquartile range, 531-1119 days), patients treated in office-based clinics had reduced risks of major amputation or death compared with outpatients treated in hospital-based centers (hazard ratio, 0.92 [95% CI, 0.89-0.95]). They also had lower adjusted all-cause mortality (hazard ratio, 0.93 [95% CI, 0.90-0.96]), major lower extremity amputation (hazard ratio, 0.84 [95% CI, 0.79-0.89]), and all-cause hospitalization (hazard ratio, 0.86 [95% CI, 0.84-0.88]). These findings persisted after stratification by critical limb ischemia, race, dual enrollment, and regional socioeconomic status, as well as among operators treating patients in both clinical settings.

CONCLUSIONS

In this large nationwide analysis of Medicare beneficiaries, office-based clinics treated a more socioeconomically disadvantaged population compared with hospital-based centers. Long-term outcomes were comparable between locations. As such, these clinics appear to be selecting lower-risk patients for outpatient peripheral vascular interventions, although there remains the possibility of unmeasured confounding.

Case Report: Endovascular Treatment of Chronic Atherosclerotic Renal Artery Total Occlusions with Failed Medical Therapy

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.

Abdominal applications of quantitative 4D flow MRI

4D flow MRI is a quantitative MRI technique that allows the comprehensive assessment of time-resolved hemodynamics and vascular anatomy over a 3-dimensional imaging volume. It effectively combines several advantages of invasive and non-invasive imaging modalities like ultrasound, angiography, and computed tomography in a single MRI acquisition and provides an unprecedented characterization of velocity fields acquired non-invasively in vivo. Functional and morphological imaging of the abdominal vasculature is especially challenging due to its complex and variable anatomy with a wide range of vessel calibers and flow velocities and the need for large volumetric coverage. Despite these challenges, 4D flow MRI is a promising diagnostic and prognostic tool as many pathologies in the abdomen are associated with changes of either hemodynamics or morphology of arteries, veins, or the portal venous system. In this review article, we will discuss technical aspects of the implementation of abdominal 4D flow MRI ranging from patient preparation and acquisition protocol over post-processing and quality control to final data analysis. In recent years, the range of applications for 4D flow in the abdomen has increased profoundly. Therefore, we will review potential clinical applications and address their clinical importance, relevant quantitative and qualitative parameters, and unmet challenges.

A new noninvasive and patient-specific hemodynamic index for the severity of renal stenosis and outcome of interventional treatment

Renal arterial stenosis (RAS) often causes renovascular hypertension, which may result in kidney failure and life-threatening consequences. Direct assessment of the hemodynamic severity of RAS has yet to be addressed. In this work, we present a computational concept to derive a new, noninvasive, and patient-specific index to assess the hemodynamic severity of RAS and predict the potential benefit to the patient from a stenting therapy. The hemodynamic index is derived from a functional relation between the translesional pressure indicator (TPI) and lumen volume reduction (S) through a parametric deterioration of the RAS. Our in-house computational platform, InVascular, for image-based computational hemodynamics is used to compute the TPI at given S. InVascular integrates unified computational modeling for both image processing and computational hemodynamics with graphic processing unit parallel computing technology. The TPI-S curve reveals a pair of thresholds of S indicating mild or severe RAS. The TPI at S = 0 represents the pressure improvement following a successful stenting therapy. Six patient cases with a total of 6 aortic and 12 renal arteries are studied. The computed blood pressure waveforms have good agreements with the in vivo measured ones and the systolic pressure is statistical equivalence to the in-vivo measurements with p < .001. Uncertainty quantification provides the reliability of the computed pressure through the corresponding 95% confidence interval. The severity assessments of RAS in four cases are consistent with the medical practice. The preliminary results inspire a more sophisticated investigation for real medical insights of the new index. This computational concept can be applied to other arterial stenoses such as iliac stenosis. Such a noninvasive and patient-specific hemodynamic index has the potential to aid in the clinical decision-making of interventional treatment with reduced medical cost and patient risks.

Society for Vascular Surgery Appropriate Use Criteria for Management of Intermittent Claudication

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.

