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Xu L, Ba H, Jiang X, Qin Y. Hypertension crisis as the first symptom of renovascular hypertension in children. Ital J Pediatr 2022; 48:191. [PMID: 36461036 PMCID: PMC9717483 DOI: 10.1186/s13052-022-01378-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 11/01/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Renovascular hypertension (RVH) is one of the main causes of hypertensive crisis (HTN-C). It is characterized by acute onset and severe disease, and early diagnosis and treatment are difficult. The objective was to describe the characteristics of RVH and factors associated with RVH leading to HTN-C in children. At present, there are few clinical studies on RVH in children with large cases in China. METHODS This study retrospectively analyzed the clinical data of inpatient children with RVH. Patients were divided into non-hypertensive crisis (non-HTN-C) group, and HTN-C group according to the first symptoms and blood pressure. Further, HTN-C were classified as hypertensive urgency (HTN-U) or hypertensive emergency (HTN-E). RESULTS Fifty-four pediatric cases (41 boys and 13 girls) were included. 83.3% of the RVH cases were ≥ 6 years old. Three cases were classified into the non-HTN-C group. Of the 51 HTN-C cases, 18 cases were grouped as HTN-U and 33 as HTN-E. The HTN-U group were mainly asymptomatic (50.0%, 9/18) while the HTN-E group mainly presented with neurological symptoms (72.7%, 24/33). The number of unknown etiology children was 32 (59.2%). The top three known etiologies were Takayasu's arteritis (50.0%, 11/22), congenital renal dysplasia (27.3%, 6/22) and fibromuscular dysplasia (13.6%, 3/22). As for the target organ damage of RVH, patients had a higher prevalence of left ventricular hypertrophy (71.4%, 35/49) and retinopathy (77.8%, 21/27). CONCLUSIONS Most RVH patients with HTN-C as the first symptoms, especially for males over 6 years old, should be assessed for RVH even if they were asymptomatic. Most asymptomatic patients with RVH already had target organ damage, and symptomatic patients even developed life-threatening complications. As preventive measures, routine monitoring of BP during children's physical examinations is advised.
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Affiliation(s)
- Lingling Xu
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Hongjun Ba
- Department of Pediatric Cardiovascular, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Xiaoyun Jiang
- Department of Pediatrics, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
| | - Youzhen Qin
- Department of Pediatric Cardiovascular, The First Affiliated Hospital of Sun Yat-Sen University, 58 Zhongshan Second Road, Guangzhou, Guangdong 510080 People’s Republic of China
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2
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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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3
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Fleury AS, Durand RE, Cahill AM, Zhu X, Meyers KE, Otero HJ. Validation of computed tomography angiography as a complementary test in the assessment of renal artery stenosis: a comparison with digital subtraction angiography. Pediatr Radiol 2021; 51:2507-2520. [PMID: 34374838 DOI: 10.1007/s00247-021-05145-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 05/27/2021] [Accepted: 06/28/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Renal artery stenosis is an important cause of hypertension in children, accounting for 5-10% of cases. When suspected, noninvasive imaging options include ultrasound (US), computed tomography (CT) angiography and magnetic resonance (MR) angiography. However, digital subtraction angiography (DSA) remains the gold standard. OBJECTIVE To investigate the accuracy and inter-reader reliability of CT angiography in children with suspected renal artery stenosis. MATERIALS AND METHODS This is a retrospective study of patients suspected of having renal artery stenosis evaluated by both CT angiography and DSA between 2008 and 2019 at a tertiary pediatric hospital. Only children who underwent CT angiography within 6 months before DSA were included. CT angiography studies were individually reviewed by two pediatric radiologists, blinded to clinical data, other studies and each other's evaluation, to determine the presence of stenosis at the main renal artery and 2nd- and 3rd-order branches. The sensitivity, specificity and accuracy were calculated using DSA as the reference. The effective radiation dose for CT angiography and DSA was also calculated. Kappa statistics were used to assess inter-reader agreement. RESULTS Seventy-four renal units were evaluated (18 girls, 19 boys). The patients' median age was 8 years (range: 1-21 years). Overall, CT angiography was effective in detecting renal artery stenosis with a sensitivity of 85.7%, specificity of 91.5% and accuracy of 88.9%. There was moderate inter-reader agreement at the main renal artery level (k=0.73) and almost perfect inter-reader agreement at the 2nd/3rd order (k=0.98). However, the sensitivity at the 2nd- and 3rd-order level was lower (14.3%). CT angiography provided excellent negative predictive value for evaluating renal artery stenosis at the main renal artery level (90.1%) and at the 2nd- or 3rd-order branches (82.7%). The median effective dose of CT angiography studies was 2.2 mSv (range: 0.6-6.3) while the effective dose of DSA was 13.7 mSv. CONCLUSION CT angiography has high sensitivity and specificity at the main renal artery level with a lower radiation dose than previously assumed. Therefore, it can be used as a diagnostic tool in patients with low to medium risk of renal artery stenosis, and as a screening and treatment planning tool in patients at high risk.
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Affiliation(s)
- Anilawan S Fleury
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Rachelle E Durand
- Department of Radiology and Biomedical Imaging, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Anne Marie Cahill
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Xiaowei Zhu
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA
| | - Kevin E Meyers
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Hansel J Otero
- Department of Radiology, Children's Hospital of Philadelphia, 3401 Civic Center Blvd., Philadelphia, PA, 19104, USA.
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4
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Alhadad A. Management of Renal Artery Stenosis - an Update. Libyan J Med 2016. [DOI: 10.3402/ljm.v3i2.4765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A. Alhadad
- Vascular Centre, Lund University, Malmö University Hospital, SE-205 02 Malmö, Sweden
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5
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Abstract
The main objectives of this expert consensus are to raise awareness about fibromuscular dysplasia, which is more frequent and more often systemic than previously thought and can sometimes have devastating consequences; to provide up-to-date recommendations for the diagnosis, evaluation, and management of the disease; and to identify research priorities. The emphasis has been put on recommendations for daily practice. The main topics covered include definition, classification, diagnosis, and management of fibromuscular dysplasia in adult patients with symptomatic involvement of the renal arteries, supra-aortic trunks, and digestive and peripheral arteries.
