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Sarafidis PA, Theodorakopoulou M, Ortiz A, Fernandez-Fernández B, Nistor I, Schmieder R, Arici M, Saratzis A, Van der Niepen P, Halimi JM, Kreutz R, Januszewicz A, Persu A, Cozzolino M. 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). Nephrol Dial Transplant 2023; 38:2835-2850. [PMID: 37202218 PMCID: PMC10689166 DOI: 10.1093/ndt/gfad095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Indexed: 05/20/2023] Open
Abstract
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.
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Affiliation(s)
- Pantelis A Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Marieta Theodorakopoulou
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Alberto Ortiz
- Department of Nephrology and Hypertension, IIS-Fundacion Jimenez Diaz UAM, Madrid, Spain
| | | | - Ionut Nistor
- Department of Internal Medicine, Nephrology and Geriatrics, Grigore T Popa University of Medicine and Pharmacy, Iasi, Romania
- Department of Nephrology, Dr C I Parhon University Hospital, Iasi, Romania
| | - Roland Schmieder
- Department of Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
| | - Mustafa Arici
- Department of Nephrology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Athanasios Saratzis
- Department of Cardiovascular Sciences & Leicester Vascular Institute, University Hospital Leicester, Leicester, UK
| | - Patricia Van der Niepen
- Department of Nephrology & Hypertension, Universitair ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jean-Michel Halimi
- Service de Néphrologie-Hypertension, Dialyses, Transplantation rénale, CHRU Tours, Tours, France and INSERM SPHERE U1246, Université Tours, Université de Nantes, Tours, France
| | - Reinhold Kreutz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Institut für Klinische Pharmakologie und Toxikologie, Berlin, Germany
| | - Andrzej Januszewicz
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc and Pole of Cardiovascular Research, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain, Brussels, Belgium
| | - Mario Cozzolino
- Renal Division, ASST Santi Paolo e Carlo, Department of Health Sciences, University of Milan, Milan, Italy
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Bhalla V, Textor SC, Beckman JA, Casanegra AI, Cooper CJ, Kim ESH, Luther JM, Misra S, Oderich GS. Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e128-e143. [PMID: 35708012 DOI: 10.1161/hyp.0000000000000217] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Joseph A, Valakkada J, Ayappan A, Dandhaniya D. Endovascular interventions in main renal artery pathologies: an overview and update. Acta Radiol 2022; 63:964-975. [PMID: 34107749 DOI: 10.1177/02841851211019806] [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: 11/15/2022]
Abstract
Renal arteries are involved in a wide spectrum of pathologies including atherosclerosis, fibromuscular dysplasia, Takayasu arteritis, aneurysms, and aortic type B dissections extending into main renal arteries. They manifest as renovascular hypertension, renal ischemia, and cardiovascular dysfunction. The location of the renal arteries in relation to the abdominal aortic aneurysm is a critical determinant of interventional options and long-term prognosis. This article provides a comprehensive review of the role of interventional radiologists in transcatheter interventions in various pathologies involving the main renal arteries with analysis of epidemiology, pathophysiology, newer interventional techniques, and management options.
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Affiliation(s)
- Ansan Joseph
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Jineesh Valakkada
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Anoop Ayappan
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
| | - Divyesh Dandhaniya
- Department of Imaging Sciences and Interventional Radiology, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
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Campbell JE, Stone PA, Bates MC. Technical discussion of diagnostic angiography and intervention of atherosclerotic renal artery stenosis. Semin Vasc Surg 2014; 26:150-60. [PMID: 25220320 DOI: 10.1053/j.semvascsurg.2014.06.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Renal artery stenting remains an important adjuvant treatment for true-resistant hypertension, although recent disappointing randomized trials highlight the importance of careful patient selection. Safe and successful renal interventions begin with critical core knowledge regarding renal artery anatomy and understanding the often hostile nature of the parent vessel (pararenal aorta). Armed with fundamental knowledge about anatomy and renal ostial disease pathology, it becomes easier to understand the advantages of less traumatic access techniques and how low-profile contemporary flexible stents have enhanced outcomes. In addition to suggested techniques based on detailed understanding of the vessel architecture and pathology, we will review the current available US Food and Drug Administration-approved balloon-expandable on-label renal stents and discuss the role of intravascular ultrasound for definition of lesion severity, stent sizing, and stent apposition. The durability of renal stenting will also be discussed, as will the velocity criteria for duplex surveillance. Lastly, the current empirical data related to renal embolic protection is provided, along with insight into technical issues in this domain.
