Endovascular treatment of renal artery stenosis in Germany: a retrospective analysis of the DEGIR registry 2018-2021

PURPOSE

 To provide an overview of endovascular treatment of renal artery stenosis (RAS) using the data of the Deutsche Gesellschaft für interventionelle Radiologie (DeGIR) quality management system.

MATERIALS AND METHODS

 A retrospective analysis was performed. Pre-, peri- and postprocedural data, technical success rates, complication rates, and clinical success rates at dismissal were examined.

RESULTS

 Between 2018 and 2021, 2134 angiography examinations of the renal arteries were performed: diagnostic angiography in 70 patients (3 %), balloon angioplasty in 795 (37 %), stent implantation in 1166 (55 %) and miscellaneous procedures in 103 (5 %). The lesion length was less than or equal to 5 mm in 1837 patients (87 %), between 5 and 10 mm in 197 (9 %), and between 10 and 20 mm in 62 (3 %). The degree of stenosis was less than 50 % in 156 patients (7 %), greater than 50 % in 239 (11 %), and greater than 70 % in 1472 (70 %). Occlusion was treated in 235 patients (11 %). Symptoms at discharge resolved in 600 patients (29 %), improved in 1012 (49 %), were unchanged in 77 (4 %), and worsened in 5 (0.2 %). Complications were reported in 51 patients (2.5 %) and the mortality rate was 0.15 %.

CONCLUSION

 A substantial number of patients with RAS and occlusions were treated by radiologists in Germany, with high technical success rates and low complication rates. The indication should be determined carefully as the current European guidelines for the treatment of RAS suggest that only carefully selected groups of patients will benefit from recanalizing treatment.

KEY POINTS

  · Carefully selected patient groups may benefit from endovascular treatment of renal artery stenosis.. · Analysis of the DEGIR quality management database shows that treatment of renal artery stenosis was performed by radiologists in Germany with high technical success rates and low complication rates.. · Recanalization even led to symptom improvement in a large proportion of patients with occlusions..

Renal and Mesenteric Artery Intervention

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.

Treatment of Renal Artery Stenosis in a Solitary Kidney Using Cutting Balloon Angioplasty in a Paediatric Patient

Aims:

Renovascular hypertension is a rare cause of paediatric hypertension. It is however, a potentially treatable cause particularly when caused by renal artery stenosis (RAS).

Materials and Methods:

We present the case of an 11-month-old girl presenting with cardiac dysfunction. She was found to be hypertensive with a systolic blood pressure >180mmHg. DMSA demonstrated a small right kidney and a divided renal function of 6% on the right and 94% on the left. Spectral analysis demonstrated abnormal waveforms suggestive of RAS of the left kidney.

Results:

Angioplasty with a cutting balloon was successful. Blood pressure measurements, renal function and left ventricular function improved.

Conclusion:

RAS can be successfully treated with cutting balloon angioplasty after failure of convention balloon angioplasty to relieve the narrowing. In our case, there was an immediate successful angiographic result that on mid-term follow-up demonstrated significant improvement in clinical and biochemical outcomes and cessation of all anti-hypertensive medication.

Tratamento da recidiva de reestenose intra-stent renal por angioplastia com balão farmacológico

Nos últimos anos, balões farmacológicos surgiram como promissora alternativa terapêutica em intervenções endovasculares. Com essa tecnologia, transferem-se drogas antiproliferativas à parede arterial, sem a necessidade de implante metálico para liberação. Descreve-se o caso de um paciente com uma segunda recidiva de reestenose intra-stent renal tratada por angioplastia com balão coberto por droga, com boa evolução clínica caracterizada por adequado controle pressórico e redução de classes e dosagem dos anti-hipertensivos. Os resultados obtidos com balões farmacológicos em outros territórios e esta experiência isolada podem contribuir como sugestão para o uso desses dispositivos na reestenose intra-stent renal, com resultados iniciais satisfatórios.

A Novel Technique of Stenting of the Renal Artery In-Stent Restenosis with GuideLiner® through Radial Approach

In-stent restenosis of the renal arteries is relatively common and its management is not well studied. An 83-year-old female with bilateral renal artery stenosis and balloon angioplasty and stenting bilaterally one year ago was found to have recurrent severe elevations in the blood pressure despite medical management. Renal artery duplex showed 60–99% stenosis of the right renal artery and 20–59% stenosis of the left renal artery. A subsequent angiography of the right renal artery revealed 80% in-stent restenosis at the ostium. We describe a new approach of balloon angioplasty and stenting through radial access site with the assistance of a GuideLiner in a complex in-stent restenosis of the renal artery.

Renal Artery Stenosis: When to Revascularize in 2017

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.

Treatment of In-Stent Restenosis in Patients with Renal Artery Stenosis

PURPOSE

To determine clinical outcomes of patients treated for renal artery in-stent restenosis (ISR) with atherosclerotic renal artery stenosis.

