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Mhaske SM, Patil B, Patwardhan SK, Gopalakrishnan G, Shelke UR, Pamecha YG. Outcome following renal autotransplantation in renal artery stenosis. Urol Ann 2019; 11:46-52. [PMID: 30787570 PMCID: PMC6362799 DOI: 10.4103/ua.ua_39_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introduction With significant advances in the area of interventional radiology, angioplasty and stenting have become preferred first-line treatment in patients with significant renal artery stenosis. However, not all patients have favorable anatomy to undergo minimally invasive treatments, and reconstruction of the renal artery is an option. In select cases, either improved renal function or maintenance of existing function and sometimes resolution of hypertension can follow surgical treatment. Material and Methods This was a prospective observational study conducted from August 2010 to June 2016. Patients <45 years of age with uncontrolled hypertension secondary to renovascular hypertension (RVH) and refractory to medical management and renal arterial disease unfavorable for percutaneous intervention were included in the study. All patients were evaluated thoroughly using computed tomography angiography and diethylenetriaminepentaacetic acid renal scan. Patients underwent autotransplantation either into the right or left iliac fossa. Some kidneys required bench reconstruction of the renal artery and/or its branches before being implanted into either iliac fossa. Results Nine patients were included in the study. The mean age was 27 years. Seven were males and two were females. Five patients had bilateral renal artery stenosis. After autotransplantation, initially five patients became free of antihypertensive medicines, but on the follow-up, two patients showed rising trend of blood pressure. The evaluation revealed narrowing at anastomosis site in both patients with salvageable kidney function in one patient. Angioplasty with stenting was done in this patient while the second patient underwent secondary nephrectomy. At 2 years of follow-up, four patients required no antihypertensive medicines. Conclusion Autotransplantation can be a successful treatment of severe RVH and should be considered in patients with renal arterial disease unfavorable for percutaneous intervention.
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Affiliation(s)
- Sunil M Mhaske
- Department of Urology, Dr. D. Y. Patil Medical College, Pune, Maharashtra, India
| | - Bhushan Patil
- Department of Urology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Sujata K Patwardhan
- Department of Urology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | | | - Umesh Ravikant Shelke
- Department of Urology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Yash G Pamecha
- Department of Urology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
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Martin LG, Rundback JH, Wallace MJ, Cardella JF, Angle JF, Kundu S, Miller DL, Wojak JC. Quality Improvement Guidelines for Angiography, Angioplasty, and Stent Placement for the Diagnosis and Treatment of Renal Artery Stenosis in Adults. J Vasc Interv Radiol 2010; 21:421-30; quiz 230. [DOI: 10.1016/j.jvir.2009.12.391] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2009] [Revised: 12/06/2009] [Accepted: 12/28/2009] [Indexed: 01/09/2023] Open
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Paraskevas KI, Perrea D, Briana DD, Liapis CD. Management of atherosclerotic renovascular disease: the effect of renal artery stenting on renal function and blood pressure. Int Urol Nephrol 2007; 38:683-91. [PMID: 17211575 DOI: 10.1007/s11255-006-9025-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
In the last few years, renal artery stenting has gradually evolved into one of the most important therapeutic modalities in the management of atherosclerotic renovascular disease. Stenting is nowadays preferred by a steadily increasing number of physicians, not only because of its significant contribution to blood pressure control, but also because of its documented ability to maintain, and even improve, renal function. At the same time, procedure-related morbidity and mortality rates are extremely low, while recurrent stenosis rates have been repeatedly reported to be minimal. Percutaneous transluminal renal angioplasty (PTRA) and stenting are nowadays considered by many physicians to be the treatment of choice for atherosclerotic renovascular disease.
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Affiliation(s)
- Kosmas I Paraskevas
- University Medical School of Pécs (Pécsi Orvostudományi Egyetem), Pecs, Hungary.