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6
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Abstract
Fibromuscular dysplasia (FMD) is a nonatherosclerotic, noninflammatory angiopathy of unknown cause affecting medium-sized (most commonly renal) arteries and causing renovascular hypertension. The most common medial multifocal type of FMD (with the “string of beads” appearance) is more than four times more prevalent in females than in males. FMD accounts for up to 10% of cases of renovascular hypertension. Compared with patients with atherosclerotic renal artery stenosis, patients with FMD are younger, have fewer risk factors for atherosclerosis, and a lower occurrence of atherosclerosis in other vessels. The etiology is multifactorial, including vessel wall ischemia and smoking, as well as hormonal and genetic factors. Intra-arterial digital subtraction angiography is still the gold standard for exclusion or confirmation of renal artery stenosis caused by FMD, at least in young patients, who more often have lesions in branches of the renal artery. For FMD patients with atherosclerosis and those who are older (>50–55 years), significant renal artery stenosis may be confirmed or excluded with ultrasonography. The FMD lesion is typically truncal or distal, whereas atherosclerotic lesions are more often proximal or ostial. Treatment options are medical, endovascular (percutaneous transluminal renal angioplasty [PTRA]), and surgical. Invasive treatment should be considered when hypertension cannot be controlled with antihypertensive drugs and in patients with impaired renal function or ischemic nephropathy. PTRA has become the treatment of choice and normally yields good results, especially in unifocal disease and young patients. Pressure gradients are normally completely abolished, and there is no indication for stent placement. Surgical revascularization is indicated after PTRA complications; thrombosis, perforation, progressive dissection, repeated PTRA failure or restenosis. Centralization of handling is recommended.
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Affiliation(s)
- Anders Gottsäter
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
| | - Bengt Lindblad
- Department of Vascular Diseases, Skåne University Hospital, Malmö, Sweden
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7
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Hiralal, Jena MR, Keshwani P, Jha A, Thakral A, Phadke R, Prasad N, Kaul A, Sharma R. Imaging and endovascular management in allograft renal artery stenosis: Case report. INDIAN JOURNAL OF TRANSPLANTATION 2014. [DOI: 10.1016/j.ijt.2014.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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8
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Boateng FK, Greco BA. Renal artery stenosis: prevalence of, risk factors for, and management of in-stent stenosis. Am J Kidney Dis 2012; 61:147-60. [PMID: 23122491 DOI: 10.1053/j.ajkd.2012.07.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 07/17/2012] [Indexed: 11/11/2022]
Abstract
Atherosclerotic renal artery stenosis is common and is associated with hypertension and chronic kidney disease. More frequent use of percutaneous renal artery stent placement for the treatment of renal artery stenosis during the past 2 decades has increased the number of patients with implanted stents. In-stent stenosis is a serious problem, occurring more frequently than earlier reports suggest and potentially resulting in late complications. Currently, there are no guidelines covering the approach to restenosis after renal artery stent placement. This article reviews data on the prevalence of and risk factors for the development of in-stent stenosis and the clinical manifestations, evaluation, and treatment of in-stent stenosis and suggests a strategy for the management of patients after percutaneous renal artery stent placement.
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Affiliation(s)
- Frank K Boateng
- Indiana University, Bloomington Hospital, Bloomington, IN, USA
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9
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Persu A, Touzé E, Mousseaux E, Barral X, Joffre F, Plouin PF. Diagnosis and management of fibromuscular dysplasia: an expert consensus. Eur J Clin Invest 2012; 42:338-47. [PMID: 21854373 DOI: 10.1111/j.1365-2362.2011.02577.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Alexandre Persu
- Division of Cardiology, Cliniques Universitaires Saint-Luc, Université Catholique de Louvain, Brussels, Belgium.
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10
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Rajan DK, Stavropoulos SW, Shlansky-Goldberg RD. Management of transplant renal artery stenosis. Semin Intervent Radiol 2011; 21:259-69. [PMID: 21331137 DOI: 10.1055/s-2004-861560] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Transplant renal artery stenosis is the most frequent vascular complication of transplantation. Early detection and correction reduce patients' morbidity and allograft dysfunction. Although noninvasive imaging can detect an underlying stenosis, angiography with subsequent angioplasty or stenting, or both, provides definitive diagnosis and treatment. With the introduction of alternative contrast agents and newer catheter and stent technology, these procedures can be performed safely with little risk of contrast-induced nephropathy or allograft loss.
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Affiliation(s)
- Dheeraj K Rajan
- Division of Vascular and Interventional Radiology, University of Toronto, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
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11
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Abstract
Fibromuscular dysplasia (FMD) encompasses a heterogeneous group of idiopathic, segmental, nonatherosclerotic diseases of the musculature of arterial walls, leading to the narrowing of small and medium-sized arteries. The most common locations of FMD are renal arteries and carotid arteries. The diagnosis of FMD is made on the "string of beads" appearance of the arteries. The French Health Authority recommends performing a CT scan or an MRA to assess the diagnosis of FMD. A recent meta-analysis showed the cure rates using current definitions of hypertension cure are only 36% and 54% after angioplasty and surgery, respectively.