How Much Debulking with Atherectomy is Enough When Treating Infrainguinal Arterial Interventions? The Balance Between Residual Stenosis and Adventitial Injury

Atherectomy is an effective vessel prepping device but not all atherectomy devices are equal. The depth of vessel injury and residual narrowing vary considerably among atherectomy devices with significant implications on outcome. Precision imaging is critical to optimize outcome using atherectomy as a vessel prepping technique. Prospective trials need to test the hypothesis that precision imaging has a significant impact on how operators approach the treatment of infrainguinal arterial disease.

Renal Artery Stenting in Consecutive High-Risk Patients With Atherosclerotic Renovascular Disease: A Prospective 2-Center Cohort Study

Background

The aim of this study was to prospectively evaluate the effects of renal artery stenting in consecutive patients with severe atherosclerotic renal artery stenosis and high‐risk clinical presentations as defined in a national protocol developed in 2015.

Methods and Results

Since the protocol was initiated, 102 patients have been referred for revascularization according to the following high‐risk criteria: severe renal artery stenosis (≥70%) with true resistant hypertension, rapidly declining kidney function, or recurrent heart failure/sudden pulmonary edema. At baseline, the mean 24‐hour ambulatory systolic blood pressure was 166.2 mm Hg (95% CI, 162.0–170.4), the defined daily dose of antihypertensive medication was 6.5 (95% CI, 5.8–7.3), and the estimated glomerular filtration rate was 41.1 mL/min per 1.73m² (95% CI, 36.6–45.6). In 96 patients with available 3‐month follow‐up data, mean 24‐hour ambulatory systolic blood pressure decreased by 19.6 mm Hg (95% CI, 15.4–23.8; P<0.001), the defined daily dose of antihypertensive medication was reduced by 52% (95% CI, 41%–62%; P<0.001), and estimated glomerular filtration rate increased by 7.8 mL/min per 1.73m² (95% CI, 4.5–11.1; P<0.001). All changes persisted after 24 month follow‐up. Among 17 patients with a history of hospitalization for acute decompensated heart failure, 14 patients had no new episodes after successful revascularization.

Conclusions

In this prospective cohort study, we observed a reduction in blood pressure and antihypertensive medication, an increase in estimated glomerular filtration rate, and a decrease in new hospital admissions attributable to heart failure/sudden pulmonary edema after renal artery stenting.

Registration

URL: https://clinicaltrials.gov. Identifier: NCT02770066.

Impact of Percutaneous Transluminal Renal Angioplasty on Autonomic Nervous System and Natriuresis in Hypertensive Patients With Renal Artery Stenosis

Background

We investigated the early postoperative effect of percutaneous transluminal renal angioplasty on ambulatory blood pressure (BP) and the circadian characteristics of natriuresis and autonomic nerve activity.

Methods and Results

A total of 64 patients with hypertension with hemodynamically significant renal artery stenosis (mean age, 60.0±21.0 years; 31.3% fibromuscular dysplasia) who underwent angioplasty were included, and circadian characteristics of natriuresis as well as heart rate variability indices, including 24‐hour BP, low‐frequency and high‐frequency (HF) components, and the percentage of differences between adjacent normal R‐R intervals >50 ms were evaluated using an oscillometric device, TM‐2425, both at baseline and 3 days after angioplasty. In both the fibromuscular dysplasia and atherosclerotic stenosis groups, 24‐hour systolic BP (fibromuscular dysplasia, −19±14; atherosclerotic renal artery stenosis, −11±9 mm Hg), percentage of differences between adjacent normal R‐R intervals >50 ms, HF, brain natriuretic peptide, and nighttime urinary sodium excretion decreased (all P<0.01), and heart rate increased (both P<0.05) after angioplasty. In both groups, revascularization increased the night/day ratios of percentage of differences between adjacent normal R‐R intervals >50 ms (both P<0.01) and HF, and decreased those of low frequency/HF (all P<0.05) and nighttime urinary sodium excretion (fibromuscular dysplasia, 1.17±0.15 to 0.78±0.09; atherosclerotic renal artery stenosis, 1.37±0.10 to 0.99±0.06, both P<0.01). Multiple logistic regression analysis indicated that a 1‐SD increase in baseline low frequency/HF was associated with at least a 15% decrease in 24‐hour systolic BP after angioplasty (odds ratio, 2.30 [95% CI, 1.03–5.67]; P<0.05).