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4
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Rocha-Singh K. Percutaneous renal artery intervention for preservation of renal function: Strategies for identification of “at-risk” patients. Catheter Cardiovasc Interv 2006; 68:507-12. [PMID: 16969840 DOI: 10.1002/ccd.20844] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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5
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Spitalewitz S, Reiser IW. Renovascular Hypertension: Diagnosis and Treatment. Hypertension 2005. [DOI: 10.1016/b978-0-7216-0258-5.50164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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6
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Ilkay E, Günal IA, Yavuzkir M, Dağli N, Karaca I, Celiker H, Doğukan A, Arslan N. Effect of renal artery stenting on renal function in patients with ischemic nephropathy. JAPANESE HEART JOURNAL 2004; 45:637-45. [PMID: 15353874 DOI: 10.1536/jhj.45.637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this study was to evaluate the effects of stenting on blood pressure and renal functions in azotemic patients with proximal/ostial atherosclerotic renal artery stenosis. Thirteen azotemic patients (5 females, 8 males, average age, 62.7 +/- 8.3 years) who had renal artery stenosis were included in the study. Their blood pressure, estimated glomerular filtration rate (EGFR), and creatinine levels were measured at baseline and during follow-up. Stents were implanted successfully in all of the cases. The average stent diameter and stent length were 7.2 +/- 0.5 mm and 17.2 +/- 3.4 mm, respectively. Antihypertensive drug was abandoned in 1 (7.6%) patient, reduced in 10 patients (76.9%), and not changed in 2 (15.3%) patients. Significant improvement was observed in the mean serum creatinine level at the 12th month when compared with baseline (2.56 +/- 0.88; 1.83 +/- 0.62, P < 0.001). EGFR was 18.38 +/- 4.64 before the procedure and 22.67 +/- 3.81 during follow-up (P < 0.0001). According to the GFR criteria, renal function was determined to be worse in 1 (7.6%) patient, stabilized in 2 (15.3%), and improved in 10 (76.9%) patients. One patient died during the follow-up period. Angiographic restenosis was observed in 2 (15.3%) patients. Follow-up major events were observed in 3 (23%) patients. Stenting azotemic patients with renal artery stenosis is a reliable and effective procedure for achieving an improvement in renal function.
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Affiliation(s)
- Erdogan Ilkay
- Department of Cardiology, Flrat University, Elazig, Turkey
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7
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Alhadad A, Ahle M, Ivancev K, Gottsäter A, Lindblad B. Percutaneous Transluminal Renal Angioplasty (PTRA) and Surgical Revascularisation in Renovascular Disease—A Retrospective Comparison of Results, Complications, and Mortality. Eur J Vasc Endovasc Surg 2004; 27:151-6. [PMID: 14718896 DOI: 10.1016/j.ejvs.2003.10.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To evaluate results, complications and mortality following percutaneous transluminal renal angioplasty (PTRA) and open surgical revascularisation for renovascular disease. METHODS A retrospective evaluation of 381 renovascular patients (median age 64, range 9-99 years, 152 women) treated at Malmö University Hospital during 1987-1996. Two hundred and sixty-two (69%) of the patients were treated with PTRA, 106 (28%) with open revascularisation. RESULTS Thirty-day mortality was 2% in the PTRA group and 9% after open surgery (p<0.001). There were no differences between groups concerning the number of re-do procedures, but first re-do was performed after seven (IQR 3-14) months in the PTRA group, and after 15 (IQR 10-44) months after open revascularisation (p<0.0001). After a median follow-up of 4 months (IQR 0-13) systolic and diastolic blood pressure (BP) had decreased (p<0.0001) in both groups. The number of antihypertensive drugs was reduced (p<0.0001) and S-creatinine levels were unchanged in both groups. Long-time survival assessed with log-rank analysis was better (p<0.01) in the PTRA group. The risk ratio for death with open revascularisation was 1.69 (p<0.01). CONCLUSIONS In this retrospective comparison, PTRA was as effective as open revascularisation, with lower complication rate and lower early and long-time mortality, but with shorter time to first re-do.