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12
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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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13
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Aytekin C, Yıldırım UM, Ozyer U, Harman A, Boyvat F. Emergency Renal Ablation for Life-Threatening Hemorrhage from Multiple Capsular Branches During Renal Artery Stenting. Cardiovasc Intervent Radiol 2009; 33:663-6. [DOI: 10.1007/s00270-009-9760-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Anchala PR, Resnick SA. The current state of endovascular therapy in the evaluation and management of renovascular disease. Semin Intervent Radiol 2009; 26:333-44. [PMID: 21326543 DOI: 10.1055/s-0029-1242202] [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: 10/20/2022]
Abstract
Hypertension is the most common reason for physician office visits among nonpregnant adults in the United States; up to one-third of Americans over the age of 18 have been diagnosed with hypertension. Patients with physiologically significant renal artery stenosis often go unnoticed because hypertension can often be well controlled with antihypertensive medications. As a result, screening for renovascular causes of hypertension is rarely done. However, the likelihood of renovascular disease increases in patients with acute, severe, or refractory hypertension and should be explored in patients who fall into these categories. Renovascular disease is a crucial consideration in the management of hypertension due to its increasing incidence and its potential for reversibility. Although renovascular disease accounts for less than 1% of patients with mild hypertension, it is estimated that between 10 and 45% of white patients with severe or malignant hypertension have renal artery stenosis (RAS). In this population, diagnosing and treating RAS can have a profound and long-lasting effect on the treatment of hypertension.
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Affiliation(s)
- Praveen R Anchala
- Department of Interventional Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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15
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Renal artery rupture following cutting balloon angioplasty for fibromuscular dysplasia: a case report. CASES JOURNAL 2009. [PMID: 20184703 PMCID: PMC2827089 DOI: 10.4076/1757-1626-2-8881] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Introduction Angioplasty with the use of cutting balloons has been suggested by some case reports and small series for the treatment of renal artery stenoses that are resistant to conventional balloon catheters. Based on this limited experience, the use of this technology has been suggested as safe. Herein, we report a renal artery rupture following angioplasty with a cutting balloon. The complication was salvaged with a stent graft. Case presentation A 30-year-old white female patient with resistant hypertension caused by a severe renal artery stenosis attributed to fibromuscular dysplasia, was submitted to conventional balloon angioplasty without success. Dilatation of the lesion with a cutting balloon resulted in arterial rupture, with concomitant retroperitoneal hematoma. Conclusion Cutting balloon angioplasty of renal artery lesions resistant to conventional balloon angioplasty should not be considered as safe as previously thought. When proceeding with such a procedure, a stent graft should be available for immediate use.
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16
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Brountzos EN, Ptohis N, Triantafyllidi H, Panagiotou I, Spyridopoulos TN, Misiakos EP, Kelekis A. Renal artery rupture following cutting balloon angioplasty for fibromuscular dysplasia: a case report. CASES JOURNAL 2009; 2:8881. [PMID: 20184703 DOI: 10.1186/1757-1626-0002-0000008881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/20/2009] [Accepted: 08/24/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Angioplasty with the use of cutting balloons has been suggested by some case reports and small series for the treatment of renal artery stenoses that are resistant to conventional balloon catheters. Based on this limited experience, the use of this technology has been suggested as safe. Herein, we report a renal artery rupture following angioplasty with a cutting balloon. The complication was salvaged with a stent graft. CASE PRESENTATION A 30-year-old white female patient with resistant hypertension caused by a severe renal artery stenosis attributed to fibromuscular dysplasia, was submitted to conventional balloon angioplasty without success. Dilatation of the lesion with a cutting balloon resulted in arterial rupture, with concomitant retroperitoneal hematoma. CONCLUSION Cutting balloon angioplasty of renal artery lesions resistant to conventional balloon angioplasty should not be considered as safe as previously thought. When proceeding with such a procedure, a stent graft should be available for immediate use.
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Affiliation(s)
- Elias N Brountzos
- Department of Radiology, Athens University Medical School, Attikon University Hospital, 1 Rimini St., 12462, Chaidari, Greece.
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17
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Reporting Standards for Carotid Artery Angioplasty and Stent Placement. J Vasc Interv Radiol 2009; 20:S349-73. [DOI: 10.1016/j.jvir.2009.04.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2003] [Accepted: 01/14/2004] [Indexed: 11/24/2022] Open
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Hupp T, Schmedt C, Richter G, Arlart J. Erkrankungen der Nierenarterien. GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00772-009-0682-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Klonaris C, Katsargyris A, Alexandrou A, Tsigris C, Giannopoulos A, Bastounis E. Efficacy of protected renal artery primary stenting in the solitary functioning kidney. J Vasc Surg 2008; 48:1414-22. [DOI: 10.1016/j.jvs.2008.07.056] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 07/12/2008] [Accepted: 07/16/2008] [Indexed: 11/29/2022]
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20
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Alhadad A. Management of renal artery stenosis - an update. Libyan J Med 2008; 3:91-100. [PMID: 21499465 PMCID: PMC3074287 DOI: 10.4176/071226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
The role of the renal vasculature in eliciting renovascular hypertension (RVH) was established in 1934, when Goldblatt et al. [1] in a classical experimental study demonstrated that partial obstruction of the renal artery increased mean arterial blood pressure (BP). The pathophysiology of renal artery stenosis (RAS) is incompletely understood but has been postulated to be related to increased afterload from neurohormonal activation and cytokine release [2]. Atherosclerotic RAS (ARAS) is increasingly diagnosed in the expanding elderly population, which also has a high prevalence of arterial hypertension. There is still considerable uncertainty concerning the optimal management of patients with RAS. Many hypertensive patients with RAS have co-existing essential hypertension and furthermore, it is often difficult to determine to what degree the RAS is responsible for the impairment of renal function. There are three possible treatment strategies: medical management, surgery, or percutaneous transluminal renal angioplasty (PTRA) with or without stent implantation. The use of stents has improved the technical success rate of PTRA and also led to lower risk of restenosis, in particular for ostial RAS. PTRA with stenting has therefore replaced surgical revascularisation for most patients with RAS and has led to a lower threshold for intervention. The treatment of choice to control hypertension in fibromuscular dysplasia (FMD) is generally accepted to be PTRA [3]. In ARAS, on the other hand, the benefits with PTRA are less clear [4] and the challenge to identify which patients are likely to benefit from revascularisation remains unknown.
