Atheroembolism during percutaneous renal artery revascularization

The Implications of Acute Anatomic Injury After Percutaneous Renal Intervention

PURPOSE

Percutaneous renal artery revascularization for hypertension and renal dysfunction remains common. The frequency, cause, and outcomes of anatomic injury associated with renal intervention are poorly delineated. This study aims to determine the frequency of acute anatomic renal injury after renal artery interventions, identify factors associated with anatomic renal injury, and determine whether anatomic renal injury related to renal intervention is associated with late adverse clinical events.

METHODS

A retrospective analysis of patients undergoing renal artery interventions for atherosclerotic renal artery disease between 2002 and 2022 was performed. Acute anatomic renal injury encompassed renal artery dissection, renal artery perforation, acute occlusion, renal parenchymal infarction, and renal parenchymal perforation. Freedom from renal-related morbidity (increase in persistent creatinine >20% of baseline, progression to hemodialysis, death from renal-related causes) and patient survival were measured.

RESULTS

A total of 968 patients underwent 1309 renal artery interventions: 47% for hypertension, 25% for hypertension associated with chronic renal dysfunction, and 28% for chronic renal dysfunction. An acute anatomic renal injury occurred in 5.9% of the patients. The occurrence of an anatomic injury was associated with a significant decrement in freedom from renal-related morbidity (79±2% vs 55±8%, no-injury vs injury group, mean±standard error of the mean; p=0.003) and markedly decreased survival at 5 year follow-up (78±3% vs 48±8%; p=0.002). No factor was identified that predicted anatomic injury. In those patients with anatomic injury, perforation was associated with decreased survival, while estimated glomerular filtration rate <60, resistive index >0.8, and dissection were associated with a lack of retained renal benefit.

CONCLUSION

Acute anatomic renal injury occurs in approximately 6% of patients undergoing percutaneous renal artery intervention and is a negative predictor of survival and is associated with subsequent renal failure, need for dialysis, and death from renal-related causes.

CLINICAL IMPACT

Acute anatomic renal injury occurs in approximately 5% of patients undergoing percutaneous renal artery intervention. Modern endovascular interventions allow for the control and remediation of injuries in the majority of cases with an overall low mortality and morbidity. There is a significant early occlusion of renal arteries following the injury within 1 month. In the long term, the occurrence of injury is a negative predictor of survival and is associated with subsequent renal failure, the need for dialysis, and death from renal-related causes.

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.

PET/CTA detection of muscle inflammation related to cholesterol crystal emboli without arterial obstruction

BACKGROUND

PET/CTA was used to evaluate the effect of cholesterol crystal emboli (CCE) on muscle injury. Cholesterol crystals (CCs) released during plaque rupture travel downstream and lodge in muscle triggering inflammation and tissue injury.

METHODS

Thigh muscles in three groups of rabbits (n = 22) were studied after intra-arterial injection of CCs, Group I (n = 10); polystyrene microspheres, Group II (n = 5); or normal saline, Group III (n = 7). After 48 hours, muscle inflammation and injury were measured by fluorodeoxy-glucose uptake using PET/CTA, serum tissue factor (TF), and creatinine phosphokinase (CPK). Macrophages were stained with RAM11 and CCs with Bodipy.

RESULTS

SUVmax of thigh muscles was greater for Group I vs Group II and III (0.40 ± 0.16 vs 0.21 ± 0.11, P = .038 and 0.23 ± 0.06, P = .036). CPK levels rose significantly in Group I vs Group II and III (6.7 ± 6.0 vs 0.6 ± 0.4, P = .007 and 0.9 ± 0.4 mg·dL-1, P = .023). No arterial thrombosis was detected by CTA or histology of embolized arteries and TF did not rise significantly. There were extensive macrophage infiltrates surrounding muscle necrosis in Group I only.

CONCLUSIONS

Cholesterol crystal emboli triggered muscle inflammation and necrosis with an intact circulation. PET/CTA may help in the early detection of inflammation caused by CCs.

Minimally invasive percutaneous transluminal renal artery stenting

BACKGROUND

Minimally invasive percutaneous transluminal renal artery stenting (MIPTRS) is a method that prevents complications to the greatest extent possible. The present study aimed to investigate the safety and efficacy of MIPTRS performed in cases of renal artery stenosis with an estimated glomerular filtration rate (eGFR)≤45mL/min.