Conclusions

Successful revascularization results in a significant BP decrease in the early postoperative period. Intrarenal perfusion might be a key modulator of the circadian patterns of autonomic nerve activity and natriuresis, and pretreatment heart rate variability evaluation seems to be important for treatment success.

Atherosclerotic Renovascular Disease: A KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference

The diagnosis and management of atherosclerotic renovascular disease (ARVD) is complex and controversial. Despite evidence from the ASTRAL (2009) and CORAL (2013) randomized controlled trials showing that percutaneous renal artery revascularization did not improve major outcomes compared with best medical therapy alone over 3-5 years, several areas of uncertainty remain. Medical therapy, including statin and antihypertensive medications, has evolved in recent years, and the use of renin-angiotensin-aldosterone system blockers is now considered the primary means to treat hypertension in the setting of ARVD. However, the criteria to identify kidneys with renal artery stenosis that have potentially salvageable function are evolving. There are also data suggesting that certain high-risk populations with specific clinical manifestations may benefit from revascularization. Here, we provide an overview of the epidemiology, diagnosis, and treatment of ARVD based on consensus recommendations from a panel of physician experts who attended the recent KDIGO (Kidney Disease: Improving Global Outcomes) Controversies Conference on central and peripheral arterial diseases in chronic kidney disease. Most focus is provided for contentious issues, and we also outline aspects of investigation and management of ARVD that require further research.

EFFECTIVENESS OF LISINOPRIL AND AMLODIPINE COMBINATION AT HYPERTENSION WITH COMORBIDITY OF ARTERIOSCLEROSIS OBLITERANS IN GENERAL PRACTICE

OBJECTIVE

The aim: To analyze the dynamics of daily monitoring of blood pressure, intracardiac (according to echocardiography), peripheral hemodynamics (according to ultrasound of the vessels of the lower extremity), the thickness of the intima-media complex (according to carotid sonography) in patients with hypertension the effect of treatment with a combination of lisinopril and amlodipine.

PATIENTS AND METHODS

Materials and methods: The study included 40 patients with hypertension with 2 (29 patients) and 3 (11 patients) degrees of hypertension in combination with AOLE with I-III stages of chronic insufficiency of the lower extremity, which revealed hyperkinetic, eukinetic, and hypokinetic types of hypertension with a predominance of the sympathetic nervous system. The groups are comparable in age, sex, duration of hypertension, and medications received in the previous stages. For antihypertensive therapy, the most common drugs for use were selected - lisinopril + amplodipine in fixed doses of 10 and 5 mg, respectively. If after 2 weeks we did not reduce the mean level of SBP and DBP by 10% or more from baseline, we doubled the dose of lisinopril without changing the dose of amlodipine.

RESULTS

Results: After 6 months of treatment, in particular, an increase in the pulse index - by 24.8%, a decrease in the resistance index - by 21.1%, an increase in linear and volumetric blood velocity - by 25.6% and 27.4%, respectively, while achieving the target blood pressure.

CONCLUSION

Conclusions: It is proved that in the absence of individual contraindications the combination of lisinopril and amlodipine is optimal and universal for effective treatment of patients with hypertension in combination with AOLE in all types of central hemodynamics.

Hot topics in interventional cardiology: Proceedings from the society for cardiovascular angiography and interventions (SCAI) 2021 think tank

The Society for Cardiovascular Angiography and Interventions (SCAI) Think Tank is a collaborative venture that brings together interventional cardiologists, administrative partners, and select members of the cardiovascular industry community annually for high-level field-wide discussions. The 2021 Think Tank was organized into four parallel sessions reflective of the field of interventional cardiology: (a) coronary intervention, (b) endovascular medicine, (c) structural heart disease, and (d) congenital heart disease. Each session was moderated by a senior content expert and co-moderated by a member of SCAI's Emerging Leader Mentorship program. This document presents the proceedings to the wider cardiovascular community in order to enhance participation in this discussion, create additional dialog from a broader base, and thereby aid SCAI, the industry community and external stakeholders in developing specific action items to move these areas forward.