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Affiliation(s)
- A Alhadad
- Vascular Centre, Lund University, Malmö University Hospital, SE-205 02, Malmö, Sweden
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21
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Meola M, Petrucci I. Color Doppler sonography in the study of chronic ischemic nephropathy. J Ultrasound 2008; 11:55-73. [PMID: 23396958 PMCID: PMC3553298 DOI: 10.1016/j.jus.2008.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
In western countries, the risk of cardiovascular disease has increased considerably in recent decades. This trend has been paralleled by an increase in cases of atherosclerotic renal disease, which is related to the improved prognosis of cardiovascular diseases, aging, and the increasing mean age of the general population. It is reasonable to expect that in the near future, there will be a sharp increase in the number of elderly patients with atherosclerotic vascular disease in chronic dialysis programs. The result will be a dramatic rise in the social and economic costs of dialysis that could constitute a true clinical emergency. In this epidemiologic scenario, one of the most important targets of 21st century nephrology will be the early diagnosis of chronic ischemic nephropathy and the development of new and more effective strategies for its treatment.Color Doppler (CD) ultrasonography has displayed high sensitivity, specificity, and positive and negative predictive values in the diagnosis of this disease in selected population, making it an ideal tool for use in screening programs. Eligibility for screening should be based on clinical criteria. For the most part, it will be aimed at adults (especially those who are elderly) with atherosclerotic vascular disease involving multiple districts and chronic kidney disease (CKD), stage 2-3, in the absence of a documented history of renal disease. In these patients, hypertension may be a secondary manifestation or a symptom of the ischemic nephropathy itself. The objectives of sonographic screening should be (1) to identify subjects in the population at risk who are affected by stenosis of the main renal artery (RAS); (2) to identify and characterize patients without RAS who have chronic ischemic nephropathy caused by nephroangiosclerosis and/or atheroembolic disease. The former group will require second-level diagnostic studies or angioplasty with stenting; the latter can be managed conservatively. The most important CD parameters in the workup of suspected RAS are those that are direct signs, i.e., increases in peak systolic velocity (PSV) and diastolic velocity (DV), spectral broadening, and an altered renal:aortic ratio (RAR). Their assessment requires full-length sampling of the renal artery and is associated with greater practical/technical difficulties. Measurement in triplicate of the PSV in the ostial, medial, and hilar segments of both arteries and bilateral measurement of parenchymal resistance indices are usually sufficient to detect the presence of stenosis and refer the patient for second-level studies. Important parameters for estimating the severity of a stenosis include the renal:aortic ratio (>3.5), disappearance of the early systolic peak in segmental vessels, lateralization of the resistance index (ΔRI > 0.05), and the evaluation of the acceleration index (AI) and acceleration time (AT). Second-level imaging studies (CT angiography, MR angiography) are still indispensable for precise definition of the location and extension of the stenosis and the therapeutic approach during digital subtraction angiography (DSA). In the absence of direct or indirect signs of RAS, increases in the intraparenchymal resistance indices (RI > 0.75-0.80; PI > 1.50) associated with systemic atherosclerotic disease are indicative of microcirculatory damage related to nephroangiosclerosis or atheroembolic disease.
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Affiliation(s)
- M. Meola
- S. Anna School of Advanced Studies, Nephrology and Dialysis Unit, Department of Internal Medicine, University of Pisa, Italy
| | - I. Petrucci
- Nephrology and Dialysis Unit, Department of Internal Medicine, University of Pisa, Italy
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22
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Kramer U, Wiskirchen J, Fenchel MC, Seeger A, Laub G, Tepe G, Finn JP, Claussen CD, Miller S. Isotropic high-spatial-resolution contrast-enhanced 3.0-T MR angiography in patients suspected of having renal artery stenosis. Radiology 2008; 247:228-40. [PMID: 18270376 DOI: 10.1148/radiol.2471070565] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The purpose of this study was to prospectively evaluate the diagnostic performance of contrast material-enhanced magnetic resonance (MR) angiography performed at 3 T for assessment of renal artery stenosis (RAS) by using parallel acquisition techniques with high acceleration factors and with digital subtraction angiography (DSA) as the reference standard. The study was institutional review board approved, and written informed consent was obtained from all patients. Twenty-nine patients (18 men, 11 women; mean age, 57.1 years +/- 14.3 [standard deviation]) suspected of having RAS underwent MR angiography. Images were evaluated qualitatively and quantitatively. The interobserver variability, sensitivity, specificity, and positive and negative predictive values of 3-T MR angiography, as compared with DSA (performed in 15 patients), were calculated. All examinations yielded good or excellent image quality. The sensitivity and specificity of MR angiography in grading significant (>75%) stenosis were 94% and 96%, respectively. Owing to its high sensitivity, contrast-enhanced 3-T MR angiography can be used reliably to exclude RAS and can serve as a useful screening method in the diagnostic work-up of patients with arterial hypertension.
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Affiliation(s)
- Ulrich Kramer
- Department of Diagnostic Radiology, University of Tuebingen, Hoppe-Seyler-Str 3, 72076 Tuebingen, Germany.
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Øvrehus KA, Andersen PE, Jacobsen IA. Treatment of renovascular hypertension by transluminal angioplasty--13 years experience in a single centre. Blood Press 2007; 16:335-40. [PMID: 17934918 DOI: 10.1080/08037050701642766] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The study is a follow-up on treatment of renovascular hypertension (RVH) with percutaneous transluminal renal angioplasty (PTRA). METHODS Patients were screened on the basis of clinical criteria of increased probability of RVH with renography and in selected cases with renal vein renin measurements. A positive work-up suggesting a functionally important renal artery stenosis led to renal angiography and PTRA if stenosis was confirmed; in 59%, an intravascular stent was inserted. RESULTS Outcome of treatment was classified as follows - group I: normotensive without medication; group II: with improved control of blood pressure; group III: unchanged blood pressure control. Grouping was performed immediately after treatment, at 1 month, 6 months and at the latest follow-up. One hundred-and-twenty-two patients (124 atherosclerotic and 12 fibromuscular lesions) were treated during 13 years. Immediately after PTRA the patients were grouped as follows - I: 31%, II: 59%, III: 10%. At 1 month, I: 13%, II: 72%, III: 15%; at 6 months, I: 11%, II: 74%, III: 15%, and at the latest follow-up, I: 11%, II: 78%, III: 11%. There were few significant complications, and renal function remained on average stable. CONCLUSION PTRA is an effective treatment of RVH in patients selected by signs of a flow-restricting stenosis. Twelve percent were normotensive after angioplasty and a further 77% had better controlled hypertension. Few complications were seen and renal function was on average unchanged as measured by serum creatinine.