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Affiliation(s)
- A Alhadad
- Department of Vascular and Renal Diseases, Malmö-Lund, Lund University, Malmö University Hospital, Sweden
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8
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García-Gimeno M, Tagarro-Villalba S, González-González M, Rodríguez-Camarero S. Cirugía de revascularización tras angioplastia-stent renal en la nefropatía isquémica: a propósito de un caso y revisión de la literatura. ANGIOLOGIA 2004. [DOI: 10.1016/s0003-3170(04)74891-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, Rosenfield K, White C, Bettmann M, Cortell S, Puschett J, Clair DG, Cole P. Guidelines for the Reporting of Renal Artery Revascularization in Clinical Trials. J Vasc Interv Radiol 2003; 14:S477-92. [PMID: 14514863 DOI: 10.1097/01.rvi.0000094621.61428.d5] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Although the treatment of atherosclerotic renal artery stenosis with use of percutaneous angioplasty, stent placement, and surgical revascularization has gained widespread use, there exist few prospective randomized controlled trials (RCTs) comparing these techniques to each other or against the standard of medical management alone. To facilitate this process as well as help answer many important questions regarding the appropriate application of renal revascularization, well-designed and rigorously conducted trials are needed. These trials must have clearly defined goals and must be sufficiently sized and performed so as to withstand intensive outcomes assessment. Toward this end, this document provides guidelines and definitions for the design, conduct, evaluation, and reporting of renal artery revascularization RCTs. In addition, areas of critically necessary renal artery revascularization investigation are identified. It is hoped that this information will be valuable to the investigator wishing to conduct research in this important area.
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Affiliation(s)
- John H Rundback
- Vascular and Interventional Radiology, Columbia Presbyterian Medical Center, Milstein Pavilion, MHB 4700, 177 Fort Washington Avenue, New York, NY 10032, USA
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10
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van Rooden CJ, van Baalen JM, van Bockel JH. Spontaneous dissection of renal artery: long-term results of extracorporeal reconstruction and autotransplantation1. J Vasc Surg 2003; 38:116-22. [PMID: 12844100 DOI: 10.1016/s0741-5214(02)75453-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE We undertook this study to assess the outcome of spontaneous dissection of the renal artery and its branches surgically treated with extracorporeal reconstruction and autotransplantation. SUBJECTS Between 1975 and 1996, 15 consecutive patients (19 kidneys) with spontaneous renal artery dissection underwent renal artery reconstruction. Fourteen patients had accelerated hypertension. Five patients had impaired renal function. In 14 patients the dissection was associated with fibrodysplasia, and in 1 patient it was related to arteriosclerosis. INTERVENTION In 17 kidneys extracorporeal reconstruction and autotransplantation was used. The renal artery of 1 kidney was reconstructed in situ. One primary nephrectomy was performed. RESULTS There were no operative deaths or major morbidity. All but 1 reconstruction was successful (94.4%). Results at follow-up (range, 1-8 years) were favorable in 14 patients; 79% had satisfactory blood pressure control, and all patients had normal renal function, including those with impaired renal function preoperatively. CONCLUSIONS Extracorporeal reconstruction and autotransplantation can be effectively used in patients with spontaneous renal artery dissection located in or extending into the distal branches. Early recognition and appreciation of the clinical presentation of spontaneous renal artery dissection are important.
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Axelrod DA, Fendrick AM, Carlos RC, Lederman RJ, Froehlich JB, Weder AB, Abrahamse PH, Stanley JC. Percutaneous stenting of incidental unilateral renal artery stenosis: decision analysis of costs and benefits. J Endovasc Ther 2003; 10:546-56. [PMID: 12932167 DOI: 10.1177/152660280301000321] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE To determine the incremental cost-effectiveness of prophylactic percutaneous transluminal angioplasty with stent placement (PTA-S) in patients with incidentally discovered, asymptomatic renal artery stenosis (RAS) compared to delaying PTA-S until patients develop refractory hypertension or renal insufficiency (therapeutic PTA-S). METHODS The Markov decision analysis model was used to determine the incremental cost per quality adjusted life year (QALY) saved for prophylactic PTA-S as compared to therapeutic PTA-S in a hypothetical cohort of patients with 50% unilateral atherosclerotic RAS followed from age 61 to death. RESULTS Prophylactic PTA-S compared to therapeutic PTA-S results in more QALYs/patient (10.9 versus 10.3) at higher lifetime costs ($23,664 versus $16,558). The incremental cost effectiveness of prophylactic PTA-S was estimated to be $12,466/QALY. Prophylactic stenting was not cost effective (>$50,000/QALY) if the modeled incidence of stent restenosis exceeded 15%/year and the incidence of progression in the contralateral renal artery was <2% of arteries/year. CONCLUSIONS PTA-S of incidental, asymptomatic unilateral RAS may improve patients' quality of life at an acceptable incremental cost. However, this technology should be used hesitantly until a randomized comparison confirms its effectiveness.
