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Drieghe B, De Buyzere M, Bové T, De Backer T. Interventions for renal artery stenosis: Appraisal of novel physiological insights and procedural techniques to improve clinical outcome. Catheter Cardiovasc Interv 2024; 104:285-299. [PMID: 38837309 DOI: 10.1002/ccd.31117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 05/07/2024] [Accepted: 05/25/2024] [Indexed: 06/07/2024]
Abstract
Randomized clinical trials failed to show additional benefit of renal artery stenting on top of medical therapy. Instead of writing an obituary on renal artery stenting, we try to explain these disappointing results. A transstenotic pressure gradient is needed to reduce renal perfusion and to activate the renin-angiotensin-aldosterone system. In only a minority of patients included in trials, a transstenotic pressure gradient is measured and reported. Like the coronary circulation, integration of physiological lesion assessment will allow to avoid stenting of non-significant lesions and select those patients that are most likely to benefit from renal artery stenting. Renal artery interventions are associated with peri-procedural complications. Contemporary techniques, including radial artery access, no-touch technique to engage the renal ostium and the use of embolic protection devices, will minimize procedural risk. Combining optimal patient selection and meticulous technique might lead to a netto clinical benefit when renal artery stenting is added to optimal medical therapy.
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Affiliation(s)
- Benny Drieghe
- Heart Center, University Hospital Gent, Gent, Belgium
| | | | - Thierry Bové
- Heart Center, University Hospital Gent, Gent, Belgium
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Fu J, Fang M, Lin Z, Qiu J, Yang M, Tian J, Dong D, Zou Y. CT-based radiomics: predicting early outcomes after percutaneous transluminal renal angioplasty in patients with severe atherosclerotic renal artery stenosis. Vis Comput Ind Biomed Art 2024; 7:1. [PMID: 38212451 PMCID: PMC10784441 DOI: 10.1186/s42492-023-00152-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/27/2023] [Indexed: 01/13/2024] Open
Abstract
This study aimed to comprehensively evaluate non-contrast computed tomography (CT)-based radiomics for predicting early outcomes in patients with severe atherosclerotic renal artery stenosis (ARAS) after percutaneous transluminal renal angioplasty (PTRA). A total of 52 patients were retrospectively recruited, and their clinical characteristics and pretreatment CT images were collected. During a median follow-up period of 3.7 mo, 18 patients were confirmed to have benefited from the treatment, defined as a 20% improvement from baseline in the estimated glomerular filtration rate. A deep learning network trained via self-supervised learning was used to enhance the imaging phenotype characteristics. Radiomics features, comprising 116 handcrafted features and 78 deep learning features, were extracted from the affected renal and perirenal adipose regions. More features from the latter were correlated with early outcomes, as determined by univariate analysis, and were visually represented in radiomics heatmaps and volcano plots. After using consensus clustering and the least absolute shrinkage and selection operator method for feature selection, five machine learning models were evaluated. Logistic regression yielded the highest leave-one-out cross-validation accuracy of 0.780 (95%CI: 0.660-0.880) for the renal signature, while the support vector machine achieved 0.865 (95%CI: 0.769-0.942) for the perirenal adipose signature. SHapley Additive exPlanations was used to visually interpret the prediction mechanism, and a histogram feature and a deep learning feature were identified as the most influential factors for the renal signature and perirenal adipose signature, respectively. Multivariate analysis revealed that both signatures served as independent predictive factors. When combined, they achieved an area under the receiver operating characteristic curve of 0.888 (95%CI: 0.784-0.992), indicating that the imaging phenotypes from both regions complemented each other. In conclusion, non-contrast CT-based radiomics can be leveraged to predict the early outcomes of PTRA, thereby assisting in identifying patients with ARAS suitable for this treatment, with perirenal adipose tissue providing added predictive value.
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Affiliation(s)
- Jia Fu
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, 100043, China
- Department of Radiology, Peking University First Hospital, Beijing, 100043, China
| | - Mengjie Fang
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, 100191, China
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Zhiyong Lin
- Department of Radiology, Peking University First Hospital, Beijing, 100043, China
| | - Jianxing Qiu
- Department of Radiology, Peking University First Hospital, Beijing, 100043, China
| | - Min Yang
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, 100043, China
| | - Jie Tian
- Beijing Advanced Innovation Center for Big Data-Based Precision Medicine, School of Engineering Medicine, Beihang University, Beijing, 100191, China
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China
| | - Di Dong
- CAS Key Laboratory of Molecular Imaging, Institute of Automation, Chinese Academy of Sciences, Beijing, 100190, China.
- School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Yinghua Zou
- Department of Interventional Radiology and Vascular Surgery, Peking University First Hospital, Beijing, 100043, China.
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Huang X, Li XL, Zhou H, Li XM. Assessment of Angiography-Based Renal Quantitative Flow Ratio Measurement in Patients with Atherosclerotic Renal Artery Stenosis. Cardiovasc Ther 2024; 2024:4618868. [PMID: 38234331 PMCID: PMC10791475 DOI: 10.1155/2024/4618868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/12/2023] [Accepted: 12/22/2023] [Indexed: 01/19/2024] Open
Abstract
Background Quantitative flow ratio (QFR) is an angiography-based fractional flow reserve measurement without pressure wire or induction of hyperemia. A recent innovation that uses combined geometrical data and hemodynamic boundary conditions to measure QFR from a single angiographic view has shown the potential to measure QFR of the renal artery-renal QFR (rQFR). Objective The aim of this pilot study was to assess the feasibility of rQFR measurement and the contribution of rQFR in selecting patients with atherosclerotic renal artery stenosis (ARAS) undergoing revascularization. Methods This retrospective trial enrolled patients who had ARAS (50-90%) and hypertension. The enrolled patients were treated by optimal antihypertensive medication or revascularization, respectively, and the therapeutic strategies were based on rFFR measurement and/or clinical feature. Results A total of 55 patients underwent rQFR measurement. Among the enrolled patients, 18 underwent optimal antihypertensive medication and 37 underwent revascularization, 19 patients in whom rQFR and rFFR were both assessed. During the 180-day follow-up, 25 patients saw an improvement in their blood pressure among the 37 patients that underwent revascularization. ROC analysis revealed that rQFR had a high diagnostic accuracy for predicting blood pressure improvement (AUCrQFR = 0.932, 95% CI 0.798-0.998). The ideal cut-off value of rQFR for predicting blood pressure improvement after revascularization is ≤0.72 (sensitivity: 72.00%, specificity: 100%). The paired t test and Bland-Altman analyses demonstrated good agreement between rQFR and rFFR (t = 1.887, 95% CI -0.021 to 0.001, 95% limits of agreement: -0.035 to 0.055, p = 0.075). The Spearman correlation test reveals that there was a significant positive correlation between rQFR and rFFR (r = 0.952, 95% CI 0.874 to 0.982, p < 0.001). Conclusion The rQFR has the potential to enhance the ability of angiography to detect functionally significant renal artery stenosis during angiography and to produce results that are comparable to invasive hemodynamic assessment.