METHODS

Cases of patients who underwent MIPTRS at our hospital between December 2010 and June 2015 in whom eGFR was ≤45mL/min were retrospectively analysed. MIPTRS was performed as follows: 1) using a 4Fr sheathless guiding catheter in a trans-radial approach and 2) using a guiding catheter non-touch technique. The amount of contrast agent used was maintained at ≤10mL with 3) carbon dioxide enhancement and 4) intravascular ultrasound guide stenting, and 5) a distal protection device was used.

RESULTS

MIPTRS was performed in 22 patients (32 lesions). The pre-MIPTRS creatinine level and eGFR were 2.01±0.88mg/dL and 29.2±9.0mL/min/1.73m², respectively. On postoperative day 2, they were 1.78±0.73mg/dL and 35.1±12.3mL/min/1.73m²; at 1month after the procedure, they were 1.80±0.74mg/dL and 33.3±12.3mL/min/1.73m². Creatinine level did not change significantly, but eGFR was significantly elevated after versus before the procedure, both 2days later (p<0.01) and 1month later (p<0.05).

CONCLUSION

The results of this study demonstrated the usefulness of MIPTRS for protecting renal function. This method can be safely used in patients with decreased renal function.

Frequency of Cholesterol Crystals in Culprit Coronary Artery Aspirate During Acute Myocardial Infarction and Their Relation to Inflammation and Myocardial Injury

Cholesterol crystals (CCs) have been associated with plaque rupture through mechanical injury and inflammation. This study evaluated the presence of CCs during acute myocardial infarction (AMI) and associated myocardial injury, inflammation, and arterial blood flow before and after percutaneous coronary intervention. Patients presenting with AMI (n = 286) had aspiration of culprit coronary artery obstruction. Aspirates were evaluated for crystal content, size, composition, and morphology by scanning electron microscopy, crystallography, and infrared spectroscopy. These were correlated with inflammatory biomarkers, cardiac enzymes, % coronary stenosis, and Thrombolysis in Myocardial Infarction (TIMI) blush and flow grades. Crystals were detected in 254 patients (89%) and confirmed to be cholesterol by spectroscopy. Of 286 patients 240 (84%) had CCs compacted into clusters that were large enough to be measured and analyzed. Moderate to extensive CC content was present in 172 cases (60%). Totally occluded arteries had significantly larger CC clusters than partially occluded arteries (p <0.05). Patients with CC cluster area >12,000 µm² had significantly elevated interleukin-1 beta (IL-1β) levels (p <0.01), were less likely to have TIMI blush grade of 3 (p <0.01), and more likely to have TIMI flow grade of 1 (p <0.01). Patients with recurrent AMI had smaller CC cluster area (p <0.04), lower troponin (p <0.02), and IL-1β levels (p <0.04). Women had smaller CC clusters (p <0.04). Macrophages in the aspirates were found to be attached to CCs. Coronary artery aspirates had extensive deposits of CCs during AMI. In conclusion, presence of large CC clusters was associated with increased inflammation (IL-1β), increased arterial narrowing, and diminished reflow following percutaneous coronary intervention.

Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts

OBJECTIVE

The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden.

METHODS

The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm³) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction.

RESULTS

The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016).

CONCLUSIONS

AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Technical discussion of diagnostic angiography and intervention of atherosclerotic renal artery stenosis

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.

Results of the retrospective analysis of renal artery stenting for the salvage of renal function study

Renal artery stenting is expected to improve or stabilize renal function. However, the efficacy of renal artery stenting in severely reduced renal function is unclear. We evaluated 23 patients with class IV or V renal dysfunction who were treated for renal artery stenosis between 2004 and 2009. Improvement in renal function was found in 7 (30%) patients, all of whom were treated with distal protection device. Deterioration of renal function was found in 4 (17%) cases. In these 4 cases, distal protection device could not be used for anatomical reasons. The use of distal protection device was associated with significantly less renal deterioration after the procedure (P < .05, odds ratio 0.21 [confidence interval 0.09-0.50]). Renal artery stenting can stabilize or improve renal function in patients with severe renal dysfunction. Distal protection devices may be beneficial in patients who require renal artery stenting due to severely reduced renal function.

Comparison of embolic load in femoropopliteal interventions: percutaneous transluminal angioplasty versus stenting

PURPOSE

To compare the incidence of distal emboli occurring during percutaneous transluminal angioplasty (PTA) and primary stent on the superficial femoral artery (SFA) METHODS: A total of 50 consecutive patients were entered in a prospective, randomized trial. Inclusion criteria were the presence of symptomatic limb ischemia due to stenosis or occlusion of the SFA. An embolic protection device was placed in the popliteal artery. The patients were then randomly assigned to undergo primary stent implantation or PTA. The filters were retrieved and sent for histologic examination.