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Affiliation(s)
- David A Axelrod
- Departments of Surgery, University of Michigan Medical Center, Ann Arbor, Michigan 498109-0604, USA.
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Axelrod DA, Fendrick AM, Carlos RC, Lederman RJ, Froehlich JB, Weder AB, Abrahamse PH, Stanley JC. Percutaneous Stenting of Incidental Unilateral Renal Artery Stenosis:Decision Analysis of Costs and Benefits. J Endovasc Ther 2003. [DOI: 10.1583/1545-1550(2003)010<0546:psoiur>2.0.co;2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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13
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Martin LG, Rundback JH, Sacks D, Cardella JF, Rees CR, Matsumoto AH, Meranze SG, Schwartzberg MS, Silverstein MI, Lewis CA. Quality improvement guidelines for angiography, angioplasty, and stent placement in the diagnosis and treatment of renal artery stenosis in adults. J Vasc Interv Radiol 2002; 13:1069-83. [PMID: 12427805 DOI: 10.1016/s1051-0443(07)61947-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Louis G Martin
- Department of Radiology, Emory University Hospital, Atlanta, GA, USA
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Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, Rosenfield K, White C, Bettmann M, Cortell S, Puschett J, Clair DG, Cole P. Guidelines for the reporting of renal artery revascularization in clinical trials. J Vasc Interv Radiol 2002; 13:959-74. [PMID: 12397117 DOI: 10.1016/s1051-0443(07)61860-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Although the treatment of atherosclerotic renal artery stenosis with use of percutaneous angioplasty, stent placement, and surgical revascularization has gained widespread use, there exist few prospective randomized controlled trials (RCTs) comparing these techniques to each other or against the standard of medical management alone. To facilitate this process as well as help answer many important questions regarding the appropriate application of renal revascularization, well-designed and rigorously conducted trials are needed. These trials must have clearly defined goals and must be sufficiently sized and performed so as to withstand intensive outcomes assessment. Toward this end, this document provides guidelines and definitions for the design, conduct, evaluation, and reporting of renal artery revascularization RCTs. In addition, areas of critically necessary renal artery revascularization investigation are identified. It is hoped that this information will be valuable to the investigator wishing to conduct research in this important area.
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Affiliation(s)
- John H Rundback
- Columbia Presbyterian Medical Center, Milstein Pavilion, Vascular and Interventional Radiology, New York, NY 10032, USA.
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Rocha-Singh KJ, Ahuja RK, Sung CH, Rutherford J. Long-term renal function preservation after renal artery stenting in patients with progressive ischemic nephropathy. Catheter Cardiovasc Interv 2002; 57:135-41. [PMID: 12357507 DOI: 10.1002/ccd.10296] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
We assessed the long-term effect of successful renal artery stent revascularization on renal function, blood pressure control, and survival in patients with progressive renal dysfunction due to ischemic nephropathy. Ischemic nephropathy presents a potentially serious risk of complete loss of renal function. Surgical renal revascularization is associated with significant risk of mortality/morbidity in this patient population. The potential role and long-term effect of renal artery stent revascularization in this patient population is not well defined. A cohort of 51 patients (mean age, 72 years; 52.9% men) with progressive azotemia, defined as a preprocedure serum creatinine (Scr) value of >or= 1.5 mg/dl and a negative slope of the reciprocal 1/Scr curve during the 12 months preceding revascularization, underwent successful primary stent deployment in 93 atherosclerotic renal artery lesions (42 bilateral, 9 solitary kidneys). Estimated glomerular filtration rate (EGFR) and serum creatinine values, blood pressure, antihypertensive medication requirements, and survival rates were monitored over a mean of 30-month follow-up. Renal artery duplex