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Affiliation(s)
- Xiang Huang
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Xiao-Lan Li
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Heng Zhou
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
| | - Xiao-Mei Li
- Department of Cardiology, Xiangyang No.1 People's Hospital, Hubei University of Medicine, Xiangyang 441000, Hubei, China
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Wang S, Zhang S, Li Y, Ma N, Li M, Ai H, Zhu H, Ren J, Li Y, Li P. Correlation of renal cortical blood perfusion and BP response after renal artery stenting. Front Cardiovasc Med 2022; 9:939519. [PMID: 36262208 PMCID: PMC9573998 DOI: 10.3389/fcvm.2022.939519] [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] [Received: 07/07/2022] [Accepted: 09/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to observe the correlation between renal cortical blood perfusion (CBP) parameters and BP response in patients with severe renal artery stenosis (RAS) who underwent stenting. Methods This was a single-center retrospective cohort study. A total of 164 patients with unilateral severe RAS after successful percutaneous transluminal renal artery stenting in Beijing Hospital from October 2017 to December 2020 were included. According to the results of BP evaluated at 12 months, all patients were divided into the BP response group (n = 98) and BP nonresponse group (n = 66). The baseline clinical and imaging characteristics and follow-up data about 24 h ABPM and CBP were recorded and analyzed. Pearson correlation analysis was used to evaluate the relationship between CBP parameters and 24 h average SBP. Univariate and multivariate logistic regression analysis was used to evaluate the risk factors for BP response. Results Among 164 patients with severe RAS, there were 100 males (61.0%), aged 37–75 years, with an average of 56.8 ± 18.4 years, and average artery stenosis of 84.0 ± 12.5%. The BP nonresponse patients had a longer duration of hypertension, more current smoking subjects and diabetic patients, lower eGFR, increased number of hypertensive agents, and rate of insulin compared with the BP response group (P < 0.05). After PTRAS, patients in the BP response group were associated with significantly lower BP and improved CPB, characterized by increased levels of maximum intensity (IMAX), area under ascending curve (AUC1), area under the descending curve (AUC2), shortened rising time (RT), mean transit time (mTT), and prolonged time to peak intensity (TTP; P < 0.05). However, the BP nonresponse group was only associated with significantly reduced RT (P < 0.05) compared with baseline data. During an average follow-up of 11.5 ± 1.7 months, the BP response group was associated with significantly lower levels of SBP, DBP, 24 h average SBP, and 24 h average DBP compared with the nonresponse group (P < 0.05). Pearson correlation analysis showed that the the pre-operative CBP parameters, including IMAX (r = 0.317), RT (r = 0.249), AUC1 (r = 0.614), AUC2 (r = 0.558), and postoperative CBP parameters, including RT (r = 0.283), AUC1 (r = 0.659), and AUC2 (r = 0.674) were significantly positively correlated with the 24 h average SBP, while the postoperative TTP (r = −0.413) and mTT (r = −0.472) were negatively correlated with 24 h average SBP (P < 0.05). Multivariate Logistic regression analysis found that diabetes (OR = 1.294), NT-proBNP (OR = 1.395), number of antihypertensive agents (OR = 2.135), pre-operation IMAX (OR = 1.534), post-operation AUC2 (OR = 2.417), and baseline dDBP (OR = 2.038) were related factors for BP response (all P < 0.05). Conclusion Patients in the BP nonresponse group often have diabetes, a longer duration of hypertension, significantly reduced glomerular filtration rate, and heavier renal artery stenosis. CBP parameters are closely related to 24 h average SBP, and pre-operation IMAX and post-operation AUC2 are markers for a positive BP response.
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Affiliation(s)
- Siyu Wang
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Sijie Zhang
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China,Graduate School of Peking Union Medical College, Beijing, China
| | - Yan Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Na Ma
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Mengpu Li
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
| | - Hu Ai
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China,Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Hui Zhu
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China,Department of Nuclear Medicine, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Junhong Ren
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, China,Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China,*Correspondence: Junhong Ren
| | - Yongjun Li
- Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China,Department of Vascular Surgery, Beijing Hospital, National Center of Gerontology, Beijing, China
| | - Peng Li
- The Key Laboratory of Geriatrics, Beijing Institute of Geriatrics, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing Hospital/National Center of Gerontology of National Health Commission, Beijing, China
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Bhalla V, Textor SC, Beckman JA, Casanegra AI, Cooper CJ, Kim ESH, Luther JM, Misra S, Oderich GS. Revascularization for Renovascular Disease: A Scientific Statement From the American Heart Association. Hypertension 2022; 79:e128-e143. [PMID: 35708012 DOI: 10.1161/hyp.0000000000000217] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Renovascular disease is a major causal factor for secondary hypertension and renal ischemic disease. However, several prospective, randomized trials for atherosclerotic disease failed to demonstrate that renal revascularization is more effective than medical therapy for most patients. These results have greatly reduced the generalized diagnostic workup and use of renal revascularization. Most guidelines and review articles emphasize the limited average improvement and fail to identify those clinical populations that do benefit from revascularization. On the basis of the clinical experience of hypertension centers, specialists have continued selective revascularization, albeit without a summary statement by a major, multidisciplinary, national organization that identifies specific populations that may benefit. In this scientific statement for health care professionals and the public-at-large, we review the strengths and weaknesses of randomized trials in revascularization and highlight (1) when referral for consideration of diagnostic workup and therapy may be warranted, (2) the evidence/rationale for these selective scenarios, (3) interventional and surgical techniques for effective revascularization, and (4) areas of research with unmet need.
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Li S, Ren Y, He Q, Wei Y, Du H. Synthesis of novel purine derivatives: antiplatelet aggregation activity evaluation and 3D‐QSAR analysis. J Heterocycl Chem 2022. [DOI: 10.1002/jhet.4539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Shunlai Li
- College of Chemistry Beijing University of Chemical Technology Beijing China
| | - Yajing Ren
- College of Chemistry Beijing University of Chemical Technology Beijing China
| | - Qiwen He
- College of Chemistry Beijing University of Chemical Technology Beijing China
| | - Yongji Wei
- College of Chemistry Beijing University of Chemical Technology Beijing China
| | - Hongguang Du
- College of Chemistry Beijing University of Chemical Technology Beijing China
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Yu H, Khan M, Wu H, Du X, Chen R, Rollins DM, Fang X, Long J, Xu C, Sawchuk AP. A new noninvasive and patient-specific hemodynamic index for the severity of renal stenosis and outcome of interventional treatment. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2022; 38:e3611. [PMID: 35509229 PMCID: PMC9539998 DOI: 10.1002/cnm.3611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/30/2021] [Accepted: 04/29/2022] [Indexed: 06/14/2023]
Abstract
Renal arterial stenosis (RAS) often causes renovascular hypertension, which may result in kidney failure and life-threatening consequences. Direct assessment of the hemodynamic severity of RAS has yet to be addressed. In this work, we present a computational concept to derive a new, noninvasive, and patient-specific index to assess the hemodynamic severity of RAS and predict the potential benefit to the patient from a stenting therapy. The hemodynamic index is derived from a functional relation between the translesional pressure indicator (TPI) and lumen volume reduction (S) through a parametric deterioration of the RAS. Our in-house computational platform, InVascular, for image-based computational hemodynamics is used to compute the TPI at given S. InVascular integrates unified computational modeling for both image processing and computational hemodynamics with graphic processing unit parallel computing technology. The TPI-S curve reveals a pair of thresholds of S indicating mild or severe RAS. The TPI at S = 0 represents the pressure improvement following a successful stenting therapy. Six patient cases with a total of 6 aortic and 12 renal arteries are studied. The computed blood pressure waveforms have good agreements with the in vivo measured ones and the systolic pressure is statistical equivalence to the in-vivo measurements with p < .001. Uncertainty quantification provides the reliability of the computed pressure through the corresponding 95% confidence interval. The severity assessments of RAS in four cases are consistent with the medical practice. The preliminary results inspire a more sophisticated investigation for real medical insights of the new index. This computational concept can be applied to other arterial stenoses such as iliac stenosis. Such a noninvasive and patient-specific hemodynamic index has the potential to aid in the clinical decision-making of interventional treatment with reduced medical cost and patient risks.