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Affiliation(s)
- John E Campbell
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304.
| | - Patrick A Stone
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
| | - Mark C Bates
- Department of Surgery, West Virginia University Division of Vascular and Endovascular Surgery, Vascular Center of Excellence, Charleston Area Medical Center, 3100 MacCorkle Avenue SE, Charleston, West Virginia 25304
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Ritschl LM, Fichter AM, von Düring M, Mitchell DA, Wolff KD, Mücke T. Introduction of a microsurgical in-vivo embolization-model in rats: the aorta-filter model. PLoS One 2014; 9:e89947. [PMID: 24587143 PMCID: PMC3935969 DOI: 10.1371/journal.pone.0089947] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 01/24/2014] [Indexed: 11/28/2022] Open
Abstract
Vascular thrombosis with subsequent distal embolization remains a critical event for patients. Prevention of this life-threatening event can be achieved pharmacologically or mechanically with intravascular filter systems. The ability to evaluate the risk of embolization of certain techniques and procedures in vascular and microvascular surgery, such as, tissue glue or fibrin based haemostatic agents lacks convincing models. We performed 64 microvascular anastomoses in 44 rats, including 44 micro-pore polyurethane filter-anastomoses and 20 non-filter anastomoses. The rats were re-anesthetized and the aorta was re-exposed and removed four hours, three, seven, fourteen, thirty-one days, and six months postoperatively. The specimens were examined macro- and microscopically with regard to the appearance of the vessel wall, condition of the filter and the amount of thrombembolic material. Typical postoperative histopathological changes in vessel architecture were observed. Media necrosis was the first significant change three days postoperatively. Localized intimal hyperplasia, media necrosis, increase of media fibromyocytes and adventitial hypercellularity were seen to a significant extent at day seven postoperatively. Significant neovascularization of adventitia adjacent to the filter was seen after 14 days. A significant amount of thrombotic material was seen after four hours, three and 14 days interval. Only three intravascular filters became completely occluded (6.82%). The aorta-filter-anastomosis model appeared to be a valid in-vivo model in situations at risk for thrombembolic events, for microsurgical research and allowed sensitive analysis of surgical procedures and protection of the vascularized tissue. It may be suitable for a wide range of in-vivo microvascular experiments particularly in the rat model.
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Affiliation(s)
- Lucas M. Ritschl
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Andreas M. Fichter
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | | | - David A. Mitchell
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Klaus-Dietrich Wolff
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
| | - Thomas Mücke
- Department of Oral and Maxillofacial Surgery, Technical University of Munich, Klinikum Rechts der Isar, Munich, Germany
- * E-mail:
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Shirasu T, Hosaka A, Okamoto H, Shigematsu K, Takeda Y, Miyata T, Watanabe T. Bowel necrosis following endovascular revascularization for chronic mesenteric ischemia: a case report and review of the literature. BMC Gastroenterol 2013; 13:118. [PMID: 23865626 PMCID: PMC3727947 DOI: 10.1186/1471-230x-13-118] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 07/11/2013] [Indexed: 12/17/2022] Open
Abstract
Background Endovascular revascularization has recently been established as a less invasive treatment method for chronic mesenteric ischemia. However, intestinal necrosis caused by distal embolization following this procedure has not been emphasized. Case presentation The present report describes a 59-year-old man who was treated with endovascular revascularization for chronic mesenteric ischemia. After the procedure, he was diagnosed with intestinal necrosis caused by distal embolization. Despite emergent bowel resection, he died on postoperative day 109. Conclusion Although endovascular revascularization for chronic mesenteric ischemia is less invasive and may be suitable for high-risk patients, attention should be paid to avoid embolic complications that can cause intestinal infarction possibly leading to a fatal condition.
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Affiliation(s)
- Takuro Shirasu
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Textor SC, Misra S, Oderich GS. Percutaneous revascularization for ischemic nephropathy: the past, present, and future. Kidney Int 2012; 83:28-40. [PMID: 23151953 PMCID: PMC3532568 DOI: 10.1038/ki.2012.363] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Occlusion of the renal arteries can threaten the viability of the kidney when severe, in addition to accelerating hypertension and circulatory congestion. Renal artery stenting procedures have evolved from a treatment mainly for renovascular hypertension to a maneuver capable of recovering threatened renal function in patients with “ischemic nephropathy” and improving management of congestive heart failure. Improved catheter design and techniques have reduced, but not eliminated hazards associated with renovascular stenting. Expanded use of endovascular stent grafts to treat abdominal aortic aneurysms has introduced a new indication for renal artery stenting to protect the renal circulation when grafts cross the origins of the renal arteries. Although controversial, prospective randomized trials to evaluate the added benefit of revascularization to current medical therapy for atherosclerotic renal artery stenosis until now have failed to identify major benefits regarding either renal function or blood pressure control. These studies have been limited by selection bias and have been harshly criticized. While studies of tissue oxygenation using blood oxygen level dependent (BOLD) MR establish that kidneys can adapt to reduced blood flow to some degree, more severe occlusive disease leads to cortical hypoxia associated with microvascular rarefication, inflammatory injury and fibrosis. Current research is directed toward identifying pathways of irreversible kidney injury due to vascular occlusion and to increase the potential for renal repair after restoring renal artery patency. The role of nephrologists likely will focus upon recognizing the limits of renal adaptation to vascular disease and identifying kidneys truly at risk for ischemic injury at a time point when renal revascularization can still be of benefit to recovering kidney function.