Renal interventions in the management of hypertension

PURPOSE OF REVIEW

In the present comprehensive review, we describe the pathophysiology, indications, and evidence for both renal artery stenting and renal artery denervation. We also discuss the procedural techniques, risks, benefits, and future directions of renal intervention in the management of hypertension (HTN).

RECENT FINDINGS

Hemodynamic confirmation of lesion severity in severe renal artery stenosis is a resting or hyperemic translesional systolic gradient >20, resting or hyperemic mean translesional gradient >10 and/or renal fractional flow reserve <0.8 are considered severe. Knowing that correct stent size was used is the best predictor of restenosis, intravascular ultrasound is effective and well tolerated for stent sizing. The main categories of renal denervation: radiofrequency ablation, ultrasound, chemical ablation, and brachytherapy have shown impressive outcomes in treating resistant HTN.

SUMMARY

Over the past decade, several studies have shown the safety and benefit of catheter-based renal interventions in managing HTN. Renal artery stenting and renal artery denervation are the leading alternative invasive treatment employed in managing HTN.

Renal revascularization by a pedicled intestinal segment wrapping the kidney: a new method for kidney revascularization

BACKGROUND

Renal artery stenosis is caused by a heterogeneous group of diseases, including atherosclerosis and fibromuscular dysplasia, which can be treated medically, via endovascular techniques, or by open revascularization; however, satisfactory and effective results are not always obtained. We aimed to assess the possibility of renal revascularization by a pedicled intestinal segment wrapping the kidney.

METHODS

Five dogs were operated on at three steps. At the first step, laparotomy was performed, and the right kidney was released. Subsequently, an 8-10 cm segment of jejunum was separated longitudinally, and mucosectomy was done. This intestinal patch wrapped up the kidney. After eight weeks, the kidney and the intestinal patch were analyzed, and the renal artery was ligated. After four weeks, the kidney and the intestinal patch were sent for pathological evaluation.

RESULTS

At the 12th week of evaluation, no evidence of abscess formation or collection was seen. All kidneys had a normal color, consistency, and size. All renal cells were alive, and neither atrophy nor necrosis was seen. Glomerulus and tubules were intact, and no inflammatory change was visible. Furthermore, thick wall vasculature was inspected in a fibromuscular tissue, rising from the intestinal flap toward the kidney. One of the dogs expired due to peritonitis and sepsis in the fifth week.

CONCLUSION

In our study, indirect perfusion of the kidney by an intestinal patch was achieved successfully. This represents new hope in patients suffering from chronic renal failure who underwent former medical and surgical interventions with undesirable results.

Renal Arteriography via Radial Artery Access with a 125 cm Long Angiographic Catheter

A 125 cm long catheter makes it possible to perform renal arteriography via radial artery, but its feasibility and safety remain unclear. Our study recruited 1,323 patients grouped by two different vascular accesses to renal arteriography, i.e., femoral artery access and radial artery access. The success rate of angiography was 100% in both groups. Differential analysis showed that the overall complication incidence of radial artery access group was significantly lower (2.5% for radial artery access vs. 4.8% for femoral artery access, p = 0.03). From this study, we suggest that using the 125 cm angiographic catheter to perform renal arteriography via radial artery access is feasible and safe.

Imaging strategies for safety surveillance after renal artery denervation

Renal denervation has emerged as a safe and effective therapy to lower blood pressure in hypertensive patients. In addition to the main renal arteries, branch vessels are also denervated in more contemporary studies. Accurate and reliable imaging in renal denervation patients is critical for long-term safety surveillance due to the small risk of renal artery stenosis that may occur after the procedure. This review summarizes three common non-invasive imaging modalities: Doppler ultrasound (DUS), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). DUS is the most widely used owing to cost considerations, ease of use, and the fact that it is less invasive, avoids ionizing radiation exposure, and requires no contrast media use. Renal angiography is used to determine if renal artery stenosis is present when non-invasive imaging suggests renal artery stenosis. We compiled data from prior renal denervation studies as well as the more recent SPYRAL-HTN OFF MED Study and show that DUS demonstrates both high sensitivity and specificity for detecting renal stenosis de novo and in longitudinal assessment of renal artery patency after interventions. In the context of clinical trials DUS has been shown, together with the use of the baseline angiogram, to be effective in identifying stenosis in branch and accessory arteries and merits consideration as the main screening imaging modality to detect clinically significant renal artery stenosis after renal denervation and this is consistent with guidelines from the recent European Consensus Statement on Renal Denervation.