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Affiliation(s)
- Huidan Yu
- Department of Mechanical and Energy EngineeringIndiana University‐Purdue University, Indianapolis (IUPUI)IndianapolisIndianaUSA
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
| | - Monsurul Khan
- Department of Mechanical and Energy EngineeringIndiana University‐Purdue University, Indianapolis (IUPUI)IndianapolisIndianaUSA
- Present address:
School of Mechanical EngineeringPurdue UniversityWest LafayetteIndianaUSA
| | - Hao Wu
- Department of Mechanical and Energy EngineeringIndiana University‐Purdue University, Indianapolis (IUPUI)IndianapolisIndianaUSA
| | - Xiaoping Du
- Department of Mechanical and Energy EngineeringIndiana University‐Purdue University, Indianapolis (IUPUI)IndianapolisIndianaUSA
| | - Rou Chen
- Department of Mechanical and Energy EngineeringIndiana University‐Purdue University, Indianapolis (IUPUI)IndianapolisIndianaUSA
- Present address:
College of Metrology and Measurement EngineeringChina Jiliang UniversityHangzhouChina
| | - Dave M. Rollins
- Vascular Diagnostic CenterIndiana University HealthIndianapolisIndianaUSA
| | - Xin Fang
- Department of Vascular Surgery, The Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineHangzhouChina
| | - Jianyun Long
- Department of Vascular Surgery, The Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineHangzhouChina
| | - Chenke Xu
- Department of Ultrasound, The Affiliated Hangzhou First People's HospitalZhejiang University School of MedicineHangzhouChina
| | - Alan P. Sawchuk
- Department of SurgeryIndiana University School of MedicineIndianapolisIndianaUSA
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Li Y, Wen X, Zheng B, Chen M, Ma W, Li J. Case Report: Combination of Pressure Guidewire and Optical Coherence Tomography-Guided Drug-Coated Balloon Revascularization for Renal Artery Fibromuscular Dysplasia. Front Cardiovasc Med 2022; 8:773563. [PMID: 35096997 PMCID: PMC8792462 DOI: 10.3389/fcvm.2021.773563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/24/2021] [Indexed: 11/13/2022] Open
Abstract
Fibromuscular dysplasia (FMD) is the second common cause of renovascular hypertension. With the advent of endovascular therapy, angiography has become a diagnostic gold standard for FMD. Optical coherence tomography (OCT) by reflecting in vivo histology may improve diagnostic and classification accuracy. Renal fractional flow reserve (rFFR), measured by pressure guidewire, may distinguish the patients who may benefit from revascularization by identifying physiologically significant stenoses. However, the role of usage of both OCT and rFFR is not well-studied. We herein report a 17-year-old male with renovascular hypertension due to FMD. Angioplasty of drug-coated balloon (DCB) guided by OCT and FFR favorably achieved blood pressure (BP) control. In conclusion, the utility of both OCT and FFR may be useful for the appropriate selection of patients with renal FMD.
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Affiliation(s)
- Yuxi Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
| | - Xinyan Wen
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
| | - Bo Zheng
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
| | - Ming Chen
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
| | - Wei Ma
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
| | - Jianping Li
- Department of Cardiology, Peking University First Hospital, Beijing, China
- Institute of Cardiovascular Disease, Peking University First Hospital, Beijing, China
- Hypertension Precision Diagnosis and Treatment Research Center, Peking University First Hospital, Beijing, China
- *Correspondence: Jianping Li
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Milnerowicz AI, Milnerowicz A, Bańkowski T, Protasiewicz M. Pressure gradient measurement to verify hemodynamic results of the chimney endovascular aortic repair (chEVAR) technique. PLoS One 2021; 16:e0249549. [PMID: 33852618 PMCID: PMC8046246 DOI: 10.1371/journal.pone.0249549] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 03/21/2021] [Indexed: 11/18/2022] Open
Abstract
PURPOSE The use of the pressure gradient measurements to assess the renal artery flow hemodynamics after chimney endovascular aortic repair (chEVAR). METHODS The study was a prospective analysis of 37 chEVAR procedures performend in 24 patients with perirenal aortic aneurysm. In all patients the measurement of: distal renal artery pressure (Pd), aortic pressure (Pa), Pd/Pa ratio (Pd/Pa) and mean gradient (MG) between the aorta and the distal renal artery were performed. Measurements were taken with 0.014 inch pressure wire catheter before and after the chEVAR procedure. MG greater than 9 mmHg and Pd/Pa ratio below 0.90 were considered as the measures of a significant decrease in distal pressure that limited flow in renal arteries. The 6 month follow-up computed tomographic angiography (CTA) was performed in all patients to diagnose potential endoleak presence and to verify the patency of the chimney stent-grafts. RESULTS All procedures were successful, and no periprocedural complications were observed in any of the patients. The mean gradient values before and after the chimney implantation did not change significantly (6,2±2,0 mmHg and 6,8±2,2 mmHg, respectively). Similarly, no significant change in Pd/Pa values was noted with the value of 0.9 observed both before and after the procedure. All chimney stents were patent on the control CTA. Type Ia endoleak was found in 4 (10.8%) patients. CONCLUSIONS The application of the described technique seems to be a safe method which allows a direct measurement of renal artery flow hemodynamics before and after chimney implantation during the chEVAR technique. The use of covered balloon expandable stents, ensures the proper blood flow in the renal arteries during the chEVAR technique.
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Affiliation(s)
| | | | - Tomasz Bańkowski
- Department of Cardiology, Lower Silesia Specialist Hospital of Tadeusz Marciniak Emergency Medicine Center, Wrocław, Poland
| | - Marcin Protasiewicz
- Department of Cardiology, Medical University of Wrocław, Wrocław, Poland
- * E-mail:
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10
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Abstract
Renal artery stenosis is the most common secondary cause of hypertension and predominantly caused by atherosclerosis. In suspected patients, a non-invasive diagnosis with ultrasound is preferred. Asymptomatic, incidentally found RAS does not require revascularization. In symptomatic patients requiring revascularization, renal artery stenting is the preferred therapy. Selecting appropriate patients for revascularization requires careful consideration of lesion severity and is optimized with a multidisciplinary team. All patients with atherosclerotic RAS should be treated with guideline-directed medical therapy, including hypertension control, diabetes control, statins, antiplatelet therapy, smoking cessation and encouraging activity.
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11
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Xiong Z, Yuan D, Wang J, Zheng T, Fan Y. Influence of renal artery stenosis morphology on hemodynamics. Comput Methods Biomech Biomed Engin 2021; 24:1294-1301. [PMID: 33565336 DOI: 10.1080/10255842.2021.1883592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Currently, the clinical classification of the severity of renal artery stenosis (RAS) solely depends on the degree of stenosis. In addition, when the stenosis degree is between 50% and 70%, the clinical strategy is decided based on whether the RAS is hemodynamically significant. In this study, the influence of RAS morphological parameters on hemodynamics was numerically analyzed to provide a theoretical basis for clinical treatment. METHODS Idealized RAS models were established to investigate the hemodynamic effects of the stenosis length, asymmetric stenosis, and direction of the opening of the renal artery. RESULTS The longer the stenosis length, the greater is the ratio of the low time-averaged wall shear stress (WSS) and high oscillatory shear index (OSI) area distal stenosis (when the stenosis area is the same). In addition, asymmetric stenosis leads to a significant increase in the ratio of the renal artery peak systolic velocity (R-PSV) and the abdominal aorta peak systolic velocity (A-PSV) when the stenosis area is 60-70%. Furthermore, the fraction flow reserve (FFR) of the RAS model with 12 mm stenosis length, upward eccentricity and upward direction of renal artery opening was approximately equal to the cumulative value of the influence of different stenosis morphologies on FFR. CONCLUSION An assessment of the severity of RAS should consider the stenosis area and other morphological parameters, including the length and asymmetry of RAS as well as the direction of the opening of renal artery, particularly when the stenosis degree of RAS is between 50% and 70%.
