Restenosis Rates After Drug-Eluting Stent Treatment for Stenotic Small-Diameter Renal Arteries

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.

Double kiss mini-crush technique to treat complex recurrent renal artery in-stent restenosis

The double-kiss mini-crush (DKMC) technique has been successfully deployed in the past for the treatment of complex coronary lesions even for left main lesions. Our case report consists of a proof-of-principle that the DKMC technique can be successfully translated as well to the field of complex renal artery lesions. Insightful thinking out-of-the "coronary" box in concert with skillful off-label application of coronary stenting procedures may open the gate for unprecedented opportunities for the treatment of difficult-to-tackle in-stent restenosis in the renal circulation.

Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association

Renovascular disease is a major causal factor for secondary hypertension and renal ischemic disease. However, several prospective, randomized trials for atherosclerotic disease failed to demonstrate that renal revascularization is more effective than medical therapy for most patients. These results have greatly reduced the generalized diagnostic workup and use of renal revascularization. Most guidelines and review articles emphasize the limited average improvement and fail to identify those clinical populations that do benefit from revascularization. On the basis of the clinical experience of hypertension centers, specialists have continued selective revascularization, albeit without a summary statement by a major, multidisciplinary, national organization that identifies specific populations that may benefit. In this scientific statement for health care professionals and the public-at-large, we review the strengths and weaknesses of randomized trials in revascularization and highlight (1) when referral for consideration of diagnostic workup and therapy may be warranted, (2) the evidence/rationale for these selective scenarios, (3) interventional and surgical techniques for effective revascularization, and (4) areas of research with unmet need.

Factors predicting long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery for chronic mesenteric ischemia

Background: To analyse the long-term outcomes of percutaneous angioplasty and stenting of the superior mesenteric artery (SMA) in the treatment of chronic mesenteric ischemia (CMI), and to assess predictive factors for a better clinical outcome. Patients and methods: Retrospective analysis of 76 consecutive patients, treated percutaneously for CMI between January 1999 and January 2018 and followed up until the end of 2018. Patients' pre-, peri- and post-interventional clinical and radiological data were gathered from the institutional electronic medical records. The Kaplan Meier method with log rank test or the Cox model were used to analyse overall survival; the cumulative incidence function with Pepe and Mori test or the Fine and Grey model were used to analyse relapse-free survival, considering death as a competing event. Results: Seventy-six consecutive patients with a mean age of 72 years were included in the study. Catheter-angiography revealed an ostial or non-ostial >90% stenosis in n=23 (29.7%) and n=53 (69.7%) of included patients, respectively. Immediate clinical success was achieved in n=68 (89.5%), and procedural complications were observed in n=13 (17.1%) patients. Long-term follow-up revealed relapse of symptoms in n=21 (28.8%) patients, and overall survival estimates are 81.8%, 57.0% and 28.2% after two, five and ten years of follow-up, respectively. A trend towards longer relapse-free survival was found in the circumferential stenosis group (78.2% at five years) compared with the non-circumferential stenosis group (55.5%) (P=0.063). Conclusions: Angioplasty and stenting of the SMA for CMI is relatively safe and effective despite a substantial number of patients experiencing clinical relapse over time. Patients with focal, circumferential stenosis might have longer relapse-free survival than patients with non-circumferential stenosis.

The birth, decline, and contemporary re-emergence of endovascular brachytherapy for prevention of in-stent restenosis

Despite the advent of drug-eluting stents and dual antiplatelet therapy in the interventional management of cardiovascular disease, restenosis rates remain high with significant sequelae. Endovascular brachytherapy-popular in the 1990s and early 2000s-has recently resurfaced as a cost-effective treatment option. In this work, we outline the history of endovascular brachytherapy starting with its earliest promise in the 1990s. We discuss the development of drug-eluting stents and dual antiplatelet strategies and their impact on the perceived benefit of endovascular brachytherapy. For the contemporary era, we propose novel roles for endovascular brachytherapy in complex coronary artery disease and in high-risk patients managed with drug-eluting stents. We discuss the impetus for reducing the requirement and duration of dual antiplatelet therapy using endovascular brachytherapy. We also review innovative opportunities for endovascular brachytherapy after bare-metal stent placement in both coronary and noncoronary territories and offer economic arguments in favor of endovascular brachytherapy. Trials of endovascular brachytherapy in these regimes are merited.

Long-term outcomes and determinants of stenosis recurrence after renal artery angioplasty in hypertensive patients with renovascular disease

INTRODUCTION

Restenosis (RS) following percutaneous angioplasty (PTA) of renal artery stenosis (RAS) might have an unfavourable impact on renal function and blood pressure (BP) outcomes.

AIM

To evaluate the prevalence and predictors of RS in patients treated with PTA for RAS, and the relationship between BP and renal function (RF) changes with RS.

MATERIAL AND METHODS

We analysed freedom from RS in 210 patients (age 64.6 ±12.8 years; range: 20-85), who underwent 248 successful stent-assisted PTAs in RAS. The change in levels of serum creatinine (SCC), estimated glomerular filtration rate (eGFR), systolic/diastolic BPs (SBP/DBP) were analysed prior to PTA, at 6-, 12-month, and final follow-up visits, and whenever RS was diagnosed.

RESULTS

RS was identified in 30 (14.3%) patients, and there were 36 (14.5%) lesions. The Kaplan-Meier RS-free survival curves in fibromuscular dysplasia, atherosclerosis, and vasculitis at 1 and 7 years were: 100% and 100%; 95.6 and 83.9%; and 71.4 and 39.7%, respectively. Patients with RS, as compared to RS-free patients, presented with less pronounced changes in respect with: SBP (1.4 ±17.6 vs. -15.8 ±25.8 mm Hg; p = 0.01), DBP (2.64 ±10.1 vs. -6.5 ±14.1 mm Hg; p = 0.002), SCC (22.4 ±55.2 vs. -3.6 ±43.9 µmol/l; p = 0.002), and eGFR (-1.85 ±18 vs. -5.34 ±19.5 mm Hg; p = 0.045). In multivariate Cox regression analysis, independent predictors of RS occurred: lack of BP decrease (HR = 4.19, 95% CI: 1.67-10.3; p = 0.002), eGFR increase < 0.17 ml/min/1.73 m2 (HR = 2.93, 95% CI: 1.08-7.91; p = 0.033), stent diameter ≤ 5 mm (HR = 2.76, 95% CI: 1.09-6.97; p = 0.031), and vasculitis (HR = 5.61, 95% CI: 1.83-17.2; p = 0.003). RS was treated in 24 patients with RS recurrence in 20%.

CONCLUSIONS

The RS rate differs depending on RAS aetiology. Lack of SBP/DBP and eGFR improvement, vasculitis, and stent diameter are associated with RS risk. Repeated PTA is effective, but recurrent RS occurs in 20% of cases.