Influence of renal artery stenosis morphology on hemodynamics

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%.

Drug-coated stent implantation vs. bypass surgery for in-stent occlusion after femoropopliteal stenting

The optimal revascularization for in-stent occlusion (ISO) lesions after femoropopliteal (FP) bare-nitinol stenting has not been established. We, therefore, investigated the comparison between drug-coated stent (DCS) implantation and bypass surgery (BSX) for ISO lesions after FP bare-nitinol stenting. This study was a dual-center, observational study from January 2004 to December 2015. A total of 172 ISO lesions were observed, and after excluding 120 ISO lesions, 52 ISO lesions (50 patients; mean age, 71.0 ± 9.2 years; male, 59.6%) after FP bare-nitinol stenting were enrolled. The included patients with clinical symptoms underwent either DCS implantation (n = 28) or BSX (n = 22). The primary endpoint was recurrent in-stent restenosis (ReISR); secondary endpoints were recurrent target lesion revascularization (ReTLR), recurrent occlusion (reocclusion) and major adverse limb events (MALE), and perioperative complications (POCs), respectively. ReISR or reocclusion was defined as ISR or occlusion after TLR. Stent restenosis was defined as a peak systolic velocity ratio (PSVR) > 2.4 on a duplex scan or ≥ 50% stenosis on angiography. Graft restenosis was defined as a PSV > 300 cm/s and velocity ratio 3.5 or uniformly low PSV < 45 cm/s throughout the entire graft based on graft surveillance. The mean follow-up period was 36.6 ± 25.5 months. At 2 years, the rates of freedom from ReISR, ReTLR, and MALE were not significantly different between the DCS implantation and BSX groups (68.9% vs. 73.7%, p = 0.81; 84.7% vs. 73.7%, p = 0.45; 84.7% vs. 78.6%, p = 0.60, respectively). However, the freedom from reocclusion rate was significantly lower in the DCS implantation group (81.6% vs. 100%, p = 0.04). The occurrence of POCs was not significantly different between the DCS implantation and BSX groups (7.1% vs 4.2%, p = 1.0). Although BSX was the gold-standard therapy for ISO lesions after FP bare-nitinol stenting, DCS implantation might be a good option because the rates of freedom from ReISR, ReTLR, and MALE were similar.

Use of percutaneous transluminal renal angioplasty in atherosclerotic renal artery stenosis: a systematic review and meta-analysis

OBJECTIVE

For patients with atherosclerotic renal artery stenosis (ARAS), the role of percutaneous transluminal renal angioplasty (PTRA) remains inconclusive. This study aimed to comparatively evaluate the benefits of best medical therapy (BMT) plus PTRA and BMT alone in treating ARAS.

METHODS

We performed a systematic review and meta-analysis, and searched for all randomized, controlled trials that reported patients with ARAS. The effectiveness and safety in the BMT plus PTRA and BMT alone groups were estimated, taking into account hypertension, stroke, renal events, cardiac events, and mortality.

RESULTS

Nine randomized, controlled trials involving 2309 patients were included. In the BMT plus PTRA group, the incidence of refractory hypertension was significantly lower compared with that in the BMT alone group (odds ratio 0.09; 95% confidence interval 0.01, 0.70). However, there were no significant differences in the rates of stroke, renal events, cardiac events, cardiac mortality, and all-cause mortality between the two groups.

CONCLUSIONS

PTRA plus BMT improves blood pressure in patients with ARAS, but there is insufficient evidence for this therapy in improving stroke, renal events, cardiac events, and cardiac and all-cause mortality.