RESULTS

Stenting in the SFA produced more emboli (1.44 mm(3)) than PTA (0.772 mm(3)), P = .031. Reanalyzing the patients according to actual treatment performed, volume of debris in the stent group was 1.271 mm(3) and in the PTA group was 0.191 mm(3), P = .00087.

CONCLUSION

Volume of embolized material during endovascular interventions in the SFA-above-knee popliteal artery is higher when a stent is used.

Pitfalls of embolic protection

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.

Predictors of embolization during protected renal artery angioplasty and stenting: Role of antiplatelet therapy

OBJECTIVE

The objective of this study was to identify the predictors of distal embolization (DE) during protected renal artery angioplasty and stenting.

BACKGROUND

DE may contribute to worsening renal function after renal artery stenting. The factors associated with DE, rates of platelet-rich emboli, and treatments that may prevent DE during renal stenting have not been evaluated.

METHODS

The current study evaluated patients randomized to receive an embolic protection device (EPD) in the RESIST trial. Forty-two patients were identified for inclusion in this study. These patients were further randomized to abciximab (N = 22) or placebo (N = 20). Modification in Diet in Renal Disease glomerular filtration rate (GFR) was used as the primary measure of renal function. Creatinine was measured by a modified Jaffe reaction using the IDMS-traceable assay. The primary endpoint was capture of platelet rich emboli in the angioguard basket.

RESULTS

DE occurred in 15/42 (35%) of the patients and platelet rich DE in 10 (24%) of the patients who received an EPD. Of the angiographic characteristics only lesion length was significantly higher in patients with DE (16 +/- 7 mm vs. 10 +/- 5 mm, P = 0.04). Preprocedural abciximab reduced DE from 42 to 8% (P = 0.02). The rate of platelet rich emboli was 50% with neither abciximab nor a thienopyridine, 36% with thienopyridine only, 15% abciximab only, and 0% in patients who received both a thienopyridine and abciximab. Only Abciximab use was associated with improved renal function at 1-month, thienopyridine was not. Angiographic characteristics including percent stenosis, minimal luminal diameter (MLD), reference diameter, change in MLD, contrast volume, and procedure time were not predictors of DE during renal stenting.

CONCLUSION

Capture of DE and specifically platelet DE are common during protected renal stenting using a filter-type EPD. Abciximab use, and potentially combined thienopyridine and abciximab use, decreased the rate of platelet rich DE; however, only abciximab improved renal function at 1-month.

Management of renal artery stenosis: the case for intervention, defending current guidelines, and screening (drive-by) renal angiography at the time of catheterization

There is little debate that an untreated significant obstruction of blood flow to the kidney, most often due to atherosclerosis, is potentially hazardous to the health of patients. The treatment of atherosclerotic renovascular disease has evolved over the past 20 years from open surgery with its inherent morbidity and risk of mortality to percutaneous endovascular treatment with stents. The current debate is on the question of which patients are offered any additional advantage by revascularization for renal artery stenosis over medications alone. The primary issue is patient selection, including the most appropriate screening strategies for renal artery stenosis, which must be balanced against the risk of procedure-related complications. The goal of this paper is to explore the most appropriate utilization of revascularization with renal stent placement.

Embolic protection devices for peripheral application: wasteful or useful?

Distal embolization following percutaneous intervention is a universal phenomenon that has been reported in various vascular beds. Distal emboli are also very common during lower extremity percutaneous peripheral interventions. Some data from case reports and registries are currently available. Clinical data have shown that the application of an embolic protection device in the lower limb arteries is safe. Prospective and, ideally, randomized trial data are warranted to justify the increased use of filters in lower extremity interventions, despite the obvious benefits that these devices provide. However, the clinical relevance of distal embolization in the lower extremity remains unquantified.

Diagnosis and management of atherosclerotic renal artery stenosis: improving patient selection and outcomes

Renal artery stenosis (RAS) is common among patients with atherosclerosis, and is found in 20-30% of individuals who undergo diagnostic cardiac catheterization. Renal artery duplex ultrasonography is the diagnostic procedure of choice for screening outpatients for RAS. Percutaneous renal artery stent placement is the preferred method of revascularization for hemodynamically significant RAS, and is favored over balloon angioplasty alone. Stent placement carries a class I recommendation for atherosclerotic RAS according to ACC and AHA guidelines. Discordance exists between the very high (>95%) procedural success rate and the moderate (60-70%) clinical response rate after renal stent placement, which is likely to be a result of poor selection of patients, inadequate angiographic assessment of lesion severity, and the presence of renal parencyhmal disease. Physiologic lesion assessment using translesional pressure gradients, and measurements of biomarkers (e.g. brain natriuretic peptide), or both, could enhance the selection of patients and improve clinical response rates. Long-term patency rates for renal stenting are excellent, with 5-year secondary patency rates greater than 90%. This Review will outline the clinical problem of atherosclerotic RAS and its diagnosis, and will critically assess treatment options and strategies to improve patients' outcomes.