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Affiliation(s)
- Stephen C Textor
- Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
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Khosla A, Misra S, Greene EL, Pflueger A, Textor SC, Bjarnason H, McKusick MA. Clinical outcomes in patients with renal artery stenosis treated with stent placement with embolic protection compared with those treated with stent alone. Vasc Endovascular Surg 2012; 46:447-54. [PMID: 22692467 DOI: 10.1177/1538574412449911] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To compare the clinical outcomes in patients with chronic renal insufficiency (CRI) and renal artery stenosis (RAS) following renal artery (RA) stent placement with and without embolic protection device (EPD) usage. MATERIALS AND METHODS Eighteen patients who had RA stent placement with EPD were matched to control patients (RA stent only). Blood pressure, number of hypertensive medications, and estimated glomerular filtration rate (eGFR) at 3 months before the procedure and after 12 months were determined. An increase of ≥ 20% in eGFR at 12 months from baseline was defined as "improvement," decrease of ≥ 20% as "deterioration," and an eGFR change between those values as "stabilization" at 12 months. RESULTS At 12 months, stage 4 patients treated with EPD had significantly higher eGFR than controls (P = .01). There was no statistical difference in blood pressure outcomes between the 2 groups. CONCLUSIONS Patients with stage 4 CRI did significantly better with EPD than those treated without it.
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Affiliation(s)
- Ankaj Khosla
- Department of Radiology, School of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Renal artery intervention to treat hypertension is one of the frontiers of ongoing research in combating this epidemic. This article focuses on recent data regarding PTRS and catheter-based renal sympathetic denervation. Despite progress in this field large multicenter, randomized trials that compare these treatment modalities with medical therapy for hypertension are lacking.
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Affiliation(s)
- Rajan A G Patel
- Department of Cardiology, Ochsner Clinic Foundation, New Orleans, LA 70121, USA
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Laird JR, Tehrani F, Soukas P, Joye JD, Ansel GM, Rocha-Singh K. Feasibility of FiberNet® embolic protection system in patients undergoing angioplasty for atherosclerotic renal artery stenosis. Catheter Cardiovasc Interv 2011; 79:430-6. [PMID: 21805607 DOI: 10.1002/ccd.23292] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 06/25/2011] [Indexed: 11/08/2022]
Affiliation(s)
- John R Laird
- The Division of Cardiovascular Medicine and the Vascular Center, UC Davis Medical Center, Sacramento, California 95817, USA.
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Abstract
Renal artery stenosis (RAS) is the most commonly caused by atherosclerosis, with fibromuscular dysplasia being the most frequent among other less common etiologies. A high index of suspicion based on clinical features is essential for diagnosis. Revascularization strategies are currently a topic of discussion and debate. When revascularization is deemed appropriate, atherosclerotic RAS is most often treated with stent placement, whereas patients with fibromuscular dysplasia are usually treated with balloon angioplasty. Ongoing randomized trials should help to better define the optimal management of RAS.
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Abstract
Some degree of distal embolization likely occurs during all transcatheter interventional procedures. The clinical sequela is defined by the sensitivity of the target organ to segmental ischemia and the burden of embolic load. The spectrum of clinical consequences varies from the extremes of stroke and no-reflow phenomena in the carotid and coronaries, respectively, to silent renal insult following renal stenting. The clinical sequela of stroke and myocardial infarction in these most sensitive end-organ distributions led to the birth of embolic protection science. Over the past 2 decades embolic protection has matured and we now have a menu of devices to consider based on our specific patient clinical and anatomic needs. The goal of this narrative is to provide an update on protection device science and, more importantly, a very practical informal guide to the currently available technologies with emphasis on the pitfalls common to specific device families.
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Affiliation(s)
- Mark C Bates
- Department of Surgery, West Virginia University School of Medicine, Charleston, WV 25304, USA.
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13
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Abstract
Renovascular diseases are common conditions with important implications on cardiovascular morbidity and mortality. Renal artery stenosis (RAS) is present in 1-5% of patients with hypertension (HTN) in the US with the vast majority of caused by atherosclerosis. Atherosclerotic RAS is related not only to uncontrolled HTN, but also to renal dysfunction. Atherosclerotic RAS in the USA has been reported to account for approximately 14-16% of new patients requiring dialysis each year. Hence a concerted effort was made in the last decade to treat renovascular stenosis using newly developed endovascular therapies to improve cardiovascular morbidity and renal function. A review on new advances in the endovascular management of renal artery stenosis with low profile stents, embolic protection devices, and drug eluting stents is presented.
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