Doppler or renal angiography were performed at a mean of 13 months (range, 7-15 months) to assess stent patency. Stent implantation was successful in 92/93 (98.9%) stenotic renal arteries (mean preprocedure serum creatinine 2.3 +/- 0.9 mg/dl; range, 1.5-8.2 mg/dl). Forty-seven patients were eligible for 30-month follow-up of the procedural effect on renal function, blood pressure control, number of antihypertensive medications, and survival. At 1-year follow-up, the slope of the 1/Scr curve increased and the EGFR values significantly improved compared to preprocedure values (19.9 +/- 6.2 to 26.8 +/- 10.1 ml/min; P < 0.0001), serum creatinine decreased from the mean preprocedure value to 1.75 +/- 0.69 mg/dl (P < 0.001), with renal function improvement or stabilization observed in 94% of patients; three patients (7.3%) required permanent hemodialysis during the 30-month follow-up period. Systolic and diastolic blood pressure significantly decreased (from 177 +/- 28 to 148 +/- 25 mm Hg and from 92 +/- 15 to 78 +/- 14 mm Hg, respectively; P < 0.001) with fewer antihypertensive medications required to control blood pressure (3.5 +/- 0.9 vs. 1.9 +/- 1.3; P < 0.001). The patient survival rate after 30-month follow-up was 87%, with three deaths related to end-stage renal failure. Renal artery stent revascularization reversed progressive renal dysfunction within the first 12 months and maintained the improved level of renal function at 30-month follow-up while improving blood pressure control and reducing the number of antihypertensive medication requirements. Renal stent revascularization should be considered a valid therapeutic option for the long-term treatment of ischemic nephropathy.
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Affiliation(s)
- Krishna J Rocha-Singh
- Prairie Heart Institute at St. John's Hospital and Prairie Education and Research Cooperative, Department of Cardiology, Southern Illinois University School of Medicine, Springfield, Illinois 62794, USA.
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Rundback JH, Sacks D, Kent KC, Cooper C, Jones D, Murphy T, Rosenfield K, White C, Bettmann M, Cortell S, Puschett J, Clair D, Cole P. Guidelines for the reporting of renal artery revascularization in clinical trials. American Heart Association. Circulation 2002; 106:1572-85. [PMID: 12234967 DOI: 10.1161/01.cir.0000029805.87199.45] [Citation(s) in RCA: 164] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Pillay WR, Kan YM, Crinnion JN, Wolfe JHN. Prospective multicentre study of the natural history of atherosclerotic renal artery stenosis in patients with peripheral vascular disease. Br J Surg 2002; 89:737-40. [PMID: 12027983 DOI: 10.1046/j.1365-2168.2002.02144.x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Many patients with peripheral vascular disease have coincident renal artery stenosis. The present study characterized the natural history of the condition. METHODS Some 98 patients (71 men) with more than 50 per cent atherosclerotic renal artery stenosis (unilateral 64, bilateral 34) were recruited prospectively. Measurements of serum creatinine, blood pressure and renal size were recorded at baseline and every 6 months, for a minimum of 2 years. RESULTS Data were available for 85 patients with a minimum follow-up of 2 years. The mean age was 71 (range 51-87) years. All 52 patients with unilateral renal artery stenosis were managed conservatively (group 1); 21 of the 33 patients with bilateral disease had no intervention (group 2) and the remaining 12 had angioplasty or reconstruction (group 3). The overall mortality rate was 32 per cent at 2 years (27 patients) and this was similar in all three groups. In only three patients was death related directly to renovascular disease; coronary disease accounted for the majority of deaths. All three patients who needed dialysis died within 1 year. In survivors from groups 1 and 3 there was a significant increase in serum creatinine concentration at follow-up. Blood pressure did not increase significantly. CONCLUSION Patients with renal artery stenosis and peripheral vascular disease had a poor prognosis, but this was not directly attributable to renal failure.
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Affiliation(s)
- W R Pillay
- Regional Vascular Unit, St Mary's Hospital, Praed Street, London W2 1NY, UK.