Distal embolic event protection using excimer laser ablation in peripheral vascular interventions: results of the DEEP EMBOLI registry

PURPOSE

To report the results from a single-center prospective registry (DEEP EMBOLI) established to evaluate distal embolization during percutaneous lower extremity interventions using excimer laser ablative therapy.

METHODS

Elective patients with infrainguinal occlusive disease were eligible for this registry if the lesion(s) met one or more of these angiographic criteria: (1) moderate or severe calcification of any length, (2) total occlusions of any length, (3) a filling defect, (4) irregular (ulcerated) lesions at least 30 mm in length, and/or (5) smooth, non-ulcerated lesions at least 50 mm in length. In all, 20 patients (15 women; mean age 70.9+/-10.8 years) with 28 lesions (de novo 13, restenotic 15) were enrolled and underwent treatment with laser atherectomy. SpiderFx filters were utilized before laser treatment in 18 of 20 patients and before final definitive treatment with angioplasty +/- stenting in all 20 patients. The primary angiographic outcome was a residual narrowing of <30% or 30% to 50% with <20 mmHg gradient across lesion after final treatment. The primary safety endpoint was the embolization rate produced by the laser based on the presence of clinically significant (>or=2 mm long) macrodebris in the filter.

RESULTS

Adjunctive angioplasty and stenting were performed in 27 (96.4%) and 17 (60.7%) lesions, respectively. All filters were deployed and retrieved successfully, with no complications. The primary angiographic endpoint was met in 100% of patients. Macrodebris was found in 12 (66.7%) of 18 patients after treatment with the laser [4 (22.2%) filters with clinically significant emboli] and in 7 (35%) of 20 patients after adjunctive treatment [4 (20.0%) clinically significant emboli]. One (5.0%) distal embolization occurred after filter removal prior to completion of definitive treatment.

CONCLUSION

Embolization does occur with laser photoablation in the lower extremity, but the rate of clinically significant macrodebris is low ( approximately 20%) and similar to that found after angioplasty and stenting. Embolic filter protection appears to be very effective in capturing macrodebris, and its use is associated with good acute angiographic outcome. Problems with filter retrieval were not encountered.

[Hypertension in patients with renal artery stenosis]

Renal artery stenosis (RAS) is often present in patients with severe hypertension and atherosclerotic vascular disease. In this setting it is important to screen patients for renovascular disease, e.g. with Duplex-ultrasound, CT- or MR-angiography. The challenge of treating these patients is to find the evidence proving that the RAS is responsible for hypertension and/or renal dysfunction. Measurement of the intra-arterial pressure gradient is necessary in order to determine hemodynamic relevance. On the other side, in these patients hypertension is often of primary and/or renoparenchymatous origin and is aggravated by a renovascular disease. This explains why hypertension cannot be cured even if a high grade stenosis has been removed. In addition, thromb- and cholesterol-embolic material is often mobilized during an invasive procedure and leads to renaparenchymatous ischemia which sustains hypertension after intervention. An individual evaluation of profit versus risk is important for the decision for or against an invasive procedure, especially since there is no sufficient evidence for a decrease of mortality after interventions of RAS. The optimal conservative treatment, including the treatment of atherosclerotic risk factors is recommended.

Preventing lower extremity distal embolization using embolic filter protection: results of the PROTECT registry

PURPOSE

To report the results from a single-center prospective registry (PROTECT) established to evaluate the safety and effectiveness of embolic filter protection (EFP) in reducing distal embolization during percutaneous lower extremity interventions.

METHODS

Patients undergoing angioplasty, stenting, or SilverHawk atherectomy and adjunctive balloon angioplasty for infrainguinal occlusive disease were eligible if the lesion(s) met one or more of these angiographic criteria: (1) moderate or severe calcification of any length, (2) total occlusions of any length, (3) a filling defect, (4) irregular (ulcerated) lesions at least 30 mm in length, and/or (5) smooth, non-ulcerated lesions at least 50 mm in length. The primary angiographic outcome was the ability of the filter to prevent angiographically visible distal embolization, slow flow, and loss of distal tibial runoff with or without capturing macrodebris.

