Percutaneous Revascularization for Atherosclerotic Renal Artery Stenosis: A Meta-Analysis of Randomized Controlled Trials

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.

Renovascular Hypertension

Renovascular hypertension (RVH) is relatively common but underrecognized cause of resistant hypertension in clinical practice. Most patients with RVH have suboptimal control of hypertension in spite of being on multiple anti hypertensive medications. Prompt diagnosis and management is crucial to prevent long term morbidity and mortality. Initial evaluation by primary care physicians can expedite this to improve patient outcomes by co-managing hypertension specialists. In addition to pharmacologic and nonpharmacologic measures, some patients may benefit from angioplasty. This article discusses various definitions of hypertension, approach to diagnosis of RVH, and management. Data from clinical trials are discussed with evidence-based medicine practice recommendations.

[Percutaneous angioplasty of renal artery stenosis: Short- and long-term results]

INTRODUCTION

Renal artery stenosis (RAS) may be symptomatic. The treatment of these lesions is primarily medical but may sometimes require surgical or endovascular revascularization. RAS angioplasty is well controlled but its results are discussed. The objective of this work was to report the short- and long-term results of the endovascular treatment of renal arteries in our center.

METHODS

We report a retrospective study between 2013 and 2018, including patients who received endovascular treatment for severe symptomatic RAS (≥75%).

RESULTS

Our population consisted of 17 patients. Mean age was 51.1 years [18-76], sex ratio 2.4. RAS was discovered during work-up for severe renovascular hypertension resistant to medical treatment for 16 patients and rapidly progressive renal failure for one patient. The etiology retained was: atherosclerosis (9 cases), fibromuscular dysplasia (6 cases) and Takayasu's disease (2 cases). The average stenosis rate was 85.9% [75-97%]. We performed simple angioplasty in 47% of the cases and stenting in 53%. The technical success rate was 100%. At 1 month, morbidity-mortality rates were zero. Mean follow-up was 12 months [6-36 months]. Patients with renovascular hypertension experienced a decrease in blood pressure, with discontinuation of antihypertensive therapy in 62.5% of cases and reduction of doses in 37.5% of cases. The permeability rate was 100% at 1 year, 94% at 2 years and 94% at 3 years. One patient had asymptomatic stent thrombosis at the 18th month. The restenosis rate was zero.

CONCLUSION

Angioplasty of symptomatic RAS may be indicated as first-line treatment. It is associated with satisfactory results in the short and long terms.

Endovascular Management of Atherosclerotic Renal Artery Stenosis: Post-Cardiovascular Outcomes in Renal Atherosclerotic Lesions Era Winner or False Alarm?

Renal artery stenosis (RAS) is frequently associated with severe comorbidities such as reduced renal perfusion, hypertension, and end-stage renal failure. In approximately 90% of patients, renal artery atherosclerosis is the main cause for RAS, and it is associated with an increased risk for fatal and non-fatal cardiovascular and renal complications. Endovascular management of atherosclerotic RAS (ARAS) has been recently evaluated by several randomized controlled trials that failed to demonstrate benefit of stenting. Furthermore, the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study did not demonstrate any benefit over the revascularization approach. In this review, we summarized the available data from retrospective, prospective and randomized trials on ARAS to provide clinicians with sufficient data in order to produce useful conclusions for everyday clinical practice.