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Lederman RJ, Mendelsohn FO, Santos R, Phillips HR, Stack RS, Crowley JJ. Primary renal artery stenting: characteristics and outcomes after 363 procedures. Am Heart J 2001; 142:314-23. [PMID: 11479472 DOI: 10.1067/mhj.2001.116958] [Citation(s) in RCA: 168] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Stenting improves the acute results of percutaneous balloon angioplasty for atherosclerotic renal artery stenosis. Predictors of benefit and angiographic restenosis are not well understood. We describe the technical and clinical success of renal artery stenting in a large consecutive series of patients with hypertension or renal insufficiency. We identify clinical, procedural, and anatomic factors that might influence outcome, restenosis, and survival. METHODS Primary renal artery stenting was performed in 300 consecutive patients who underwent 363 stent procedures in 358 arteries. Angiograms were analyzed quantitatively. Clinical and angiographic follow-up data are available after a median of 16.0 months. RESULTS At baseline, 87% of patients had hypertension, and 37% had chronic renal insufficiency. The mean age was 70 years (interquartile range 63.1-74.6) years. The stenosis was unilateral in 49% and bilateral in 48% and involved a solitary functioning kidney in 3.6%. The stenting procedure was successful in all attempts. There were no procedural deaths or emergency renal surgical procedures. Postprocedure azotemia was seen in 45 of 363 (12%) procedures but persisted in only 6 patients (2%), all of whom had baseline renal insufficiency. Systolic and diastolic blood pressures were significantly reduced (systolic blood pressure from 164.0 +/- 28.7 to 142.4 +/- 19.1 mm Hg, P <.001). At follow-up, 70% of patients had improved blood pressure control regardless of renal function. In patients with baseline renal insufficiency, 19% had improvement in serum creatinine levels at follow-up, 54% had stabilization, and 27% had deterioration. Follow-up mortality was 10% and was predicted by baseline creatinine levels (odds ratio 1.72 for each 1 mg/dL creatinine increment, 95% confidence interval 1.13-2.49) and extent of coronary artery disease (odds ratio 1.66 for each diseased coronary artery, 95% confidence interval 1.03-2.67). Angiographic restenosis was found in 21% of 102 patients overall and was less common (12%) in arteries with a reference caliber >4.5 mm (P <.01 vs caliber <4.5 mm). Neither poststenotic dilation nor severity of angiographic stenosis predicted clinical outcome. CONCLUSIONS Primary renal artery stenting can be performed safely with nearly uniform technical success. The majority of patients with hypertension or renal insufficiency derive benefit. Follow-up mortality is 5-fold higher in patients with baseline renal insufficiency. Clinical and angiographic features did not predict blood pressure or renal functional outcome. Restenosis is more common in renal arteries with a reference caliber less than 4.5 mm.
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Affiliation(s)
- R J Lederman
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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Matsumoto AH. Who Should Perform Renal Interventions? J Vasc Interv Radiol 2001. [DOI: 10.1016/s1051-0443(01)70066-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Abstract
Ischemic nephropathy is a long-term cause of hypertension and renal failure. Although its real incidence is unknown, ischemic nephropathy is growing because of the increased mean age of the population and the greater prevalence of hypertensive and diabetic populations. This review describes the clinical profile of afflicted patients. Atherosclerosis in different vascular beds is common in these patients. The evolution of ischemic nephropathy is generally progressive, although some patients present with acute renal failure, either secondary to the administration of angiotensin-converting enzyme inhibitors or caused by thrombosis of the renal arteries. Revascularizing surgery may stabilize or improve renal function, even in patients with nonfunctioning kidneys. The results obtained with intraluminal angioplasty are worse, with a high percentage of restenosis. Placement of an endoprothesis is recommended when the lesions affect the ostium or proximal third of the artery. This complex disease typically affects multiple organs, thus making individual assessment essential.
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Affiliation(s)
- J M Alcazar
- Department of Nephrology, Hospital Universitario 12 de Octubre, Madrid, Spain.
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Sacks D, Rundback JH, Martin LG. Renal angioplasty/stent placement and hypertension in the year 2000. J Vasc Interv Radiol 2000; 11:949-53. [PMID: 10997455 DOI: 10.1016/s1051-0443(07)61321-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- D Sacks
- Department of Radiology, The Reading Hospital and Medical Center, Pennsylvania 19603, USA.
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