RESULTS

Forty patients (23 men; mean age 71.4+/-11.5 years) with 56 lesions (42 de novo and 14 restenotic) underwent treatment with angioplasty/stenting (group A, n = 29; 43 lesions) or SilverHawk atherectomy (group B, n = 11; 13 lesions). One filter was used per patient (25 SpiderFX and 15 EmboShield). Macroembolization occurred in 22 (55.0%) patients, 11 (37.9%) in group A and 11 (100%) in group B (p<0.001). Clinically significant (> or =2 mm in diameter) macrodebris was found in 18 (45.0%) patients: 8 (27.6%) in group A and 10 (90.9%) in group B (p<0.001). All filters were retrieved successfully with no complications. One side-branch embolization occurred proximal to the filter. In another case, the filter was overfilled, resulting in no distal flow; it was retrieved, with subsequent tibial embolization when the procedure was continued without protection.

CONCLUSION

Macroembolization is very frequent in patients undergoing lower extremity interventions, particularly with SilverHawk atherectomy. EFP appears to be very effective in capturing macrodebris, and its use is associated with good acute angiographic outcome. The clinical significance of these findings needs to be determined in future studies.

Renal artery revascularization: collaborative approaches for specialists

Endovascular revascularization for atherosclerotic renal artery stenosis (RAS) is the revascularization strategy of choice for patients with hemodynamically and clinically significant renal artery stenosis. Surgical revascularization is reserved for failed endovascular therapy or concomitant abdominal aortic surgery. Endovascular renal artery stenting is associated with excellent technical success, low complication rates, and acceptable long-term patency. This technique has been proven to be beneficial for preserving kidney function and stabilizing or improving blood pressure control in selected patients. Nevertheless, deterioration in kidney function after the procedure in 10% to 20% of cases may limit the immediate benefits of this technique. Atheroembolism appears to play an important role in the cause of kidney dysfunction after renal revascularization. Renal revascularization with a distal embolic protection device is a promising strategy in reducing the risk of atheroembolism and deterioration in kidney function.

Endovascular management of atherosclerotic renovascular disease: early results following primary intervention

OBJECTIVE

This retrospective review examines periprocedural morbidity and early functional responses to primary renal artery angioplasty and stenting (RA-PTAS) for patients with atherosclerotic renovascular disease (RVD).

METHODS

Consecutive patients undergoing primary RA-PTAS for hemodynamically significant atherosclerotic RVD with hypertension and/or ischemic nephropathy were identified from a prospectively maintained registry. Hypertension responses were determined based on pre- and post-intervention blood pressure measurements and medication requirements. Estimated glomerular filtration rate (eGFR) was used to determine renal function responses. Both hypertension and renal function responses were assessed at least three weeks after RA-PTAS. Stepwise multivariable regression analysis was used to examine associations between blood pressure and renal function responses to RA-PTAS and select clinical variables.

RESULTS

One-hundred ten primary RA-PTAS were performed on 99 patients with atherosclerotic RVD with a mean angiographic diameter-reducing stenosis of 79.2 +/- 12.9%. All patients had hypertension (mean of 3.4 +/- 1.3 antihypertensive agents). Mean pre-intervention eGFR was 49.9 +/- 22.7 mL/min/1.73 m(2), and 74 patients had a pre-intervention eGFR < 60 mL/min/1.73 m(2). The technical success rate for RA-PTAS was 94.5%. The periprocedural complication rate was 5.5%; there were no periprocedural deaths. Statistically significant decreases in mean systolic blood pressure (161.3 +/- 25.2 vs. 148.5 +/- 25.2 post-intervention, P < .0001), diastolic blood pressure (78.6 +/- 13.3 versus 72.5 +/- 13.5 post-intervention, P < .0001), and number of antihypertensive agents (3.3 +/- 1.2 versus 3.1+/- 1.3 post-intervention, P = .009) were observed. Assessed categorically, hypertension response to RA-PTAS was cured in 1.1%, improved in 20.5%, and unchanged in 78.4%. Categorical eGFR response to RA-PTAS was improved in 27.7%, unchanged in 65.1%, and worsened in 7.2%. Multivariable stepwise regression revealed associations between pre- and post-intervention systolic blood pressure (P < .0001), diastolic blood pressure (P < .0001), and eGFR (P < .0001), as well as a trend toward improved diastolic blood pressure response among patients managed with staged bilateral intervention (P = .0589).

CONCLUSION

Primary RA-PTAS for atherosclerotic RVD was associated with low peri-procedural morbidity and mortality but only modest early improvements in blood pressure and renal function. Results from ongoing prospective trials are needed to assess the long term outcomes associated with RA-PTAS and clarify its role in the management of atherosclerotic RVD.