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Kang KP, Lee S, Kim W, Han YM, Kang SK, Park SK. Renal subcapsular hematoma : a consequence of reperfusion injury of long standing renal artery stenosis. Electrolyte Blood Press 2007; 5:136-9. [PMID: 24459513 PMCID: PMC3894514 DOI: 10.5049/ebp.2007.5.2.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Accepted: 10/15/2007] [Indexed: 12/04/2022] Open
Abstract
Renal artery stenosis is a cause of secondary hypertension which can be cured by surgical or radiological intervention such as percutaneous transluminal renal artery stent placement. In this case we present a subcapsular hematoma of the kidney, a complication following percutaneous transluminal stent placement in the renal artery. Reperfusion injury to the kidney may be a possible mechanism of subcapsular hematoma of the kidney. Long standing severe renal artery stenosis and high pre- and post-procedure pressure gradient might contribute to the complication.
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Affiliation(s)
- Kyung Pyo Kang
- Department of Internal Medicine and Renal Regeneration Laboratory, Chonbuk National University Medical School, Jeonju, Korea
| | - Sik Lee
- Department of Internal Medicine and Renal Regeneration Laboratory, Chonbuk National University Medical School, Jeonju, Korea
| | - Won Kim
- Department of Internal Medicine and Renal Regeneration Laboratory, Chonbuk National University Medical School, Jeonju, Korea
| | - Young-Min Han
- Department of Diagnostic Radiology, Research Institute of Clinical Medicine, Chonbuk National University Medical School, Jeonju, Korea
| | - Sung Kyew Kang
- Department of Internal Medicine and Renal Regeneration Laboratory, Chonbuk National University Medical School, Jeonju, Korea
| | - Sung Kwang Park
- Department of Internal Medicine and Renal Regeneration Laboratory, Chonbuk National University Medical School, Jeonju, Korea
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Lum DP, Johnson KM, Paul RK, Turk AS, Consigny DW, Grinde JR, Mistretta CA, Grist TM. Transstenotic Pressure Gradients: Measurement in Swine—Retrospectively ECG-gated 3D Phase-Contrast MR Angiography versus Endovascular Pressure-sensing Guidewires. Radiology 2007; 245:751-60. [PMID: 18024452 DOI: 10.1148/radiol.2453061946] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Darren P Lum
- Department of Radiology, University of Wisconsin Hospital and Clinics, 600 Highland Ave, CSC E3/311, Madison, WI 53792, USA.
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Clinical features of renal artery stenosis in elderly patients. Chin Med J (Engl) 2007. [DOI: 10.1097/00029330-200702020-00018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Fenchel M, Martirosian P, Langanke J, Giersch J, Miller S, Stauder NI, Kramer U, Claussen CD, Schick F. Perfusion MR Imaging with FAIR True FISP Spin Labeling in Patients with and without Renal Artery Stenosis: Initial Experience. Radiology 2006; 238:1013-21. [PMID: 16439565 DOI: 10.1148/radiol.2382041623] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
The purpose of this study was to prospectively evaluate an arterial spin-labeling technique, flow-sensitive alternating inversion-recovery (FAIR) true fast imaging with steady-state precession (FISP), for noninvasive quantification of renal perfusion in patients without a history of renal artery stenosis (RAS) and in patients with proved RAS. The study was approved by the local ethics committee, and all participants provided written informed consent. Six patients with hypertension but no history of renal artery disease and 12 patients with RAS underwent FAIR true FISP magnetic resonance (MR) imaging in a whole-body 1.5-T unit. RAS grade and scintigraphic perfusion data served as the reference standards. On the FAIR true FISP perfusion images, severe RAS (>70% luminal narrowing) could be clearly distinguished from no or mild RAS and moderate RAS (< or =70% luminal narrowing) (P < .005). Significant correlations between FAIR perfusion data and stenosis grade (r = -0.76) and between FAIR and single photon emission computed tomographic perfusion values (r = 0.83) were observed. FAIR true FISP was found to be suitable for quantitative perfusion imaging of the kidneys in patients with RAS.
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Affiliation(s)
- Michael Fenchel
- Department of Diagnostic Radiology, Eberhard-Karls-University Tuebingen, Germany.
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Krijnen P, Steyerberg EW, Postma CT, Flobbe K, de Leeuw PW, Hunink MGM. Validation of a prediction rule for renal artery stenosis. J Hypertens 2005; 23:1583-8. [PMID: 16003186 DOI: 10.1097/01.hjh.0000174395.65267.e1] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES We previously developed a prediction rule to estimate the probability of renal artery stenosis. This rule should be validated before it can be used reliably to select hypertensive patients for renal angiography. We determined the validity of the prediction rule in recent patients and in other settings. DESIGN We studied three aspects of validity (agreement between predicted and observed probability of stenosis, discriminative ability, and clinical usefulness) in 180 consecutive patients with drug-resistant hypertension and normal or mildly impaired renal function, who visited six hypertension clinics of academic and community hospitals in the Netherlands. Thirty-five patients (19%) had a significant stenosis. RESULTS The clinical characteristics in the rule (age, sex, vascular disease, recent onset of hypertension, smoking, body mass index, abdominal bruit, serum creatinine concentration, and hypercholesterolemia) had similar predictive value in the validation sample and development sample. The predicted probabilities of stenosis agreed well with the observed frequencies (Hosmer-Lemeshow goodness-of-fit test, P = 0.87). The prediction rule discriminated reasonably between patients with and without stenosis in the validation sample with an area under the receiver operating characteristic curve of 0.71. If only patients with predicted probabilities of stenosis of 5% or more were referred for renal angiography, the number of referrals was reduced by 20%, while 9% of patients with a stenosis were missed. CONCLUSIONS The prediction rule was valid in more recently treated patients in other settings. If used conservatively, the rule can reliably exclude a small proportion of patients from angiography.