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Affiliation(s)
- Zhuxiang Xiong
- Department of Applied Mechanics, Sichuan University, Chengdu, China
| | - Ding Yuan
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jiarong Wang
- Department of Vascular Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Tinghui Zheng
- Department of Applied Mechanics, Sichuan University, Chengdu, China
| | - Yubo Fan
- Beijing Advanced Innovation Centre for Biomedical Engineering, Beihang University, Beijing
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12
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Ai H, Zhang HP, Yang GJ, Zheng NX, Tang GD, Li H, Zhou Q, Ren JH, Zhao Y, Sun FC. <p>Severely Impaired Renal Function in Unilateral Atherosclerotic Renal Artery Stenosis Indicated by Renal Slow Perfusion</p>. Int J Gen Med 2020; 13:839-845. [PMID: 33116776 PMCID: PMC7569045 DOI: 10.2147/ijgm.s279457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/23/2020] [Indexed: 11/23/2022] Open
Affiliation(s)
- Hu Ai
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Hui-Ping Zhang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Guo-Jian Yang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Nai-Xin Zheng
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Guo-Dong Tang
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Hui Li
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Qi Zhou
- The MOH Key Laboratory of Geriatrics, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Jun-Hong Ren
- Department of Sonography, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
| | - Ying Zhao
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
- Correspondence: Ying Zhao; Fu-Cheng Sun Department of Cardiology, Beijing Hospital, National Center of Gerontology, No. 1 DaHua Road, Dong Dan, Beijing100730, ChinaTel +86 15901059087; Tel +86 15901059087 Email ;
| | - Fu-Cheng Sun
- Department of Cardiology, Beijing Hospital, National Center of Gerontology, Beijing, 100730, China
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How should we define appropriate patients for percutaneous transluminal renal angioplasty treatment? Hypertens Res 2020; 43:1015-1027. [PMID: 32572170 DOI: 10.1038/s41440-020-0496-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 01/15/2023]
Abstract
Renovascular hypertension (RVH) is one of the most common causes of secondary hypertension and can result in resistant hypertension. RVH is associated with an increased risk for progressive decline in renal function, cardiac destabilization syndromes including "flash" pulmonary edema, recurrent congestive heart failure, and cerebrocardiovascular disease. The most common cause of renal artery stenosis (RAS) is atherosclerotic lesions, followed by fibromuscular dysplasia. The endovascular technique of percutaneous transluminal renal angioplasty (PTRA) with or without stenting is one of the standard treatments for RAS. Randomized controlled trials comparing medical therapy with PTRA to medical therapy alone have failed to show a benefit of PTRA; however, the subjects of these randomized clinical trials were limited to atherosclerotic RAS patients, and patients with the most severe RAS, who would be more likely to benefit from PTRA, might not have been enrolled in these trials. This review compares international guidelines related to PTRA, reevaluates the effects of PTRA treatment on blood pressure and renal and cardiac function, discusses strategies for the management of RVH patients, and identifies factors that may predict which patients are most likely to benefit from PTRA.
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Manaktala R, Tafur-Soto JD, White CJ. Renal Artery Stenosis in the Patient with Hypertension: Prevalence, Impact and Management. Integr Blood Press Control 2020; 13:71-82. [PMID: 32581575 PMCID: PMC7276195 DOI: 10.2147/ibpc.s248579] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 04/29/2020] [Indexed: 11/23/2022] Open
Abstract
Atherosclerosis is the primary cause of renal artery stenosis. Atherosclerotic renal artery stenosis (ARAS) is associated with three clinical problems: renovascular hypertension, ischemic nephropathy and cardiac destabilization syndrome which pose huge healthcare implications. There is a significant rate of natural disease progression with worsening severity of renal artery stenosis when renal revascularization is not pursued in a timely manner. Selective sub-groups of individuals with ARAS have had good outcomes after percutaneous renal artery stenting (PTRAS). For example, individuals that underwent PTRAS and had improved renal function were reported to have a 45% survival advantage compared to those without improvement in their renal function. Advances in the imaging tools have allowed for better anatomic and physiologic measurements of ARAS. Measuring translesional hemodynamic gradients has allowed for accurate assessment of ARAS severity. Renal revascularization with PTRAS provides a survival advantage in individuals with significant hemodynamic renal artery stenosis lesions. It is important that we screen, diagnosis, intervene with invasive and medical treatments appropriately in these high-risk patients.
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Affiliation(s)
- Rohini Manaktala
- Ochsner Clinic Foundation, Department of Cardiovascular Medicine, New Orleans, LA, USA
| | - Jose D Tafur-Soto
- Ochsner Clinic Foundation, Department of Cardiovascular Medicine, New Orleans, LA, USA
| | - Christopher J White
- Ochsner Clinic Foundation, Department of Cardiovascular Medicine, New Orleans, LA, USA
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Prince M, Tafur JD, White CJ. When and How Should We Revascularize Patients With Atherosclerotic Renal Artery Stenosis? JACC Cardiovasc Interv 2020; 12:505-517. [PMID: 30898248 DOI: 10.1016/j.jcin.2018.10.023] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 09/19/2018] [Accepted: 10/01/2018] [Indexed: 01/21/2023]
Abstract
Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension and may lead to resistant (refractory) hypertension, progressive decline in renal function, and cardiac destabilization syndromes (pulmonary edema, recurrent heart failure, or acute coronary syndromes) despite guideline-directed medical therapy. Although randomized controlled trials comparing medical therapy with medical therapy and renal artery stenting have failed to show a benefit for renal artery stenting, according to comparative effectiveness reviews by the Agency for Healthcare Research and Quality, the trials may not have enrolled patients with the most severe atherosclerotic renal artery stenosis, who would be more likely to benefit from renal stenting. Because of limitations of conventional angiography, it is critical that the hemodynamic severity of moderately severe (50% to 70%) atherosclerotic renal artery stenosis lesions be confirmed on hemodynamic measurement. The authors review techniques to optimize patient selection, to minimize procedural complications, and to facilitate durable patency of renal stenting. The authors also review the current American College of Cardiology and American Heart Association guidelines and the Society for Cardiovascular Angiography and Interventions appropriate use criteria as they relate to renal stenting.
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Affiliation(s)
- Marloe Prince
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana.
| | - Jose D Tafur
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Christopher J White
- Department of Cardiology at Ochsner Clinic Foundation, New Orleans, Louisiana
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Mishima E, Suzuki T, Ito S. Selection of Patients for Angioplasty for Treatment of Atherosclerotic Renovascular Disease: Predicting Responsive Patients. Am J Hypertens 2020; 33:391-401. [PMID: 31996895 DOI: 10.1093/ajh/hpaa016] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/24/2020] [Accepted: 01/27/2020] [Indexed: 01/22/2023] Open
Abstract
Atherosclerotic renal artery stenosis (ARAS) can cause secondary hypertension, progressive decline in renal function, and cardiac complications. Recent randomized controlled trials including the Cardiovascular Outcomes in Renal Atherosclerotic Lesions study have not reported the benefit of renal artery stenting compared with medical therapy alone to improve renal function or reduce cardiovascular and renal events in the enrolled patients with ARAS. However, observational evidence indicating the benefits of angioplasty in the selected high-risk patients with ARAS has been increasing. Thus, the timely correction of stenosis through angioplasty may have a beneficial effect in selected patients. However, optimal patient selection for angioplasty has been debated and can be challenging at times. Clinicians must identify the responsive patients who would benefit from angioplasty through risk stratification and the prediction of outcomes. Efforts have been made for the determination of predictors that can identify the subgroups of patients who would benefit from angioplasty. Lower age, more severe stenosis, preserved renal perfusion, and absence of diabetes or generalized atherosclerosis have been reported as the predictors for the improvement of hypertension after angioplasty. Global renal ischemia, rapidly declining renal function over 6-12 months, progressive shrinkage of the affected kidney, lower resistive index, and lower levels of albuminuria have been reported as predictors of improved or preserved renal function after angioplasty. This review discusses the identification of ARAS patients who will potentially respond well to angioplasty.
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Affiliation(s)
- Eikan Mishima
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Takehiro Suzuki
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Sadayoshi Ito
- Department of Medicine, Katta General Hospital, Shiroishi, Japan
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Abstract
Atherosclerotic renal artery stenosis is the most common cause of secondary hypertension and may cause progressive renal disease and cardiac destabilization syndromes. Guideline-directed medical therapy is advised in all patients. Patients with refractory symptoms and hemodynamically significant stenoses are more likely to benefit from renal artery stent placement. Chronic mesenteric ischemia (CMI) is an infrequent and difficult to diagnose illness. Due to robust collateralization, clinical symptoms from mesenteric artery stenosis or occlusion is uncommon. Atherosclerosis is the most common etiology of CMI. Current evidence suggests that, compared with open surgical repair, endovascular therapy is the most cost-effective choice for CMI.