Carotid intraplaque neovascularization predicts atherosclerotic renal artery stenosis in patients with carotid artery stenosis

BACKGROUND AND AIMS

This study aimed to examine whether intraplaque neovascularization (IPN) of carotid plaques, as characterized by contrast-enhanced ultrasound (CEUS), is associated with atherosclerotic renal artery stenosis (ARAS) in patients with normal kidney function.

METHODS AND RESULTS

We investigated carotid IPN using CEUS in 198 consecutive patients with normal kidney function with and without ARAS. IPN was graded on the basis of the presence and location of microbubbles within each plaque (0, no visible microbubbles in the plaque; 1, moderate microbubbles confined to the shoulder and/or adventitial side of the plaque; and 2, extensive microbubbles throughout the plaque). The grades of each plaque were averaged to obtain an overall score per patient. ARAS was determined angiographically. We found that a higher CEUS-assessed carotid IPN score was associated with ARAS (Odd Ratio, OR: 7.281; 95% Confidence Interval, 95% CI: 3.246-16.336; P < 0.001). Furthermore, an IPN score >1.75 predicted severe stenosis with a sensitivity of 81% and specificity of 58%. Compared with using the IPN score alone, the addition of the homocysteine (HCY) cutoff value (>22.5 mmol/L) resulted in a stronger predictive value (Area Under Curve, AUC: 0.893 vs 0.834; P < 0.001) for severe ARAS.

CONCLUSION

Carotid plaque neovascularization combined with HCY levels is predictive of severe ARAS in patients with normal kidney function. CEUS-assessed carotid IPN is clinically useful for stratification of ARAS in patients with normal kidney function.

How should we define appropriate patients for percutaneous transluminal renal angioplasty treatment?

Renovascular hypertension (RVH) is one of the most common causes of secondary hypertension and can result in resistant hypertension. RVH is associated with an increased risk for progressive decline in renal function, cardiac destabilization syndromes including "flash" pulmonary edema, recurrent congestive heart failure, and cerebrocardiovascular disease. The most common cause of renal artery stenosis (RAS) is atherosclerotic lesions, followed by fibromuscular dysplasia. The endovascular technique of percutaneous transluminal renal angioplasty (PTRA) with or without stenting is one of the standard treatments for RAS. Randomized controlled trials comparing medical therapy with PTRA to medical therapy alone have failed to show a benefit of PTRA; however, the subjects of these randomized clinical trials were limited to atherosclerotic RAS patients, and patients with the most severe RAS, who would be more likely to benefit from PTRA, might not have been enrolled in these trials. This review compares international guidelines related to PTRA, reevaluates the effects of PTRA treatment on blood pressure and renal and cardiac function, discusses strategies for the management of RVH patients, and identifies factors that may predict which patients are most likely to benefit from PTRA.

Renal Artery Stenosis in the Patient with Hypertension: Prevalence, Impact and Management

Atherosclerosis is the primary cause of renal artery stenosis. Atherosclerotic renal artery stenosis (ARAS) is associated with three clinical problems: renovascular hypertension, ischemic nephropathy and cardiac destabilization syndrome which pose huge healthcare implications. There is a significant rate of natural disease progression with worsening severity of renal artery stenosis when renal revascularization is not pursued in a timely manner. Selective sub-groups of individuals with ARAS have had good outcomes after percutaneous renal artery stenting (PTRAS). For example, individuals that underwent PTRAS and had improved renal function were reported to have a 45% survival advantage compared to those without improvement in their renal function. Advances in the imaging tools have allowed for better anatomic and physiologic measurements of ARAS. Measuring translesional hemodynamic gradients has allowed for accurate assessment of ARAS severity. Renal revascularization with PTRAS provides a survival advantage in individuals with significant hemodynamic renal artery stenosis lesions. It is important that we screen, diagnosis, intervene with invasive and medical treatments appropriately in these high-risk patients.

When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis?

Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension and may lead to resistant (refractory) hypertension, progressive decline in renal function, and cardiac destabilization syndromes (pulmonary edema, recurrent heart failure, or acute coronary syndromes) despite guideline-directed medical therapy. Although randomized controlled trials comparing medical therapy with medical therapy and renal artery stenting have failed to show a benefit for renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials may not have enrolled patients with the most severe atherosclerotic renal artery stenosis, who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is critical that the hemodynamic severity of moderately severe (50% to 70%) atherosclerotic renal artery stenosis lesions be confirmed on hemodynamic measurement. The authors review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. The authors also review the current American College of Cardiology and American Heart Association guidelines and the Society for Cardiovascular Angiography and Interventions appropriate use criteria as they relate to renal stenting.

Thirty-Day Readmission After Medical Versus Endovascular Therapy for Atherosclerotic Renal Artery Stenosis

Whether renal artery stenting (RAS) confers benefit over medical therapy (MT) alone in patients with atherosclerotic renal artery stenosis admitted with acute coronary syndromes (ACS), congestive heart failure (CHF), or hypertensive crisis remains unknown. We identified a nationally-weighted cohort of 116,056 patients from the Nationwide Readmissions Database with a preexisting diagnosis of atherosclerotic renal artery stenosis and an index hospitalization diagnosis of ACS, CHF, or hypertensive crisis, and propensity-matched on the likelihood of undergoing inpatient RAS. Thirty-day readmission rates, index hospitalization complications, hospital lengths-of-stay, and cost were compared between treatment groups. Overall, all-cause, nonelective 30-day readmission rates did not differ between RAS and MT alone (18.2% vs 18.7%, respectively, p = 0.49). RAS was associated with higher index rates of acute kidney injury, major bleeding, transfusion, and vascular complications, and were similar irrespective of index hospitalization diagnosis. Index hospitalization length of stay (6 vs 4 days; p <0.001) and cost ($23,020 vs. $11,459; p <0.001) were higher with RAS. In conclusion, nearly 1-in-5 patients hospitalized with atherosclerotic renal artery stenosis and ACS, CHF, or hypertensive crisis were readmitted within 30-days. Index hospitalization complications occurred more frequently among those treated with RAS than MT alone, but the likelihood of readmission did not differ by treatment strategy.

Vascular Teams in Peripheral Vascular Disease

Peripheral vascular disease affects millions of individuals worldwide, and results in significant morbidity and mortality. The complex nature of the disease, the presence of multiple comorbidities, and the existence of a wide variety of therapeutic options suggests that a multidisciplinary approach to treatment has the potential to improve care of these patients. The success of the heart team for complex coronary artery and structural heart disease could serve as a model for the efficient and effective management of patients with peripheral vascular disease. In this paper, the authors propose a multidisciplinary vascular team approach for the treatment of critical limb ischemia, pulmonary embolism, acute ischemic stroke, and acute aortic syndromes. The successful implementation of such vascular teams has the potential to significantly enhance quality of care, improve clinical outcomes, and reduce costs. Prospective evaluation is warranted to determine how to best integrate this approach into routine clinical care.

Diagnostic and Therapeutic Approaches in the Management of Infrapopliteal Arterial Disease

Chronic limb-threatening ischemia represents end-stage peripheral artery disease. It is underdiagnosed; it relies on clinical symptoms and traditional noninvasive tests, which significantly underestimate the severity of disease. Innovative techniques, approaches, technologies, and risk-assessment tools have significantly improved our ability to treat these patients and to better understand their complex disease process. For patients with chronic limb-threatening ischemia considered without options, the reengineering of deep venous arterialization procedures has shown promising results. Finally, the creation of interactive and multidisciplinary teams in centers of excellence is of paramount importance to significantly improve the care and outcomes of these patients.

Renal and Mesenteric Artery Intervention

Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.

Iliac Artery Intervention

Endovascular revascularization for aortoiliac occlusive disease (AIOD) is now considered first-line therapy for patients with claudication and critical limb ischemia and in asymptomatic patients in whom large-bore access is required (eg, mechanical circulatory support or transcatheter aortic valve replacement). The authors review the data supporting endovascular therapy for AIOD, indications and contraindications for AIOD revascularization, as well as the procedural techniques required to safely perform endovascular therapy in this vascular bed. They review prevention and management of the major complications that can occur during these procedures. Finally, they discuss postprocedural management to maintain patency and optimize patient outcomes.