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Affiliation(s)
- Pieta Krijnen
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands.
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Mendes WDS, Silva LFD, Espinosa G, Fernandes AL, Furtado R, Gonçalves R. Estenose arterial nos transplantes renais. Rev Col Bras Cir 2005. [DOI: 10.1590/s0100-69912005000500004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJETIVO: Relacionar a influência dos dois tipos de anastomoses arteriais empregadas (término-terminal e término-lateral), da idade do receptor, do rim de doador vivo ou cadáver e do uso de remendo aórtico ("patch") quanto à presença ou não de estenose da artéria renal e, avaliar o tratamento destas estenoses. MÉTODO: Estudo retrospectivo de 278 pacientes submetidos a transplante renal no Hospital Universitário Clementino Fraga Filho (HUCFF), de maio de 1989 a maio de 2001. RESULTADOS: Não se mostrou relação entre as variáveis estudadas com a presença ou não de estenose da artéria renal. A estenose da artéria renal foi detectada em oito casos, que foram tratados, com sucesso, mediante angioplastia transluminal percutânea (ATP), com implante primário de "stent" (n = 7) ou sem implante de "stent" (n = 1). CONCLUSÕES: As variáveis estudadas não influenciaram no aparecimento da estenose da artéria renal e o tratamento endovascular foi efetivo na correção destas lesões estenóticas.
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Hiramoto J, Hansen KJ, Pan XM, Edwards MS, Sawhney R, Rapp JH. Atheroemboli during renal artery angioplasty: An ex vivo study. J Vasc Surg 2005; 41:1026-30. [PMID: 15944605 DOI: 10.1016/j.jvs.2005.02.042] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We hypothesized that atheroemboli released during renal angioplasty could be responsible for the modest functional result of renal angioplasty even after anatomic reduction of renal artery stenosis. To test this hypothesis, we enumerated and sized fragments released during ex vivo angioplasty and stenting of human renal artery atherosclerotic specimens removed during aortorenal endarterectomy. METHODS Thirty-three intact aortorenal atheroma specimens (16 pairs with adjacent aortic atheroma and one specimen with a single renal artery orifice) were removed from 17 patients with renal artery occlusive disease who underwent renal artery endarterectomy. specimens. Endarterectomy specimens were removed with a ring of aortic plaque and "fitted" with a polytetrafluoroethylene "adventitia". Ex vivo angioplasty was technically successful in 31 of the 33 specimens and was performed by using a 0.018-inch guidewire and 3.0-mm and 5.0-mm angioplasty balloons inflated for 30 seconds at 15 atmospheres pressure. Stenting was performed with either a 5-mm or 6-mm self-expanding Wallstent. Each artery was flushed with 20 mL of saline after guidewire placement, each angioplasty, and stent placement. The effluent was collected for analysis for counting with either a microscope (size >100 microm) or a Coulter counter (size <100 microm). The number and size of embolic fragments in the effluent collected after each manipulation was recorded. RESULTS Each manipulation of the specimens, including simply advancing the guidewire through the atherosclerotic lesion, released thousands of fragments. The numbers of fragments in each size category increased with decreasing particle size. Positioning and deploying the Wallstent released an additional bolus of fragments similar to that released after balloon angioplasty. CONCLUSIONS Ex vivo renal angioplasty releases thousands of atherosclerotic fragments of sufficient size to create vascular occlusions and initiate significant renal parenchymal damage. The results of renal angioplasty procedures could be improved by placing distal protection devices to prevent atheroembolization. CLINICAL RELEVANCE Athero-emboli produce a local arteritis in the kidney and could cause substantial damage to the renal parenchyma. This report explores the quantity of athero-emboli released during ex vivo angioplasty and stenting of renal atheroma specimens. The number of emboli found in this ex vivo study suggest that the use of protection devices may be advisable to protect the end organ, as done with angioplasty of the carotid artery. Of necessity, this was an ex vivo study and direct application to the clinical setting will need further study. Fortunately, multi-center trials examining the value of protection devices are currently in progress.
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Bolduc JP, Oliva VL, Therasse E, Giroux MF, Bouchard L, Perreault P, Cliché A, Soulez G. Diagnosis and treatment of renovascular hypertension: a cost-benefit analysis. AJR Am J Roentgenol 2005; 184:931-7. [PMID: 15728620 DOI: 10.2214/ajr.184.3.01840931] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We sought to evaluate and compare the relative cost-benefit of Doppler sonography, MR angiography, and captopril-enhanced renal scintigraphy as techniques for predicting a patient's clinical response to renal angioplasty. MATERIALS AND METHODS Estimations of positive and negative predictive values of baseline and captopril-enhanced renal scintigraphy and Doppler sonography examinations for predicting a favorable outcome after renal angioplasty were based on a previously published prospective study involving 74 patients who underwent this treatment. For gadolinium-enhanced MR angiography, predictive values were calculated from a subpopulation of 57 of these 74 subjects. The value of different combined strategies with these techniques for predicting clinical success after angioplasty was evaluated in this population. The costs of investigation and treatment per improved patient were calculated for each imaging technique and for combined strategies in a hypothetic 1,000-patient population with a 30% prevalence of renal artery stenosis, relying on the diagnostic performance reported in the literature for each technique in detecting renal artery stenosis. RESULTS The costs for each improved patient were $12,579 for patients selected on the basis of a positive finding on Doppler sonography (false-negative results = 12/1,000) and $10,149 for patients selected with criteria combining a positive finding on Doppler sonography with a bilateral resistive index of less than 0.75 (false-negative results = 32/1,000). Patient selection based on a positive finding on MR angiography cost $18,119 (false-negative results = 0), whereas the cost of patient selection based on a positive finding on renal scintigraphy was $12,939 (false-negative results = 29/1,000). CONCLUSION Doppler sonography is more cost-efficient but less sensitive than MR angiography for identifying patients with renovascular hypertension. MR angiography should be favored in hypertensive patients who are resistant to medical therapy to avoid false-negative examinations.