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Affiliation(s)
- Tamunoinemi Bob-Manuel
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA
| | - Christopher J White
- Department of Cardiovascular Diseases, John Ochsner Heart and Vascular Center, Ochsner Medical Center, The Ochsner Clinical School, University of Queensland, 1514 Jefferson Highway, New Orleans, LA 70121, USA; Department of Cardiology, Ochsner Medical Center, 3rd Floor, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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Differences in renal hemodynamics and renin secretion between patients with unifocal and multifocal fibromuscular dysplasia. J Hypertens 2018; 36:1729-1735. [DOI: 10.1097/hjh.0000000000001755] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Khan Z, Tolia S, Sanam K, Gholkar G, Zughaib M, Naik S, Zughaib M. Is there still a role for renal artery stenting in the management of renovascular hypertension - A single-center experience and where do we stand? CARDIOVASCULAR REVASCULARIZATION MEDICINE 2018; 20:202-206. [PMID: 29934065 DOI: 10.1016/j.carrev.2018.06.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 05/20/2018] [Accepted: 06/08/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Renal artery (RA) stenosis has been implicated in the pathophysiological mechanism for resistant hypertension. Despite the increasingly diagnosed frequency of hemodynamically significant lesions, the value of RA revascularization remains controversial. Our group had previously demonstrated significant blood pressure (BP) reduction in a retrospective cohort of appropriately selected patients undergoing RA stenting up to 18-months of follow-up. We herein present long-term clinical outcomes data 5-years post revascularization on 26 subjects who continued follow-up at our institution. METHODS Retrospective analysis was performed on subjects who underwent RA stenting at our institution for hemodynamically significant (≥70%) RA stenosis and systolic hypertension on ≥3 antihypertensive agents. Clinical outcome data for systolic blood pressure (SBP), diastolic blood pressure (DBP), creatinine level and number of antihypertensive drugs was assessed prior to and then later at 6-12 months and 3-5 years post RA stenting. RESULTS Mean age was 69 ± 9 years; 27% (7/26) were male. Median follow-up was 5.1 years. Blood pressure reduction was sustained at long-term follow-up (135/70 ± 18/11 mmHg) compared to initial reduction noted at 6-months (136/69 ± 16/8 mmHg; p ≤0.01 for both) and from baseline (162/80 ± 24/18 mmHg; p ≤0.001 for both). The number of antihypertensive agents also decreased from 4.1 ± 1.0 to 2.7 ± 2.1 (p = 0.002) at 6-months and was sustained at long-term follow-up, 3.4 ± 1.2 (p = 0.03) with no difference in renal function between short- and long-term follow-up compared to baseline. CONCLUSIONS This study shows sustained benefit of RA stenting in BP reduction in an appropriately selected cohort with significant stenosis ≥70% and uncontrolled hypertension on multiple medications on long-term follow-up.
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Affiliation(s)
- Zubair Khan
- Providence-Providence Park Hospital, Southfield, Michigan, USA.
| | - Sunit Tolia
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Kumar Sanam
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Gunjan Gholkar
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marc Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Sunil Naik
- Providence-Providence Park Hospital, Southfield, Michigan, USA
| | - Marcel Zughaib
- Providence-Providence Park Hospital, Southfield, Michigan, USA
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Abstract
Purpose of Review Randomized trials have failed to show clinical benefit in patients with atherosclerotic renal artery stenosis who were treated with angioplasty with or without stenting. However, these studies were done in patients with a high-grade stenosis. This paper examines whether there are arguments to consider patients with low-grade stenosis for angioplasty. Recent Findings Patients with low-grade (< 50%) atherosclerotic renal artery stenosis have an excess risk for cardiovascular and renal complications. This could be related to inflammatory factors being generated by the stenotic kidney. Moreover, even a kidney with low-grade stenosis clears less or produces more of the natural nitric oxide inhibitor ADMA. Summary Patients with low-grade atherosclerotic renal artery stenosis have an increased risk for a variety of complications. In addition, the abnormality is progressive. There is a case for setting up a prospective trial to examine whether angioplasty confers benefit in patients with low-grade renal artery stenosis.
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Gomes Júnior MPM, Alves CMR, Barbosa AHP, Caixeta A, Batista MC, Pestana JOM, Carvalho AC. Initial experience with the use of fractional flow reserve in the hemodynamic evaluation of transplant renal artery stenosis. Catheter Cardiovasc Interv 2018; 91:820-826. [DOI: 10.1002/ccd.27476] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 11/07/2017] [Accepted: 11/25/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Manuel Pereira Marques Gomes Júnior
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Cláudia Maria Rodrigues Alves
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Adriano Henrique Pereira Barbosa
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Adriano Caixeta
- Interventional Cardiology Catheterization Laboratory Unit, Cardiology Division, Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM, São Paulo; SP Brazil
| | - Marcelo Costa Batista
- Departament of Nefrology; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
| | - José Osmar Medina Pestana
- Departament of Nefrology; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
| | - Antônio Carlos Carvalho
- Cardiology Division; Universidade Federal de São Paulo, Escola Paulista de Medicina, UNIFESP/EPM; São Paulo SP Brazil
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Stratigis S, Stylianou K, Kyriazis PP, Dermitzaki EK, Lygerou D, Syngelaki P, Stratakis S, Koukouraki S, Parthenakis F, Tsetis D, Daphnis E. Renal artery stenting for atherosclerotic renal artery stenosis identified in patients with coronary artery disease: Does captopril renal scintigraphy predict outcomes? J Clin Hypertens (Greenwich) 2018; 20:373-381. [PMID: 29316212 DOI: 10.1111/jch.13160] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Revised: 09/21/2017] [Accepted: 09/29/2017] [Indexed: 11/29/2022]
Abstract
The authors evaluated the effectiveness of percutaneous renal revascularization (PRR) with stenting for the treatment of atherosclerotic renal artery stenosis (ARAS) in patients with coronary artery disease and the usefulness of captopril renal scintigraphy for predicting clinical outcomes after PRR. Sixty-four consecutive patients, referred for evaluation of suspected ARAS, after coronary angiography, underwent baseline captopril renal scintigraphy followed by renal angiography. Forty-four patients (68.7%) were diagnosed with a significant ARAS≥ 60% and were treated with PRR plus medical therapy. Twenty-four months after PRR, 86.4% and 73.3% of patients showed a hypertension and renal benefit, respectively. Captopril renal scintigraphy positivity had moderate sensitivity and high specificity in predicting a hypertension and renal benefit. In patients with ARAS≥ 70%, the sensitivity and specificity were 100% for both a hypertension and renal benefit.PRR for ARAS conferred a substantial benefit in patients with a high coronary artery disease burden. Captopril renal scintigraphy was highly accurate in predicting clinical outcomes.
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Affiliation(s)
- Spyros Stratigis
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
| | - Kostas Stylianou
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
| | - Periklis P Kyriazis
- Department of Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, MA, USA
| | | | - Dimitra Lygerou
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
| | | | - Stavros Stratakis
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
| | - Sophia Koukouraki
- Department of Nuclear Medicine, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Fragiskos Parthenakis
- Department of Cardiology, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Dimitrios Tsetis
- Interventional Radiology Unit, Department of Radiology, Heraklion University Hospital, University of Crete, Crete, Greece
| | - Eugene Daphnis
- Department of Nephrology, Heraklion University Hospital, Crete, Greece
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ACR Appropriateness Criteria® Renovascular Hypertension. J Am Coll Radiol 2017; 14:S540-S549. [DOI: 10.1016/j.jacr.2017.08.040] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 08/14/2017] [Indexed: 11/24/2022]
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Klein AJ, Jaff MR, Gray BH, Aronow HD, Bersin RM, Diaz-Sandoval LJ, Dieter RS, Drachman DE, Feldman DN, Gigliotti OS, Gupta K, Parikh SA, Pinto DS, Shishehbor MH, White CJ. SCAI appropriate use criteria for peripheral arterial interventions: An update. Catheter Cardiovasc Interv 2017; 90:E90-E110. [PMID: 28489285 DOI: 10.1002/ccd.27141] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 05/05/2017] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University, Providence, RI
| | | | | | | | | | | | | | - Kamal Gupta
- University of Kansas Medical Center, Kansas City, KS
| | - Sahil A Parikh
- Columbia University Medical Center/NY Presbyterian Hospital, New York, NY
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van Brussel PM, van de Hoef TP, de Winter RJ, Vogt L, van den Born BJ. Hemodynamic Measurements for the Selection of Patients With Renal Artery Stenosis: A Systematic Review. JACC Cardiovasc Interv 2017; 10:973-985. [PMID: 28521931 DOI: 10.1016/j.jcin.2017.02.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 01/27/2017] [Accepted: 02/12/2017] [Indexed: 11/25/2022]
Abstract
Interventions targeting renal artery stenoses have been shown to lower blood pressure and preserve renal function. In recent studies, the efficacy of catheter-based percutaneous transluminal renal angioplasty with stent placement has been called into question. In the identification of functional coronary lesions, hyperemic measurements have earned a place in daily practice for clinical decision making, allowing discrimination between solitary coronary lesions and diffuse microvascular disease. Next to differences in clinical characteristics, the selection of renal arteries suitable for intervention is currently on the basis of anatomic grading of the stenosis by angiography rather than functional assessment under hyperemia. It is conceivable that, like the coronary circulation, functional measurements may better predict therapeutic efficacy of percutaneous transluminal renal angioplasty with stent placement. In this systematic review, the authors evaluate the available clinical evidence on the optimal hyperemic agents to induce intrarenal hyperemia, their association with anatomic grading, and their predictive value for treatment effects. In addition, the potential value of combined pressure and flow measurements to discriminate macrovascular from microvascular disease is discussed.