MATERIALS AND METHODS

A retrospective review was performed of the clinical data of all patients who underwent renal artery stent placement for atherosclerotic renal artery stenosis from 1996 to 2009. Medical records of patients were reviewed for relevant clinical history, including blood pressure, antihypertensive medications, and renal function data before and after an intervention. In 1,052 patients, 1,090 renal artery stent placements were performed. Of these, 101 stents in 79 patients developed ISR, which was treated with either percutaneous transluminal angioplasty (PTA) or repeat stent placement. Procedural details, including modality of intervention, stent diameter, and time to restenosis, were recorded. Hypertensive agent and use of statins were recorded. Univariate analysis was performed to identify risk factors associated with restenosis after treatment of ISR.

RESULTS

Patients treated with repeat stent placement were 6.89 times more likely to lose patency after treatment than patients treated with PTA (P < .01). No additional clinical or procedural factor, including smoking history; presence of cardiac, renal, or metabolic disease; use of statin at time of ISR treatment; or diameter of treatment (stent or PTA), had a significant association with duration of stent or angioplasty patency.

CONCLUSIONS

Treatment of renal artery ISR with PTA among patients with atherosclerotic renal artery stenosis has a lower rate of subsequent ISR compared with repeat stent placement.

Treatment of a recurrent renal artery stenosis and stent fracture using a drug eluting stent in a pediatric patient

Renal artery obstruction is uncommon in the pediatric population and therefore represents a challenging diagnosis to ascertain and treat. While angioplasty and surgery have been used to treat it, stent implantation has been left mainly for adult use. In the following paper, we expose the case of an 8-year-old female who presented with severe arterial hypertension. Initially, the patient was evaluated and up to 5 antihypertensive medications were started. After complete evaluation, she was found to have severe right renal artery distal and proximal stenosis. She underwent recurrent angioplasties and then a bare metal stent (BMS) implantation, due to recurrence of stenosis. The original BMS developed a circumferential fracture, leading to a second stent implant, this time using a drug eluting stent (DES). She has been stable for 8 years since the last intervention, although using 2 antihypertensive medications. The use of BMS and DES may add another tool in the armamentarium of the pediatric interventionist to treat these children with recurrent stenosis that fail angioplasty.

Renal artery stenosis: prevalence of, risk factors for, and management of in-stent stenosis

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.

Reinterventions for stent restenosis in patients treated for atherosclerotic mesenteric artery disease

OBJECTIVE

Mesenteric artery angioplasty and stenting (MAS) has been plagued by high restenosis and reintervention rates. The purpose of this study was to review the outcomes of patients treated for mesenteric artery in-stent restenosis (MAISR).

METHODS

The clinical data of 157 patients treated for chronic mesenteric ischemia with MAS of 170 vessels was entered into a prospective database (1998-2010). Fifty-seven patients (36%) developed MAISR after a mean follow-up of 29 months, defined by duplex ultrasound peak systolic velocity >330 cm/s and angiographic stenosis >60%. We reviewed the clinical data, radiologic studies, and outcomes of patients who underwent reintervention for restenosis. End points were mortality and morbidity, patient survival, symptom recurrence, reintervention, and patency rates.

RESULTS

There were 30 patients (25 female and five male; mean age, 69 ± 14 years) treated with reintervention for MAISR. Twenty-four patients presented with recurrent symptoms (21 chronic, three acute), and six had asymptomatic preocclusive lesions. Twenty-six patients (87%) underwent redo endovascular revascularization (rER) with stent placement in 17 (13 bare metal and four covered) or percutaneous transluminal angioplasty (PTA) in nine. The other four patients (13%) had open bypass, one for acute ischemia. There was one death (3%) in a patient treated with redo stenting for acute mesenteric ischemia. Seven patients (27%) treated by rER developed complications, including access site problems in four patients, and distal embolization with bowel ischemia, congestive heart failure and stent thrombosis in one each. Symptom improvement was noted in 22 of the 24 symptomatic patients (92%). After a mean follow-up of 29 ± 12 months, 15 patients (50%) developed a second restenosis, and seven (23%) required other reintervention. Rates of symptom recurrence, restenosis, and reinterventions were 0/4, 0/4, and 0/4 for covered stents, 2/9, 3/9, and 2/9 for PTA, 5/13, 8/13, and 5/13 for bare metal stents, and 1/4, 4/4, and 0/4 for open bypass. For all patients, freedom from recurrent symptoms, restenosis, and reinterventions were 70% ± 10%, 60% ± 10% and 50% ±10% at 2 years. For patients treated by rER, secondary patency rates were 72 ± 12 at the same interval.

CONCLUSIONS

Nearly 40% of patients developed mesenteric artery in-stent restenosis, of which half required reintervention because of symptom recurrence or progression to an asymptomatic preocclusive lesion. Mesenteric reinterventions were associated with low mortality (3%), high complication rate (27%), and excellent symptom improvement (92%).