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Affiliation(s)
- Jean Philippe Bolduc
- Department of Radiology, CHUM-Notre-Dame Hospital, 1560 Sherbrooke East, Montreal, Quebec, Canada
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Feldman L, Beberashvili I, Averbukh Z, Weissgarten J. Renal artery stenosis of solitary kidney: the dilemma. Ren Fail 2005; 26:525-9. [PMID: 15526910 DOI: 10.1081/jdi-200031740] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND Renal artery stenosis is an important cause of hypertension and renal failure. When present in a solitary kidney, it is associated with extremely high morbidity and mortality. Although guidelines suggest an aggressive approach by revascularization in these cases, available evidence is too weak and contradictory to provide definite recommendations for treatment. OBJECTIVES To discuss the various clinical factors predicting the benefit from revascularization. METHODS AND RESULTS Review of more recent clinical trials is presented. DISCUSSION The approach to the patient with single kidney and renal artery stenosis is discussed and, although there is insufficient evidence-based medicine for guidelines, some suggestions are made to predict revascularization results in these cases. CONCLUSION Continuous development of clinical prediction rules will help in the management of renal artery stenosis of solitary kidney.
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Affiliation(s)
- Leonid Feldman
- Sackler Faculty of Medicine, Nephrology Division, Tel Aviv University, Assaf Harofeh Medical Center, Zerifin, Israel.
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Axelrod DJ, Freeman H, Pukin L, Guller J, Mitty HA. Guide wire perforation leading to fatal perirenal hemorrhage from transcortical collaterals after renal artery stent placement. J Vasc Interv Radiol 2004; 15:985-7. [PMID: 15361567 DOI: 10.1097/01.rvi.0000130861.14338.12] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
After successful renal artery angioplasty and stent placement, a patient in a fully anticoagulated state developed hypotension and flank pain. Review of the intraprocedural angiogram demonstrated transcortical position of the guide wire. Computed tomography of the abdomen revealed a large perinephric hematoma. Although only a single renal artery branch was accessed with the guide wire during stent placement, subsequent emergent angiography revealed extravasation from multiple capsular branches. Renal artery embolization failed to control the hemorrhage. The patient's course rapidly deteriorated and he ultimately died. The unique angiographic finding and proposed mechanism of this fatal complication are described and discussed.
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Affiliation(s)
- David J Axelrod
- Division of Vascular and Interventional Radiology, Department of Radiology, Mount Sinai School of Medicine, Box 1234, 1 Gustave L. Levy Place, New York, NY 10029, USA
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Liu BC, Tang RN, Feng Y, Wang YL, Yin LF, Ma GS. A single chinese center investigation of renal artery stenosis in 141 consecutive cases with coronary angiography. Am J Nephrol 2004; 24:630-4. [PMID: 15627718 DOI: 10.1159/000082935] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2004] [Accepted: 11/19/2004] [Indexed: 11/19/2022]
Abstract
BACKGROUND There is an increasing prevalence of ischemic nephropathy in the aging population of the world. However, the exact incidence of ischemic nephropathy in the Chinese population is still uncertain. The present study investigated the incidence of renal artery stenosis (RAS) in patients with suspected coronary artery disease (CAD) using renal angiography. METHODS Renal angiography was performed immediately after coronary artery angiography in 141 patients with suspected CAD, including 59 males and 82 females whose mean ages were 59 +/- 10 years. Comorbidities included hypertension (n = 69), diabetes mellitus (n = 21), hyperlipidemia (n = 19), hypokalemia (n = 7) and preoperative renal insufficiency (Cr >132 micromol/l; n = 14). The patients were divided into CAD (luminal narrowing of > or =50%) and non-CAD (luminal narrowing of <50%) subgroups, and RAS (luminal narrowing of > or =50%) and non-RAS subgroups. In the RAS group, there were 11 patients (5 males, 6 females) in whom percutaneous transluminal renal angioplasty was performed in conjunction with stent implantation due to refractory hypertension. RESULTS The incidence of RAS was 18.4% (26/141) in all cases and 30.8% (16/52) in patients with CAD identified by coronary artery angiography. Ten cases with RAS were found among the 89 cases with normal coronary arteries (11.2%). The incidence of RAS in patients with CAD was higher than that in patients without CAD (30.8 vs. 11.2%, p< 0.05). In 52 cases with CAD, the incidence of RAS with three vessel lesions was significantly higher than that with one or two vessel lesions. Hypertension, CAD, renal insufficiency, hyperlipidemia and hypokalemia were associated with a higher risk of RAS. CONCLUSIONS This study suggests that RAS is very common in the elderly Chinese population, specifically for those with three vessel lesions in CAD. For early detection of potential ischemic nephropathy, renal angiography is necessary in patients who receive coronary artery angiography.
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Affiliation(s)
- Bi-Cheng Liu
- Institute of Nephrology, Zhong Da Hospital, Southeast University, Nanjing, PR China.