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Affiliation(s)
- Peter M van Brussel
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Tim P van de Hoef
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Robbert J de Winter
- Heart Center, Department of Interventional Cardiology, Academic Medical Center, Amsterdam, the Netherlands
| | - Liffert Vogt
- Department of Nephrology, Academic Medical Center, Amsterdam, the Netherlands
| | - Bert-Jan van den Born
- Department of Vascular Medicine, Academic Medical Center, Amsterdam, the Netherlands.
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Abstract
Atherosclerotic renal artery stenosis is the leading cause of secondary hypertension; it can also cause progressive renal insufficiency and cardiovascular complications such as refractory heart failure and flash pulmonary edema. Medical therapy including risk factor modification, renin-angiotensin-aldosterone system antagonists, lipid lowering agents, and antiplatelet therapy is the first line of treatment in all patients. Patients with uncontrolled renovascular hypertension despite optimal medical therapy, ischemic nephropathy, and cardiac destabilization syndromes who have severe renal artery stenosis are likely to benefit from renal artery revascularization. Screening for renal artery stenosis can be done with Doppler ultrasonography, computed tomographic angiography and magnetic resonance angiography. Invasive physiologic measurements are useful to confirm the severity of renal hypoperfusion and therefore improve the selection patients likely to respond to renal artery revascularization. Primary patency exceeds 80% at 5 years and surveillance for in-stent restenosis can be done with periodic clinical, laboratory, and imaging follow-up.
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Abstract
PURPOSE OF REVIEW Atherosclerotic renovascular disease remains highly prevalent and presents an array of clinical syndromes. Recent prospective trials have dampened enthusiasm for revascularization generally, but clinicians recognize the need to identify patients likely to benefit from vascular intervention. RECENT FINDINGS This article highlights the inflammatory nature of vascular occlusive disease and the limits of the kidney to adapt to reduced blood flow. Although moderate reductions can be tolerated, severe impairment of renal perfusion leads to tissue hypoxia and activates inflammatory injury within the kidney. Hence, assessment of kidney viability and potential tools to modify mitochondrial and inflammatory damage may be important to identify patients for whom clinical intervention should be undertaken. SUMMARY Clinicians must recognize clinical syndromes that identify 'high-risk' groups and apply revascularization in those likely to benefit. Future efforts to protect the kidney (e.g., mitochondrial protection) or cell-based therapy may amplify clinical recovery when combined with restoring renal blood flow.
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Miao Z, Liebeskind DS, Lo W, Liu L, Pu Y, Leng X, Song L, Xu X, Jia B, Gao F, Mo D, Sun X, Liu L, Ma N, Wang B, Wang Y, Wang Y. Fractional Flow Assessment for the Evaluation of Intracranial Atherosclerosis: A Feasibility Study. INTERVENTIONAL NEUROLOGY 2016; 5:65-75. [PMID: 27610123 DOI: 10.1159/000444333] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE Current studies on endovascular intervention for intracranial atherosclerosis select patients based on luminal stenosis. Coronary studies demonstrated that fractional flow measurements assess ischemia better than anatomical stenosis and can guide patient selection for intervention. We similarly postulated that fractional flow can be used to assess ischemic stroke risk. METHODS This was a feasibility study to assess the technical use and safety of applying a pressure guidewire to measure fractional flow across intracranial stenoses. Twenty patients with severe intracranial stenosis were recruited. The percentage of luminal stenosis, distal to proximal pressure ratios (fractional flow) and the fractional flow gradients across the stenosis were measured. Procedural success rate and safety outcomes were documented. RESULTS All 20 patients had successful crossing of stenosis by the pressure guidewire. Ten patients underwent angioplasty, and 5 had stenting performed. There was one perforator stroke, but not related to the use of the pressure wire. For the 13 patients with complete pre- and postintervention data, the mean preintervention stenosis, fractional flow and translesional pressure gradient were 76.2%, 0.66 and 29.9 mm Hg, whilst the corresponding postintervention measurements were 24.7%, 0.88 and 10.9 mm Hg, respectively. Fractional flow (r = -0.530, p = 0.001) and the translesional pressure gradient (r = 0.501, p = 0.002) only had a modest correlation with the luminal stenosis. CONCLUSION Fractional flow measurement by floating a pressure guidewire across the intracranial stenosis was technically feasible and safe in this study. Further studies are needed to validate its use for ischemic stroke risk assessment.
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Affiliation(s)
- ZhongRong Miao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - WaiTing Lo
- Department of Medicine, Queen Elizabeth Hospital, Hong Kong, SAR, China
| | - LiPing Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YueHua Pu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XinYi Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, SAR, China
| | - LiGang Song
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - XiaoTong Xu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - BaiXue Jia
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Feng Gao
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - DaPeng Mo
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Sun
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Liu
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ning Ma
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bo Wang
- Departments of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YiLong Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - YongJun Wang
- Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
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Jujo K, Saito K, Ishida I, Furuki Y, Ouchi T, Kim A, Suzuki Y, Sekiguchi H, Yamaguchi J, Ogawa H, Hagiwara N. Efficacy of 24-Hour Blood Pressure Monitoring in Evaluating Response to Percutaneous Transluminal Renal Angioplasty. Circ J 2016; 80:1922-30. [PMID: 27439675 DOI: 10.1253/circj.cj-16-0347] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Percutaneous transluminal renal angioplasty (PTRA) improves patency in atherosclerotic renal artery stenosis (ARAS), but improvement in clinic blood pressure (BP) is seen in only 20-40% of patients who undergo PTRA. This study investigated the effects of PTRA on BP lowering, assessed on 24-h ambulatory BP monitoring (ABPM), and identified preoperative features predictive of satisfactory BP improvement after PTRA. METHODS AND RESULTS Of 1,753 consecutive patients undergoing coronary angiography, 31 patients with angiographically significant ARAS and translesional pressure gradient (TLPG) >20 mmHg underwent PTRA. ABPM was performed before, at 1 month and at 1 year after PTRA; patients with average systolic ABPM-BP decrease >10 mmHg at 1 month from baseline were categorized as responders. There was no obvious relationship between clinic BP and ABPM-BP at baseline. ABPM-BP was significantly higher in responders at baseline (SBP: 148 vs. 126 mmHg, P<0.01) and was improved 1 month after PTRA. This difference persisted until 1 year after PTRA. Night-time BP improved more than daytime BP in responders. Patients with higher baseline ABPM-BP achieved a larger decrease in ABPM-BP, but the severity of stenosis reflected by TLPG; renal duplex findings; and neurohumoral parameters other than baseline renal function, did not differ between the groups. CONCLUSIONS Clinic BP does not represent daily hemodynamic status, whereas high ABPM-BP is a potent predictor of satisfactory BP response to PTRA. (Circ J 2016; 80: 1922-1930).