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Higashida RT, Meyers PM, Phatouros CC, Connors JJ, Barr JD, Sacks D. Reporting Standards for Carotid Artery Angioplasty and Stent Placement. Stroke 2004; 35:e112-34. [PMID: 15105523 DOI: 10.1161/01.str.0000125713.02090.27] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Gandy SJ, Sudarshan TAP, Sheppard DG, Allan LC, McLeay TB, Houston JG. Dynamic MRI contrast enhancement of renal cortex: a functional assessment of renovascular disease in patients with renal artery stenosis. J Magn Reson Imaging 2004; 18:461-6. [PMID: 14508783 DOI: 10.1002/jmri.10381] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE To evaluate differences in the magnitude and time course of renal cortical contrast uptake in patients with minimal, moderate, and severe renal artery stenosis (RAS) using contrast-enhanced magnetic resonance renography (CE-MRR). MATERIALS AND METHODS CE-MRR was performed on 56 patients with renovascular disease using a three-dimensional volume interpolated breath-hold examination (VIBE) perfusion sequence. After administration of 2 mL of contrast, nine sequential axial VIBE datasets were acquired: at baseline, 7, 14, 21, 45, 60, 120, 180, and 240 seconds. Aortic peak signal enhancement and cortical peak signal enhancement through the mid portion of each kidney was recorded, along with the time delay between each peak. Each renal artery was subsequently examined using three-dimensional contrast-enhanced MR angiography, and graded as being minimally (0%-30%), moderately (31%-70%), or severely (71%-100%) stenotic. RESULTS When the data were subdivided by RAS category, the cortical to aortic peak enhancement ratio (CAPR) reduced with increasing RAS. Further, the cortical to aortic time delay (CATD) increased with increasing RAS. These measurements were statistically significant between patients with minimal and moderate RAS compared to severe RAS CONCLUSION: CE-MRR can assist in the differentiation of patients with minimal or moderate RAS from those with severe RAS.
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Affiliation(s)
- Stephen J Gandy
- Tayside Institute for Cardiovascular Research, Department of Clinical Radiology, Ninewells Hospital, Dundee, UK.
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Surowiec SM, Sivamurthy N, Rhodes JM, Lee DE, Waldman DL, Green RM, Davies MG. Percutaneous Therapy for Renal Artery Fibromuscular Dysplasia. Ann Vasc Surg 2003; 17:650-5. [PMID: 14534846 DOI: 10.1007/s10016-003-0070-6] [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: 11/25/2022]
Abstract
Fibromuscular dysplasia (FMD) accounts for 10% of cases of renal artery stenosis. This study evaluates the anatomic and functional outcomes of endovascular therapy for symptomatic renal artery FMD at an academic medical center. A retrospective analysis of records from patients who underwent percutaneous transluminal renal artery angioplasty (PTRA) found 14 patients (all female) who underwent 19 interventions on 18 renal artery segments. Significant cardiovascular comorbidities were few in this patient population. The PTRA technical success rate was 95%. There were no periprocedural mortalities. Primary patency rates were 81%, 69%, 69%, and 69% at 2, 4, 6, and 8 years. Assisted primary patency rates were 87%, 87%, 87%, and 87% at 2, 4, 6, and 8 years. The restenosis rate was 25% at 8 years. Clinical benefit (improved or cured hypertension) was seen in 79% of patients overall; 65% of patients maintained this benefit at 8 years by life-table analysis. Percutaneous endovascular intervention for clinically symptomatic FMD of the renal arteries is technically successful, safe, and durable. Most patients demonstrate immediate clinical benefit and retain durable functional outcomes.
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Affiliation(s)
- Scott M Surowiec
- Division of Vascular Surgery, Center for Vascular Disease, University of Rochester Medical Center, Rochester, NY 14642, USA
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Barr JD, Connors JJ, Sacks D, Wojak JC, Becker GJ, Cardella JF, Chopko B, Dion JE, Fox AJ, Higashida RT, Hurst RW, Lewis CA, Matalon TAS, Nesbit GM, Pollock JA, Russell EJ, Seidenwurm DJ, Wallace RC. Quality Improvement Guidelines for the Performance of Cervical Carotid Angioplasty and Stent Placement. J Vasc Interv Radiol 2003; 14:S321-35. [PMID: 14514840 DOI: 10.1097/01.rvi.0000088568.65786.e5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- John D Barr
- Society of Interventional Radiology, 10201 Lee Highway, Suite 500, Fairfax, VA 22030, USA
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Parildar M, Parildar Z, Oran I, Kabaroglu C, Memis A, Bayindir O. Nitric oxide and oxidative stress in atherosclerotic renovascular hypertension: effect of endovascular treatment. J Vasc Interv Radiol 2003; 14:887-92. [PMID: 12847196 DOI: 10.1097/01.rvi.0000083841.97061.12] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Because activation of the renin-angiotensin system leads to an increase in oxidative stress, the authors investigated nitric oxide (NO; nitrite + nitrate), superoxide dismutase (SOD), catalase, and malondialdehyde (MDA) levels and the effect of endovascular treatment on these parameters in patients with atherosclerotic renovascular hypertension. The relationship of NO with blood pressure and renal functional indexes was also investigated. MATERIALS AND METHODS In this prospective cohort study, serum creatinine, NO, SOD, catalase, plasma MDA, urinary microalbumin, and NO levels, and blood pressure were determined in 21 patients with hypertension and unilateral renal artery stenosis caused by atherosclerosis at entry and after 24 hours, 2 weeks, and 6 weeks of endovascular treatment. RESULTS MDA concentrations decreased 24 hours after intervention and remained low 2 and 6 weeks later. In addition, serum SOD and NO and urine NO levels were increased significantly 24 hours after endovascular treatment and decreased after 2 and 6 weeks. However, serum catalase levels did not differ after the intervention. Blood pressures decreased after treatment. There were no significant differences in urinary microalbumin levels, estimated glomerular filtration rates, and creatinine levels after endovascular treatment. CONCLUSIONS Endovascular treatment decreases oxidative stress and may offer new benefits in the treatment of patients with hypertension associated with renal artery stenosis. The decrease in oxidative stress and/or the upregulation of SOD may increase the bioavailability of NO, which in turn may lead to the rapid hypotensive response.
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Affiliation(s)
- Mustafa Parildar
- Department of Radiology, Ege University Faculty of Medicine, 35100 Bornova, Izmir, Turkey
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