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Affiliation(s)
- Kentaro Jujo
- Department of Cardiology, Tokyo Women's Medical University
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O’Connor PJ, Lookstein RA. Endovascular Treatment of Renal Artery Stenosis in the Post CORAL Era. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:48. [DOI: 10.1007/s11936-016-0474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Patel SM, Li J, Parikh SA. Renal Artery Stenosis: Optimal Therapy and Indications for Revascularization. Curr Cardiol Rep 2016; 17:623. [PMID: 26238738 DOI: 10.1007/s11886-015-0623-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Atherosclerotic renal artery stenosis (ARAS) is associated with increased cardiovascular risk and overall mortality. Manifestations of ARAS include resistant or malignant hypertension, progressive deterioration of renal function, and cardiac dysfunction syndromes of flash pulmonary edema and angina. Diagnosis rests upon non-invasive studies such as duplex ultrasonography and is confirmed using invasive renal arteriography. Regardless of the severity of ARAS, management of this entity has been a topic of contentious debate. For over two decades, the use of percutaneous revascularization to treat ARAS has been studied with various clinical trials. Though case series seem to demonstrate favorable clinical response to revascularization, the overwhelming majority of randomized clinical trials have not mirrored a robust outcome. In these trials, poor correlation is noted between the reduction of stenosis and the improvement of renovascular hypertension and glomerular filtration rate, and decrease in cardiovascular outcomes and mortality. With dichotomizing results, the explanation for these discrepant findings has been attributed to improper trial design and inappropriate patient selection. An overview of the treatment options available will be provided, with a focus on the methodology and design of clinical trials investigating the efficacy of percutaneous revascularization. Emphasis is placed on appropriate patient selection criteria, which may necessitate the use of hemodynamic lesion assessment and clinical correlation based on individualized care. When clinical equipoise exists between optimal medical therapy and revascularization, the current paradigm supports ongoing medical therapy as the treatment of choice. However, renal artery stenting remains a viable therapeutic option for those who continue to have clinical syndromes consistent with renal hypoperfusion while adequately treated with optimal medical therapy. Despite observational studies suggesting clinical benefit for this specific patient population, there remains a paucity of randomized clinical trial data. Further trials targeting the patients who are inadequately treated with optimal medical therapy need to be undertaken to confirm the efficacy of revascularization.
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Affiliation(s)
- Sandeep M Patel
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Lougheed N, Jaskolka J, Beecroft R, Menezes R. Determination of the Best Parameter for Defining the Hemodynamic Significance of an Iliac Artery Stenosis Detected on Computed Tomography Angiography. Can Assoc Radiol J 2016; 67:298-303. [PMID: 27240435 DOI: 10.1016/j.carj.2015.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2014] [Revised: 08/23/2015] [Accepted: 09/09/2015] [Indexed: 11/25/2022] Open
Abstract
PURPOSE The purpose of this study was to determine the best parameter, derived from computed tomography angiography (CTA) for accurate prediction of a hemodynamically significant stenosis of the common or external iliac artery. METHODS A retrospective keyword search was performed on the Radiology Information System at our tertiary academic medical centre. Reports from January 2008 to September 2013 were searched using the keywords iliac, stenosis, and pressure. Patients who had both and CTA and a pelvic angiogram with pressure measurements obtained across a potential stenosis were selected. Using 3D postprocessing software (TeraRecon, Foster City, CA), the CTAs were analysed for the following parameters of each lesion: minimum diameter of stenosis, minimum cross-sectional area of stenosis, percent narrowing of vessel diameter, and percent reduction in vessel area. The percent stenosis was calculated in reference to the outer diameter at the point of maximal narrowing and also in reference to a normal segment of vessel more distal to the stenosis. These parameters were then compared with the measured pressure gradient using receiver-operating characteristic analysis and the Mann-Whitney U test to determine which best predicted a significant stenosis, defined as a greater than 10% drop in systolic pressure across a lesion. RESULTS One hundred and two stenoses in 83 patients (26 women, 57 men; 47-88 years old) were identified. Mean diameter of the stenosis was 2.8 mm for significant stenosis compared to 3.8 mm in nonsignificant stenoses (P = .005). Mean minimum area for significant stenoses was 11.8 mm(2) compared to 17.22 mm(2) for nonsignificant stenoses (P = .032) No other variables showed a significant difference between significant and nonsignificant stenoses. A minimum diameter of ≤4.0 mm at the level of a stenosis is 92% sensitive and 48% specific for predicting a hemodynamically significant iliac artery stenosis, with a positive predictive value of 88%. CONCLUSIONS A simple measurement of the minimum diameter of an iliac artery at the level of stenosis is the best predictor of the hemodynamic significance of a stenosis in the common or external iliac artery.
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Affiliation(s)
- Nick Lougheed
- Joint Department of Medical Imaging, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Jeff Jaskolka
- Joint Department of Medical Imaging, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Rob Beecroft
- Joint Department of Medical Imaging, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
| | - Ravi Menezes
- Joint Department of Medical Imaging, University Health Network, Toronto General Hospital, Toronto, Ontario, Canada
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To Stent or Not to Stent? Update on Revascularization for Atherosclerotic Renovascular Disease. Curr Hypertens Rep 2016; 18:45. [PMID: 27130448 DOI: 10.1007/s11906-016-0655-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Renal artery stenosis (RAS) is increasingly encountered in clinical practice. The two most common etiologies are fibromuscular dysplasia (FMD) and atherosclerotic renal artery disease (ARAS), with the latter accounting for the vast majority of cases. Significant RAS activates the renin-angiotensin-aldosterone system and is associated with three major clinical syndromes: ischemic nephropathy, hypertension, and destabilizing cardiac syndromes. Over the past two decades, advancements in diagnostic and interventional techniques have led to improved detection and the widespread use of endovascular renal artery revascularization strategies in the management of ARAS. However, renal artery stenting for ARAS remains controversial. Although several studies have demonstrated some benefit with renal artery revascularization, this has not been to the extent anticipated or predicted. Moreover, these trials have significant flaws in their study design and are hampered with inherent bias which make their interpretation challenging. In this review, we evaluate the existing body of evidence and offer an approach to the management of patients with ARAS in light of the current literature. From the data provided, identification of subgroup of patients, namely, those with a hemodynamically significant RAS in the context of progressive renal insufficiency and/or deteriorating arterial hypertension, seems possible and may derive clinical benefit from ARAS stent revascularization. Appropriate patient selection is therefore the key and more robust studies are required.
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Gafoor S, Franke J, Sievert H. The CORAL Trial, Round 2∗. J Am Coll Cardiol 2015; 66:2495-7. [DOI: 10.1016/j.jacc.2015.09.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 09/23/2015] [Accepted: 09/24/2015] [Indexed: 11/24/2022]
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Odudu A, Vassallo D, Kalra PA. From anatomy to function: diagnosis of atherosclerotic renal artery stenosis. Expert Rev Cardiovasc Ther 2015; 13:1357-75. [DOI: 10.1586/14779072.2015.1100077] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- Sarah C O'Connor
- Cleveland Clinic Lerner College of Medicine, Case Western University, Cleveland, OH
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Protasiewicz M, Początek K, Podgórski M, Poręba R, Derkacz A, Gosławska K, Kwiatkowska W, Mazur G, Mysiak A, Januszewicz A. Kidney microcirculation response to adenosine stimulation in renal artery stenosis. Blood Press 2015; 24:293-7. [PMID: 26114734 DOI: 10.3109/08037051.2015.1053205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The purpose of this study was to assess the vasoconstrictive effects of adenosine in the kidney microcirculation in hypertensive patients with renal artery stenosis (RAS). Twelve patients with resistant hypertension and moderate RAS were selected for the study. In all patients, systolic, diastolic and mean translesional pressure gradients, distal pressure (Pd), aortic pressure (Pa) and Pd/Pa ratio were measured using a pressure guidewire at baseline and after intrarenal bolus administration of 400 μg adenosine. We observed significant changes in mean translesional pressure gradient and systolic Pd after pharmacological stimulation. The results suggest that in hypertensive patients with RAS, vasomotor activity of the kidney microcirculation may be preserved.
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Comparison of the renal hyperemic effects of papaverine and dopamine in patients with renal artery stenosis. ACTA ACUST UNITED AC 2015; 9:9-14. [DOI: 10.1016/j.jash.2014.10.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Revised: 10/09/2014] [Accepted: 10/09/2014] [Indexed: 11/20/2022]
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Abstract
Atherosclerotic renovascular disease is the most common cause of secondary hypertension. The patients with renovascular disease are at increased risk for adverse cardiac outcomes. Recent trials comparing medical therapy alone to medical therapy with stenting are flawed, but lay to rest any existing debate that unselected revascularization is unwarranted; however, revascularization may be appropriate in high-risk populations. Defining an appropriate population for revascularization is an area of ongoing study. Furthermore, delivery of optimal medical therapy in this population is inadequate. This review describes recent developments in renal artery revascularization.
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Affiliation(s)
- Sharon S Choi
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX, 75390, USA
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Aronow HD, Li J, Parikh SA. Where and when device therapy may be useful in the management of drug-resistant hypertension. Curr Cardiol Rep 2014; 16:546. [PMID: 25326400 DOI: 10.1007/s11886-014-0546-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Device therapy for the treatment of uncontrolled and resistant hypertension has evolved significantly over the past several decades. Both renal artery disease and sympathetic hyperactivity have been linked to resistant hypertension. This manuscript will review the current evidence base supporting device therapy (e.g., renal artery revascularization, sympathetic nervous system modulation) for resistant hypertension.
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Affiliation(s)
- Herbert D Aronow
- Michigan Heart, 5325 Elliott Dr., Ste. #202, Ypsilanti, MI, 48197, USA,
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Kądziela J, Prejbisz A, Michałowska I, Adamczak M, Warchoł-Celińska E, Pregowska-Chwała B, Januszewicz M, Więcek A, Januszewicz A, Witkowski A. Relationship between hemodynamic parameters of renal artery stenosis and the changes of kidney function after renal artery stenting in patients with hypertension and preserved renal function. Blood Press 2014; 24:30-4. [DOI: 10.3109/08037051.2014.958304] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
| | | | | | - Marcin Adamczak
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
| | | | | | | | - Andrzej Więcek
- Department of Nephrology, Endocrinology and Metabolic Diseases, Medical University of Silesia, Katowice, Poland
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Prigent A, Chaumet-Riffaud P. Clinical problems in renovascular disease and the role of nuclear medicine. Semin Nucl Med 2014; 44:110-22. [PMID: 24484748 DOI: 10.1053/j.semnuclmed.2013.10.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Although renovascular disease remains defined as a stenosis of the main renal artery or its proximal branches (renal artery stenosis [RAS]), its clinical overview has changed dramatically over the last 15-20 years and its management is more controversial than ever before. The clinical problems, not only diagnosis and treatment but also the relative contribution of different pathophysiological mechanisms involved in the progression of kidney disease, have shifted dramatically. This presentation aims to emphasize the paradigm change revisiting the (recent) past focused on renovascular hypertension (RVH) to the current context of preservation or recovery of threatened renal function in patients with progressive atherosclerotic renovascular disease until its last stage of irreversible "ischemic nephropathy." In the past, the foreground was occupied by RVH, a very rare disease, where the activation of the renin-angiotensin-aldosterone system (RAAS) was supposed to play the major, if not only, role in RVH issues. The retrospective RVH diagnosis was established either on the improvement or, more rarely, on the cure of hypertension after revascularization by, most often, a percutaneous transluminal renal angioplasty with or without a stent placement. At this time, captoptril radionuclide renography was an efficient diagnostic tool, because it was a functional (angiotensin-converting enzyme inhibition), noninvasive test aiming to evidence both the RAAS activation and the lateralization (or asymmetry) of renin secretion by the kidney affected by a "hemodynamically significant" RAS. At present, even if captoptril radionuclide renography could be looked upon as the most efficient (and cost effective in selected high-risk patients) noninvasive, functional test to predict the improvement of hypertension after RAS correction, its clinical usefulness is questioned as the randomized, prospective trials failed to demonstrate any significant benefits (either on blood pressure control or on renal function protection) of the revascularization over current antihypertensive therapy. Today many patients with RVH remain undetected for years because they are treated successfully and at low expense with these new blockers of RAAS. In addition to its well-known role in hemodynamics, angiotensin II promotes activations of profibrogenic and inflammatory factors and cells and stimulates reactive oxygen species generation. The "atherosclerotic milieu" itself plays a role in the loss of renal microvessels and defective angiogenesis. After an "adaptative" phase, ischemia eventually develops and induces hypoxia, the substratum of ischemic nephropathy. Because blood oxygen level-dependent MRI may provide an index of oxygen content in vivo, it may be useful to predict renal function outcome after percutaneous transluminal renal angioplasty. New PET tracers, dedicated to assess RAAS receptors, inflammatory cell infiltrates, angiogenesis, and apoptose, would be tested in this context of atherosclerotic renovascular disease.
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Affiliation(s)
- Alain Prigent
- Service de Biophysique et Médecine Nucléaire, AP-HP Hôpitaux Universitaires Paris-Sud Bicêtre, Paris, France.
| | - Philippe Chaumet-Riffaud
- Service de Biophysique et Médecine Nucléaire, AP-HP Hôpitaux Universitaires Paris-Sud Bicêtre, Paris, France; IR4M UMR8081 CNRS, Université Paris-Sud, Orsay, France
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Parikh SA, Shishehbor MH, Gray BH, White CJ, Jaff MR. SCAI expert consensus statement for renal artery stenting appropriate use. Catheter Cardiovasc Interv 2014; 84:1163-71. [PMID: 25138644 DOI: 10.1002/ccd.25559] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2014] [Accepted: 05/25/2014] [Indexed: 11/08/2022]
Abstract
The pathophysiology of atherosclerotic renal artery stenosis (RAS) includes activation of the renin-angiotensin-aldosterone axis with resultant renovascular hypertension. Renal artery stenting has emerged as the primary revascularization strategy in most patients with hemodynamically significant atherosclerotic RAS. Despite the frequency with which hemodynamically significant RAS is observed and high rates of technical success of renal artery stenting, there remains considerable debate among experts regarding the role of medical therapy versus revascularization for renovascular hypertension. Modern, prospective, multicenter registries continue to demonstrate improvement in systolic and diastolic blood pressure with excellent safety profiles in patients with RAS. Modern randomized, controlled clinical trials of optimal medical therapy versus renal stenting particularly designed to demonstrate preservation in renal function after renal artery stenting have demonstrated limited benefit. However, these trials frequently excluded patients that may benefit from renal artery stenting. This document was developed to guide physicians in the modern practical application of renal stenting, to highlight the current limitations in the peer-reviewed literature, to suggest best-practices in the performance of renal stenting and to identify opportunities to advance the field.
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Affiliation(s)
- Sahil A Parikh
- University Hospitals Case Medical Center, Harrington Heart and Vascular Institute and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Abstract
Severe atherosclerotic renal artery stenosis can manifest as treatment-resistant hypertension, ischemic nephropathy and/or cardiac disturbance syndromes of recurrent flash pulmonary edema and refractory angina. Renal artery revascularization can dramatically impact patient outcome. However, patient selection for revascularization can be challenging. Renal artery stenting is most commonly used for renal revascularization and is a safe procedure when performed in carefully selected patients. This review addresses the pathophysiology of renal artery stenosis and the data supporting revascularization in such patients.
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Affiliation(s)
- Jun Li
- Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA
| | - Sahil A Parikh
- Division of Cardiovascular Medicine, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA; Interventional Cardiology Fellowship Program, Experimental Interventional Cardiology Laboratory, Department of Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Hokimoto S, Mizobe M, Akasaka T, Arima Y, Kaikita K, Nakagawa K, Ogawa H. Impact of CYP2C19 Polymorphism and Proton Pump Inhibitors on Platelet Reactivity to Clopidogrel and Clinical Outcomes Following Stent Implantation. Thromb Res 2014; 133:599-605. [DOI: 10.1016/j.thromres.2014.01.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2013] [Revised: 11/09/2013] [Accepted: 01/03/2014] [Indexed: 12/22/2022]
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